475
Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00 00102 7 00 00 00 00 ZZZ $0.00 00103 7 00 00 00 00 ZZZ $0.00 00104 7 00 00 00 00 ZZZ $0.00 00120 7 00 00 00 00 ZZZ $0.00 00124 7 00 00 00 00 ZZZ $0.00 ARKANSAS MEDICAID PHYSICIAN FEE SCHEDULE This fee schedule does not address the various coverage limitations routinely applied by Arkansas Medicaid before 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 not guarantee payment, coverage or amount allowed. Run Date 10/4/17 Although every effort is made to ensure the accuracy of this information, discrepancies may occur. This fee schedule may be changed or updated at any time to correct such discrepancies. The reimbursement rates reflected in this fee schedule are in effect as of the date of this report. The reimbursement rate applied to a claim depends on the claim’s date of service because Arkansas Medicaid’s reimbursement rates are date-of-service effective. This fee schedule reflects only procedure codes that are currently payable. Any procedure code reflecting a Medicaid maximum of $0.00 is manually priced with the exception of anesthesia and solid organ transplant procedure codes. The anesthesia procedure codes will also reflect a Medicaid maximum of $0.00 since the reimbursement rate is determined when the claim is processed. The payment for anesthesiology services is calculated using the base rate ($23.96 for an anesthesiologist or $19.17 for a CRNA) times the base units. The solid organ transplants listed at the end of the fee schedule are covered through a different protocol; therefore, they reflect a Medicaid maximum of $0.00. For details concerning reimbursement of solid organ transplants, refer to the reimbursement section of your provider manual. Please note that Arkansas Medicaid will reimburse the lesser of the amount billed or the Medicaid maximum. For a full explanation of the procedure codes and modifiers listed here, refer to your Arkansas Medicaid provider manual. Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Provider Type: 01

Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

Embed Size (px)

Citation preview

Page 1: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

Procedure

Code

Type of

Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code

Medicaid

Maximum

Allowed

Amount

00100 7 00 00 00 00 ZZZ $0.00

00102 7 00 00 00 00 ZZZ $0.00

00103 7 00 00 00 00 ZZZ $0.00

00104 7 00 00 00 00 ZZZ $0.00

00120 7 00 00 00 00 ZZZ $0.00

00124 7 00 00 00 00 ZZZ $0.00

ARKANSAS MEDICAID PHYSICIAN FEE SCHEDULE

This fee schedule does not address the various coverage limitations routinely applied by Arkansas

Medicaid before 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

not guarantee payment, coverage or amount allowed.

Run Date 10/4/17

Although every effort is made to ensure the accuracy of this information, discrepancies may occur. This

fee schedule may be changed or updated at any time to correct such discrepancies. The

reimbursement rates reflected in this fee schedule are in effect as of the date of this report. The

reimbursement rate applied to a claim depends on the claim’s date of service because Arkansas

Medicaid’s reimbursement rates are date-of-service effective. This fee schedule reflects only procedure

codes that are currently payable. Any procedure code reflecting a Medicaid maximum of $0.00 is

manually priced with the exception of anesthesia and solid organ transplant procedure codes.

The anesthesia procedure codes will also reflect a Medicaid maximum of $0.00 since the

reimbursement rate is determined when the claim is processed. The payment for anesthesiology

services is calculated using the base rate ($23.96 for an anesthesiologist or $19.17 for a CRNA) times

the base units.

The solid organ transplants listed at the end of the fee schedule are covered through a different

protocol; therefore, they reflect a Medicaid maximum of $0.00. For details concerning

reimbursement of solid organ transplants, refer to the reimbursement section of your provider

manual.

Please note that Arkansas Medicaid will reimburse the lesser of the amount billed or the Medicaid

maximum. For a full explanation of the procedure codes and modifiers listed here, refer to your

Arkansas Medicaid provider manual.

Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data

contained therein) is copyright © 2015 American Dental Association. All rights reserved. Applicable

FARS/DFARS apply.

Provider Type: 01

Page 2: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

00126 7 00 00 00 00 ZZZ $0.00

00140 7 00 00 00 00 ZZZ $0.00

00142 7 00 00 00 00 ZZZ $0.00

00144 7 00 00 00 00 ZZZ $0.00

00145 7 00 00 00 00 ZZZ $0.00

00147 7 00 00 00 00 ZZZ $0.00

00148 7 00 00 00 00 ZZZ $0.00

00160 7 00 00 00 00 ZZZ $0.00

00162 7 00 00 00 00 ZZZ $0.00

00164 7 00 00 00 00 ZZZ $0.00

00170 7 00 00 00 00 ZZZ $0.00

00172 7 00 00 00 00 ZZZ $0.00

00174 7 00 00 00 00 ZZZ $0.00

00176 7 00 00 00 00 ZZZ $0.00

00190 7 00 00 00 00 ZZZ $0.00

00192 7 00 00 00 00 ZZZ $0.00

00210 7 00 00 00 00 ZZZ $0.00

00211 7 00 00 00 00 ZZZ $0.00

00212 7 00 00 00 00 ZZZ $0.00

00214 7 00 00 00 00 ZZZ $0.00

00215 7 00 00 00 00 ZZZ $0.00

00216 7 00 00 00 00 ZZZ $0.00

00218 7 00 00 00 00 ZZZ $0.00

00220 7 00 00 00 00 ZZZ $0.00

00222 7 00 00 00 00 ZZZ $0.00

00300 7 00 00 00 00 ZZZ $0.00

00320 7 00 00 00 00 ZZZ $0.00

00322 7 00 00 00 00 ZZZ $0.00

00326 7 00 00 00 00 ZZZ $0.00

00350 7 00 00 00 00 ZZZ $0.00

00352 7 00 00 00 00 ZZZ $0.00

00400 7 00 00 00 00 ZZZ $0.00

00402 7 00 00 00 00 ZZZ $0.00

00404 7 00 00 00 00 ZZZ $0.00

00406 7 00 00 00 00 ZZZ $0.00

00410 7 00 00 00 00 ZZZ $0.00

00450 7 00 00 00 00 ZZZ $0.00

00454 7 00 00 00 00 ZZZ $0.00

00470 7 00 00 00 00 ZZZ $0.00

00472 7 00 00 00 00 ZZZ $0.00

Page 3: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

00474 7 00 00 00 00 ZZZ $0.00

00500 7 00 00 00 00 ZZZ $0.00

00520 7 00 00 00 00 ZZZ $0.00

00522 7 00 00 00 00 ZZZ $0.00

00524 7 00 00 00 00 ZZZ $0.00

00528 7 00 00 00 00 ZZZ $0.00

00529 7 00 00 00 00 ZZZ $0.00

00530 7 00 00 00 00 ZZZ $0.00

00532 7 00 00 00 00 ZZZ $0.00

00534 7 00 00 00 00 ZZZ $0.00

00537 7 00 00 00 00 ZZZ $0.00

00539 7 00 00 00 00 ZZZ $0.00

00540 7 00 00 00 00 ZZZ $0.00

00541 7 00 00 00 00 ZZZ $0.00

00542 7 00 00 00 00 ZZZ $0.00

00546 7 00 00 00 00 ZZZ $0.00

00548 7 00 00 00 00 ZZZ $0.00

00550 7 00 00 00 00 ZZZ $0.00

00560 7 00 00 00 00 ZZZ $0.00

00561 7 00 00 00 00 ZZZ $0.00

00562 7 00 00 00 00 ZZZ $0.00

00563 7 00 00 00 00 ZZZ $0.00

00566 7 00 00 00 00 ZZZ $0.00

00567 7 00 00 00 00 ZZZ $0.00

00580 7 00 00 00 00 ZZZ $0.00

00600 7 00 00 00 00 ZZZ $0.00

00604 7 00 00 00 00 ZZZ $0.00

00620 7 00 00 00 00 ZZZ $0.00

00625 7 00 00 00 00 ZZZ $0.00

00626 7 00 00 00 00 ZZZ $0.00

00630 7 00 00 00 00 ZZZ $0.00

00632 7 00 00 00 00 ZZZ $0.00

00635 7 00 00 00 00 ZZZ $0.00

00640 7 00 00 00 00 ZZZ $0.00

00670 7 00 00 00 00 ZZZ $0.00

00700 7 00 00 00 00 ZZZ $0.00

00702 7 00 00 00 00 ZZZ $0.00

00730 7 00 00 00 00 ZZZ $0.00

00740 7 00 00 00 00 ZZZ $0.00

00750 7 00 00 00 00 ZZZ $0.00

Page 4: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

00752 7 00 00 00 00 ZZZ $0.00

00754 7 00 00 00 00 ZZZ $0.00

00756 7 00 00 00 00 ZZZ $0.00

00770 7 00 00 00 00 ZZZ $0.00

00790 7 00 00 00 00 ZZZ $0.00

00792 7 00 00 00 00 ZZZ $0.00

00794 7 00 00 00 00 ZZZ $0.00

00796 7 00 00 00 00 ZZZ $0.00

00797 7 00 00 00 00 ZZZ $0.00

00800 7 00 00 00 00 ZZZ $0.00

00802 7 00 00 00 00 ZZZ $0.00

00810 7 00 00 00 00 ZZZ $0.00

00820 7 00 00 00 00 ZZZ $0.00

00830 7 00 00 00 00 ZZZ $0.00

00832 7 00 00 00 00 ZZZ $0.00

00834 7 00 00 00 00 ZZZ $0.00

00836 7 00 00 00 00 ZZZ $0.00

00840 7 00 00 00 00 ZZZ $0.00

00842 7 00 00 00 00 ZZZ $0.00

00844 7 00 00 00 00 ZZZ $0.00

00846 7 00 00 00 00 ZZZ $0.00

00848 7 00 00 00 00 ZZZ $0.00

00851 7 00 00 00 00 ZZZ $0.00

00860 7 00 00 00 00 ZZZ $0.00

00862 7 00 00 00 00 ZZZ $0.00

00864 7 00 00 00 00 ZZZ $0.00

00865 7 00 00 00 00 ZZZ $0.00

00866 7 00 00 00 00 ZZZ $0.00

00868 7 00 00 00 00 ZZZ $0.00

00870 7 00 00 00 00 ZZZ $0.00

00872 7 00 00 00 00 ZZZ $0.00

00873 7 00 00 00 00 ZZZ $0.00

00880 7 00 00 00 00 ZZZ $0.00

00882 7 00 00 00 00 ZZZ $0.00

00902 7 00 00 00 00 ZZZ $0.00

00904 7 00 00 00 00 ZZZ $0.00

00906 7 00 00 00 00 ZZZ $0.00

00908 7 00 00 00 00 ZZZ $0.00

00910 7 00 00 00 00 ZZZ $0.00

00912 7 00 00 00 00 ZZZ $0.00

Page 5: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

00914 7 00 00 00 00 ZZZ $0.00

00916 7 00 00 00 00 ZZZ $0.00

00918 7 00 00 00 00 ZZZ $0.00

00920 7 00 00 00 00 ZZZ $0.00

00921 7 00 00 00 00 ZZZ $0.00

00922 7 00 00 00 00 ZZZ $0.00

00924 7 00 00 00 00 ZZZ $0.00

00926 7 00 00 00 00 ZZZ $0.00

00928 7 00 00 00 00 ZZZ $0.00

00930 7 00 00 00 00 ZZZ $0.00

00932 7 00 00 00 00 ZZZ $0.00

00934 7 00 00 00 00 ZZZ $0.00

00936 7 00 00 00 00 ZZZ $0.00

00938 7 00 00 00 00 ZZZ $0.00

00940 7 00 00 00 00 ZZZ $0.00

00942 7 00 00 00 00 ZZZ $0.00

00944 7 00 00 00 00 ZZZ $0.00

00948 7 00 00 00 00 ZZZ $0.00

00950 7 00 00 00 00 ZZZ $0.00

00952 7 00 00 00 00 ZZZ $0.00

01112 7 00 00 00 00 ZZZ $0.00

01120 7 00 00 00 00 ZZZ $0.00

01130 7 00 00 00 00 ZZZ $0.00

01140 7 00 00 00 00 ZZZ $0.00

01150 7 00 00 00 00 ZZZ $0.00

01160 7 00 00 00 00 ZZZ $0.00

01170 7 00 00 00 00 ZZZ $0.00

01173 7 00 00 00 00 ZZZ $0.00

01180 7 00 00 00 00 ZZZ $0.00

01190 7 00 00 00 00 ZZZ $0.00

01200 7 00 00 00 00 ZZZ $0.00

01202 7 00 00 00 00 ZZZ $0.00

01210 7 00 00 00 00 ZZZ $0.00

01212 7 00 00 00 00 ZZZ $0.00

01214 7 00 00 00 00 ZZZ $0.00

01215 7 00 00 00 00 ZZZ $0.00

01220 7 00 00 00 00 ZZZ $0.00

01230 7 00 00 00 00 ZZZ $0.00

01232 7 00 00 00 00 ZZZ $0.00

01234 7 00 00 00 00 ZZZ $0.00

Page 6: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

01250 7 00 00 00 00 ZZZ $0.00

01260 7 00 00 00 00 ZZZ $0.00

01270 7 00 00 00 00 ZZZ $0.00

01272 7 00 00 00 00 ZZZ $0.00

01274 7 00 00 00 00 ZZZ $0.00

01320 7 00 00 00 00 ZZZ $0.00

01340 7 00 00 00 00 ZZZ $0.00

01360 7 00 00 00 00 ZZZ $0.00

01380 7 00 00 00 00 ZZZ $0.00

01382 7 00 00 00 00 ZZZ $0.00

01390 7 00 00 00 00 ZZZ $0.00

01392 7 00 00 00 00 ZZZ $0.00

01400 7 00 00 00 00 ZZZ $0.00

01402 7 00 00 00 00 ZZZ $0.00

01404 7 00 00 00 00 ZZZ $0.00

01420 7 00 00 00 00 ZZZ $0.00

01430 7 00 00 00 00 ZZZ $0.00

01432 7 00 00 00 00 ZZZ $0.00

01440 7 00 00 00 00 ZZZ $0.00

01442 7 00 00 00 00 ZZZ $0.00

01444 7 00 00 00 00 ZZZ $0.00

01462 7 00 00 00 00 ZZZ $0.00

01464 7 00 00 00 00 ZZZ $0.00

01470 7 00 00 00 00 ZZZ $0.00

01472 7 00 00 00 00 ZZZ $0.00

01474 7 00 00 00 00 ZZZ $0.00

01480 7 00 00 00 00 ZZZ $0.00

01482 7 00 00 00 00 ZZZ $0.00

01484 7 00 00 00 00 ZZZ $0.00

01486 7 00 00 00 00 ZZZ $0.00

01490 7 00 00 00 00 ZZZ $0.00

01500 7 00 00 00 00 ZZZ $0.00

01502 7 00 00 00 00 ZZZ $0.00

01520 7 00 00 00 00 ZZZ $0.00

01522 7 00 00 00 00 ZZZ $0.00

01610 7 00 00 00 00 ZZZ $0.00

01620 7 00 00 00 00 ZZZ $0.00

01622 7 00 00 00 00 ZZZ $0.00

01630 7 00 00 00 00 ZZZ $0.00

01634 7 00 00 00 00 ZZZ $0.00

Page 7: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

01636 7 00 00 00 00 ZZZ $0.00

01638 7 00 00 00 00 ZZZ $0.00

01650 7 00 00 00 00 ZZZ $0.00

01652 7 00 00 00 00 ZZZ $0.00

01654 7 00 00 00 00 ZZZ $0.00

01656 7 00 00 00 00 ZZZ $0.00

01670 7 00 00 00 00 ZZZ $0.00

01680 7 00 00 00 00 ZZZ $0.00

01682 7 00 00 00 00 ZZZ $0.00

01710 7 00 00 00 00 ZZZ $0.00

01712 7 00 00 00 00 ZZZ $0.00

01714 7 00 00 00 00 ZZZ $0.00

01716 7 00 00 00 00 ZZZ $0.00

01730 7 00 00 00 00 ZZZ $0.00

01732 7 00 00 00 00 ZZZ $0.00

01740 7 00 00 00 00 ZZZ $0.00

01742 7 00 00 00 00 ZZZ $0.00

01744 7 00 00 00 00 ZZZ $0.00

01756 7 00 00 00 00 ZZZ $0.00

01758 7 00 00 00 00 ZZZ $0.00

01760 7 00 00 00 00 ZZZ $0.00

01770 7 00 00 00 00 ZZZ $0.00

01772 7 00 00 00 00 ZZZ $0.00

01780 7 00 00 00 00 ZZZ $0.00

01782 7 00 00 00 00 ZZZ $0.00

01810 7 00 00 00 00 ZZZ $0.00

01820 7 00 00 00 00 ZZZ $0.00

01829 7 00 00 00 00 ZZZ $0.00

01830 7 00 00 00 00 ZZZ $0.00

01832 7 00 00 00 00 ZZZ $0.00

01840 7 00 00 00 00 ZZZ $0.00

01842 7 00 00 00 00 ZZZ $0.00

01844 7 00 00 00 00 ZZZ $0.00

01850 7 00 00 00 00 ZZZ $0.00

01852 7 00 00 00 00 ZZZ $0.00

01860 7 00 00 00 00 ZZZ $0.00

01916 7 00 00 00 00 ZZZ $0.00

01920 7 00 00 00 00 ZZZ $0.00

01922 7 00 00 00 00 ZZZ $0.00

01924 7 00 00 00 00 ZZZ $0.00

Page 8: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

01925 7 00 00 00 00 ZZZ $0.00

01926 7 00 00 00 00 ZZZ $0.00

01930 7 00 00 00 00 ZZZ $0.00

01931 7 00 00 00 00 ZZZ $0.00

01932 7 00 00 00 00 ZZZ $0.00

01933 7 00 00 00 00 ZZZ $0.00

01935 7 00 00 00 00 ZZZ $0.00

01936 7 00 00 00 00 ZZZ $0.00

01951 7 00 00 00 00 ZZZ $0.00

01952 7 00 00 00 00 ZZZ $0.00

01958 7 00 00 00 00 ZZZ $0.00

01960 7 00 00 00 00 ZZZ $0.00

01961 7 00 00 00 00 ZZZ $0.00

01962 7 00 00 00 00 ZZZ $0.00

01963 7 00 00 00 00 ZZZ $0.00

01964 7 00 00 00 00 ZZZ $0.00

01965 7 00 00 00 00 ZZZ $0.00

01966 7 00 00 00 00 ZZZ $0.00

01967 7 00 00 00 00 ZZZ $0.00

01990 7 00 00 00 00 ZZZ $0.00

01991 7 00 00 00 00 ZZZ $0.00

01992 7 00 00 00 00 ZZZ $0.00

01996 7 00 00 00 00 ZZZ $29.00

01999 7 00 00 00 00 ZZZ $0.00

10021 2 00 00 00 00 ZZZ $99.00

10021 8 00 00 00 00 ZZZ $19.80

10022 2 00 00 00 00 ZZZ $101.49

10022 8 00 00 00 00 ZZZ $20.30

10030 2 00 00 00 00 ZZZ $935.96

10030 8 00 00 00 00 ZZZ $187.19

10035 2 00 00 00 00 ZZZ $511.89

10035 8 00 00 00 00 ZZZ $102.38

10036 2 00 00 00 00 ZZZ $442.32

10036 8 00 00 00 00 ZZZ $88.46

10040 2 00 00 00 00 ZZZ $75.90

10040 8 00 00 00 00 ZZZ $15.18

10060 2 00 00 00 00 ZZZ $55.60

10060 8 00 00 00 00 ZZZ $11.12

10061 2 00 00 00 00 ZZZ $167.20

10061 8 00 00 00 00 ZZZ $33.44

Page 9: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

10080 2 00 00 00 00 ZZZ $65.83

10080 8 00 00 00 00 ZZZ $13.17

10081 2 00 00 00 00 ZZZ $156.20

10081 8 00 00 00 00 ZZZ $31.24

10120 2 00 00 00 00 ZZZ $63.73

10120 8 00 00 00 00 ZZZ $12.75

10121 2 00 00 00 00 ZZZ $155.02

10121 8 00 00 00 00 ZZZ $31.00

10140 2 00 00 00 00 ZZZ $67.14

10140 8 00 00 00 00 ZZZ $13.43

10160 2 00 00 00 00 ZZZ $58.48

10160 8 00 00 00 00 ZZZ $11.70

10180 2 00 00 00 00 ZZZ $141.57

10180 8 00 00 00 00 ZZZ $28.31

11000 2 00 00 00 00 ZZZ $65.27

11000 8 00 00 00 00 ZZZ $13.05

11001 2 00 00 00 00 ZZZ $30.00

11001 8 00 00 00 00 ZZZ $6.00

11004 2 00 00 00 00 ZZZ $693.77

11004 8 00 00 00 00 ZZZ $138.75

11005 2 00 00 00 00 ZZZ $945.07

11005 8 00 00 00 00 ZZZ $189.01

11006 2 00 00 00 00 ZZZ $873.74

11006 8 00 00 00 00 ZZZ $174.75

11008 2 00 00 00 00 ZZZ $355.74

11008 8 00 00 00 00 ZZZ $71.15

11010 2 00 00 00 00 ZZZ $361.71

11010 8 00 00 00 00 ZZZ $72.34

11011 2 00 00 00 00 ZZZ $430.38

11011 8 00 00 00 00 ZZZ $86.08

11012 2 00 00 00 00 ZZZ $598.84

11012 8 00 00 00 00 ZZZ $119.77

11036 8 00 00 00 00 ZZZ $5.03

11042 2 00 00 00 00 ZZZ $76.21

11042 8 00 00 00 00 ZZZ $15.24

11043 2 00 00 00 00 ZZZ $164.23

11043 8 00 00 00 00 ZZZ $32.85

11044 2 00 00 00 00 ZZZ $230.77

11044 8 00 00 00 00 ZZZ $46.15

11045 2 00 00 00 00 ZZZ $38.58

Page 10: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

11045 8 00 00 00 00 ZZZ $7.72

11046 2 00 00 00 00 ZZZ $68.30

11046 8 00 00 00 00 ZZZ $13.66

11047 2 00 00 00 00 ZZZ $112.38

11047 8 00 00 00 00 ZZZ $112.38

11055 2 00 00 00 00 ZZZ $19.39

11055 8 00 00 00 00 ZZZ $3.88

11056 2 00 00 00 00 ZZZ $27.64

11056 8 00 00 00 00 ZZZ $5.53

11057 2 00 00 00 00 ZZZ $30.11

11057 8 00 00 00 00 ZZZ $6.02

11100 2 00 00 00 00 ZZZ $52.80

11100 8 00 00 00 00 ZZZ $10.56

11101 2 00 00 00 00 ZZZ $30.80

11101 8 00 00 00 00 ZZZ $6.16

11200 2 00 00 00 00 ZZZ $55.00

11200 8 00 00 00 00 ZZZ $11.00

11201 2 00 00 00 00 ZZZ $16.50

11201 8 00 00 00 00 ZZZ $3.30

11300 2 00 00 00 00 ZZZ $58.30

11300 8 00 00 00 00 ZZZ $11.66

11301 2 00 00 00 00 ZZZ $67.10

11301 8 00 00 00 00 ZZZ $13.42

11302 2 00 00 00 00 ZZZ $94.60

11302 8 00 00 00 00 ZZZ $18.92

11303 2 00 00 00 00 ZZZ $135.00

11303 8 00 00 00 00 ZZZ $27.00

11305 2 00 00 00 00 ZZZ $55.00

11305 8 00 00 00 00 ZZZ $11.00

11306 2 00 00 00 00 ZZZ $62.70

11306 8 00 00 00 00 ZZZ $12.54

11307 2 00 00 00 00 ZZZ $86.90

11307 8 00 00 00 00 ZZZ $17.38

11308 2 00 00 00 00 ZZZ $130.90

11308 8 00 00 00 00 ZZZ $26.18

11310 2 00 00 00 00 ZZZ $79.26

11310 8 00 00 00 00 ZZZ $15.85

11311 2 00 00 00 00 ZZZ $101.18

11311 8 00 00 00 00 ZZZ $20.24

11312 2 00 00 00 00 ZZZ $116.56

Page 11: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

11312 8 00 00 00 00 ZZZ $23.31

11313 2 00 00 00 00 ZZZ $190.58

11313 8 00 00 00 00 ZZZ $38.12

11400 2 00 00 00 00 ZZZ $64.52

11400 8 00 00 00 00 ZZZ $12.90

11401 2 00 00 00 00 ZZZ $78.15

11401 8 00 00 00 00 ZZZ $15.63

11402 2 00 00 00 00 ZZZ $94.60

11402 8 00 00 00 00 ZZZ $18.92

11403 2 00 00 00 00 ZZZ $106.21

11403 8 00 00 00 00 ZZZ $21.24

11404 2 00 00 00 00 ZZZ $123.20

11404 8 00 00 00 00 ZZZ $24.64

11406 2 00 00 00 00 ZZZ $267.00

11406 8 00 00 00 00 ZZZ $53.00

11420 2 00 00 00 00 ZZZ $62.94

11420 8 00 00 00 00 ZZZ $12.59

11421 2 00 00 00 00 ZZZ $83.14

11421 8 00 00 00 00 ZZZ $16.63

11422 2 00 00 00 00 ZZZ $94.94

11422 8 00 00 00 00 ZZZ $18.99

11423 2 00 00 00 00 ZZZ $116.18

11423 8 00 00 00 00 ZZZ $23.24

11424 2 00 00 00 00 ZZZ $131.92

11424 8 00 00 00 00 ZZZ $26.38

11426 2 00 00 00 00 ZZZ $265.10

11426 8 00 00 00 00 ZZZ $53.02

11440 2 00 00 00 00 ZZZ $80.30

11440 8 00 00 00 00 ZZZ $16.06

11441 2 00 00 00 00 ZZZ $101.20

11441 8 00 00 00 00 ZZZ $20.24

11442 2 00 00 00 00 ZZZ $116.60

11442 8 00 00 00 00 ZZZ $23.32

11443 2 00 00 00 00 ZZZ $189.20

11443 8 00 00 00 00 ZZZ $37.84

11444 2 00 00 00 00 ZZZ $210.10

11444 8 00 00 00 00 ZZZ $42.02

11446 2 00 00 00 00 ZZZ $436.00

11446 8 00 00 00 00 ZZZ $87.00

11450 2 00 00 00 00 ZZZ $372.99

Page 12: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

11450 8 00 00 00 00 ZZZ $74.60

11451 2 00 00 00 00 ZZZ $295.17

11451 8 00 00 00 00 ZZZ $59.03

11462 2 00 00 00 00 ZZZ $211.65

11462 8 00 00 00 00 ZZZ $42.33

11463 2 00 00 00 00 ZZZ $253.41

11463 8 00 00 00 00 ZZZ $50.68

11470 2 00 00 00 00 ZZZ $261.20

11470 8 00 00 00 00 ZZZ $52.24

11471 2 00 00 00 00 ZZZ $297.30

11471 8 00 00 00 00 ZZZ $59.46

11600 2 00 00 00 00 ZZZ $108.90

11600 8 00 00 00 00 ZZZ $21.78

11601 2 00 00 00 00 ZZZ $119.90

11601 8 00 00 00 00 ZZZ $23.98

11602 2 00 00 00 00 ZZZ $156.20

11602 8 00 00 00 00 ZZZ $31.24

11603 2 00 00 00 00 ZZZ $189.20

11603 8 00 00 00 00 ZZZ $37.84

11604 2 00 00 00 00 ZZZ $217.80

11604 8 00 00 00 00 ZZZ $43.56

11606 2 00 00 00 00 ZZZ $353.00

11606 8 00 00 00 00 ZZZ $71.00

11620 2 00 00 00 00 ZZZ $105.60

11620 8 00 00 00 00 ZZZ $21.12

11621 2 00 00 00 00 ZZZ $127.60

11621 8 00 00 00 00 ZZZ $25.52

11622 2 00 00 00 00 ZZZ $192.50

11622 8 00 00 00 00 ZZZ $38.50

11623 2 00 00 00 00 ZZZ $210.10

11623 8 00 00 00 00 ZZZ $42.02

11624 2 00 00 00 00 ZZZ $268.40

11624 8 00 00 00 00 ZZZ $53.68

11626 2 00 00 00 00 ZZZ $388.30

11626 8 00 00 00 00 ZZZ $77.66

11640 2 00 00 00 00 ZZZ $130.90

11640 8 00 00 00 00 ZZZ $26.18

11641 2 00 00 00 00 ZZZ $195.80

11641 8 00 00 00 00 ZZZ $39.16

11642 2 00 00 00 00 ZZZ $257.40

Page 13: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

11642 8 00 00 00 00 ZZZ $51.48

11643 2 00 00 00 00 ZZZ $315.70

11643 8 00 00 00 00 ZZZ $63.14

11644 2 00 00 00 00 ZZZ $370.70

11644 8 00 00 00 00 ZZZ $74.14

11646 2 00 00 00 00 ZZZ $356.40

11646 8 00 00 00 00 ZZZ $71.28

11719 2 00 00 00 00 ZZZ $12.85

11719 8 00 00 00 00 ZZZ $2.57

11720 2 00 00 00 00 ZZZ $27.61

11720 8 00 00 00 00 ZZZ $5.52

11721 2 00 00 00 00 ZZZ $46.72

11721 8 00 00 00 00 ZZZ $9.34

11730 2 00 00 00 00 ZZZ $49.50

11730 8 00 00 00 00 ZZZ $9.90

11732 2 00 00 00 00 ZZZ $26.40

11732 8 00 00 00 00 ZZZ $5.28

11740 2 00 00 00 00 ZZZ $38.50

11740 8 00 00 00 00 ZZZ $7.70

11750 2 00 00 00 00 ZZZ $179.97

11750 8 00 00 00 00 ZZZ $35.99

11755 2 00 00 00 00 ZZZ $83.60

11755 8 00 00 00 00 ZZZ $16.72

11760 2 00 00 00 00 ZZZ $77.89

11760 8 00 00 00 00 ZZZ $15.58

11762 2 00 00 00 00 ZZZ $170.50

11762 8 00 00 00 00 ZZZ $34.10

11765 2 00 00 00 00 ZZZ $86.25

11765 8 00 00 00 00 ZZZ $17.25

11770 2 00 00 00 00 ZZZ $268.09

11770 8 00 00 00 00 ZZZ $53.62

11771 2 00 00 00 00 ZZZ $407.00

11771 8 00 00 00 00 ZZZ $81.40

11772 2 00 00 00 00 ZZZ $511.50

11772 8 00 00 00 00 ZZZ $102.30

11960 2 00 00 00 00 ZZZ $711.39

11960 8 00 00 00 00 ZZZ $142.28

11970 2 00 00 00 00 ZZZ $669.52

11970 8 00 00 00 00 ZZZ $628.70

11971 2 00 00 00 00 ZZZ $191.13

Page 14: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

11971 8 00 00 00 00 ZZZ $38.23

11976 A FP 00 00 00 ZZZ $96.25

11976 J 00 00 00 00 ZZZ $57.75

11980 2 00 00 00 00 ZZZ $126.65

11980 8 00 00 00 00 ZZZ $25.33

11981 2 00 00 00 00 ZZZ $132.00

11981 8 00 00 00 00 ZZZ $26.40

11981 A FP 00 00 00 ZZZ $166.19

11981 J 00 00 00 00 ZZZ $66.48

11982 2 00 00 00 00 ZZZ $150.58

11982 8 00 00 00 00 ZZZ $30.12

11983 2 00 00 00 00 ZZZ $244.22

11983 8 00 00 00 00 ZZZ $48.84

12001 2 00 00 00 00 ZZZ $86.54

12001 8 00 00 00 00 ZZZ $17.31

12002 2 00 00 00 00 ZZZ $95.20

12002 8 00 00 00 00 ZZZ $19.04

12004 2 00 00 00 00 ZZZ $113.56

12004 8 00 00 00 00 ZZZ $22.71

12005 2 00 00 00 00 ZZZ $141.10

12005 8 00 00 00 00 ZZZ $28.22

12006 2 00 00 00 00 ZZZ $184.63

12006 8 00 00 00 00 ZZZ $36.93

12007 2 00 00 00 00 ZZZ $201.94

12007 8 00 00 00 00 ZZZ $40.39

12011 2 00 00 00 00 ZZZ $92.05

12011 8 00 00 00 00 ZZZ $18.41

12013 2 00 00 00 00 ZZZ $104.38

12013 8 00 00 00 00 ZZZ $20.88

12014 2 00 00 00 00 ZZZ $123.79

12014 8 00 00 00 00 ZZZ $24.76

12015 2 00 00 00 00 ZZZ $156.57

12015 8 00 00 00 00 ZZZ $31.31

12016 2 00 00 00 00 ZZZ $189.88

12016 8 00 00 00 00 ZZZ $37.98

12017 2 00 00 00 00 ZZZ $251.24

12017 8 00 00 00 00 ZZZ $50.25

12018 2 00 00 00 00 ZZZ $307.11

12018 8 00 00 00 00 ZZZ $61.42

12020 2 00 00 00 00 ZZZ $125.88

Page 15: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

12020 8 00 00 00 00 ZZZ $25.18

12021 2 00 00 00 00 ZZZ $87.33

12021 8 00 00 00 00 ZZZ $17.47

12031 2 00 00 00 00 ZZZ $105.43

12031 8 00 00 00 00 ZZZ $21.09

12032 2 00 00 00 00 ZZZ $120.11

12032 8 00 00 00 00 ZZZ $24.02

12034 2 00 00 00 00 ZZZ $143.19

12034 8 00 00 00 00 ZZZ $28.64

12035 2 00 00 00 00 ZZZ $164.96

12035 8 00 00 00 00 ZZZ $32.99

12036 2 00 00 00 00 ZZZ $213.74

12036 8 00 00 00 00 ZZZ $42.75

12037 2 00 00 00 00 ZZZ $305.79

12037 8 00 00 00 00 ZZZ $61.16

12041 2 00 00 00 00 ZZZ $117.49

12041 8 00 00 00 00 ZZZ $23.50

12042 2 00 00 00 00 ZZZ $132.18

12042 8 00 00 00 00 ZZZ $26.44

12044 2 00 00 00 00 ZZZ $151.85

12044 8 00 00 00 00 ZZZ $30.37

12045 2 00 00 00 00 ZZZ $178.07

12045 8 00 00 00 00 ZZZ $35.61

12046 2 00 00 00 00 ZZZ $225.81

12046 8 00 00 00 00 ZZZ $45.16

12047 2 00 00 00 00 ZZZ $257.54

12047 8 00 00 00 00 ZZZ $51.51

12051 2 00 00 00 00 ZZZ $121.69

12051 8 00 00 00 00 ZZZ $24.34

12052 2 00 00 00 00 ZZZ $136.38

12052 8 00 00 00 00 ZZZ $27.28

12053 2 00 00 00 00 ZZZ $152.64

12053 8 00 00 00 00 ZZZ $30.53

12054 2 00 00 00 00 ZZZ $179.12

12054 8 00 00 00 00 ZZZ $35.82

12055 2 00 00 00 00 ZZZ $298.10

12055 8 00 00 00 00 ZZZ $59.62

12056 2 00 00 00 00 ZZZ $304.70

12056 8 00 00 00 00 ZZZ $60.94

12057 2 00 00 00 00 ZZZ $355.30

Page 16: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

12057 8 00 00 00 00 ZZZ $71.06

13100 2 00 00 00 00 ZZZ $145.82

13100 8 00 00 00 00 ZZZ $29.16

13101 2 00 00 00 00 ZZZ $257.40

13101 8 00 00 00 00 ZZZ $51.48

13102 2 00 00 00 00 ZZZ $83.74

13102 8 00 00 00 00 ZZZ $16.75

13120 2 00 00 00 00 ZZZ $156.05

13120 8 00 00 00 00 ZZZ $31.21

13121 2 00 00 00 00 ZZZ $210.10

13121 8 00 00 00 00 ZZZ $42.02

13122 2 00 00 00 00 ZZZ $97.36

13122 8 00 00 00 00 ZZZ $19.47

13131 2 00 00 00 00 ZZZ $203.50

13131 8 00 00 00 00 ZZZ $40.70

13132 2 00 00 00 00 ZZZ $374.00

13132 8 00 00 00 00 ZZZ $74.80

13133 2 00 00 00 00 ZZZ $143.98

13133 8 00 00 00 00 ZZZ $28.80

13151 2 00 00 00 00 ZZZ $304.70

13151 8 00 00 00 00 ZZZ $60.94

13152 2 00 00 00 00 ZZZ $421.30

13152 8 00 00 00 00 ZZZ $84.26

13153 2 00 00 00 00 ZZZ $158.42

13153 8 00 00 00 00 ZZZ $31.68

13160 2 00 00 00 00 ZZZ $432.20

13160 8 00 00 00 00 ZZZ $86.44

14000 2 00 00 00 00 ZZZ $305.01

14000 8 00 00 00 00 ZZZ $61.00

14001 2 00 00 00 00 ZZZ $414.11

14001 8 00 00 00 00 ZZZ $82.82

14020 2 00 00 00 00 ZZZ $454.30

14020 8 00 00 00 00 ZZZ $90.86

14021 2 00 00 00 00 ZZZ $547.80

14021 8 00 00 00 00 ZZZ $109.56

14040 2 00 00 00 00 ZZZ $566.50

14040 8 00 00 00 00 ZZZ $113.30

14041 2 00 00 00 00 ZZZ $834.90

14041 8 00 00 00 00 ZZZ $166.98

14060 2 00 00 00 00 ZZZ $798.60

Page 17: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

14060 8 00 00 00 00 ZZZ $159.72

14061 2 00 00 00 00 ZZZ $1,052.70

14061 8 00 00 00 00 ZZZ $210.54

14301 2 00 00 00 00 ZZZ $1,352.53

14301 8 00 00 00 00 ZZZ $270.51

14302 2 00 00 00 00 ZZZ $296.87

14302 8 00 00 00 00 ZZZ $59.37

14350 2 00 00 00 00 ZZZ $437.71

14350 8 00 00 00 00 ZZZ $87.54

15002 2 00 00 00 00 ZZZ $395.04

15002 8 00 00 00 00 ZZZ $79.01

15003 2 00 00 00 00 ZZZ $118.09

15003 8 00 00 00 00 ZZZ $23.62

15004 2 00 00 00 00 ZZZ $395.04

15004 8 00 00 00 00 ZZZ $79.01

15005 2 00 00 00 00 ZZZ $118.09

15005 8 00 00 00 00 ZZZ $23.62

15040 2 00 00 00 00 ZZZ $322.96

15040 8 00 00 00 00 ZZZ $64.59

15050 2 00 00 00 00 ZZZ $210.33

15050 8 00 00 00 00 ZZZ $42.07

15100 2 00 00 00 00 ZZZ $511.50

15100 8 00 00 00 00 ZZZ $102.30

15101 2 00 00 00 00 ZZZ $193.49

15101 8 00 00 00 00 ZZZ $38.70

15110 2 00 00 00 00 ZZZ $1,020.09

15110 8 00 00 00 00 ZZZ $204.02

15111 2 00 00 00 00 ZZZ $161.24

15111 8 00 00 00 00 ZZZ $32.25

15115 2 00 00 00 00 ZZZ $958.44

15115 8 00 00 00 00 ZZZ $191.69

15116 2 00 00 00 00 ZZZ $209.14

15116 8 00 00 00 00 ZZZ $41.83

15120 2 00 00 00 00 ZZZ $667.70

15120 8 00 00 00 00 ZZZ $133.54

15121 2 00 00 00 00 ZZZ $310.63

15121 8 00 00 00 00 ZZZ $62.13

15130 2 00 00 00 00 ZZZ $846.99

15130 8 00 00 00 00 ZZZ $169.40

15131 2 00 00 00 00 ZZZ $131.84

Page 18: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

15131 8 00 00 00 00 ZZZ $26.37

15135 2 00 00 00 00 ZZZ $1,025.78

15135 8 00 00 00 00 ZZZ $205.16

15136 2 00 00 00 00 ZZZ $122.83

15136 8 00 00 00 00 ZZZ $24.57

15150 2 00 00 00 00 ZZZ $847.47

15150 8 00 00 00 00 ZZZ $169.49

15151 2 00 00 00 00 ZZZ $170.25

15151 8 00 00 00 00 ZZZ $34.05

15152 2 00 00 00 00 ZZZ $209.14

15152 8 00 00 00 00 ZZZ $41.83

15155 2 00 00 00 00 ZZZ $848.42

15155 8 00 00 00 00 ZZZ $169.68

15156 2 00 00 00 00 ZZZ $221.47

15156 8 00 00 00 00 ZZZ $44.29

15157 2 00 00 00 00 ZZZ $245.18

15157 8 00 00 00 00 ZZZ $49.04

15200 2 00 00 00 00 ZZZ $401.52

15200 8 00 00 00 00 ZZZ $80.30

15201 2 00 00 00 00 ZZZ $97.90

15201 8 00 00 00 00 ZZZ $19.58

15220 1 00 00 00 00 ZZZ $310.00

15220 2 00 00 00 00 ZZZ $409.39

15220 8 00 00 00 00 ZZZ $81.88

15221 2 00 00 00 00 ZZZ $120.76

15221 8 00 00 00 00 ZZZ $24.15

15240 2 00 00 00 00 ZZZ $667.70

15240 8 00 00 00 00 ZZZ $133.54

15241 2 00 00 00 00 ZZZ $186.50

15241 8 00 00 00 00 ZZZ $37.30

15260 2 00 00 00 00 ZZZ $693.00

15260 8 00 00 00 00 ZZZ $138.60

15261 2 00 00 00 00 ZZZ $219.14

15261 8 00 00 00 00 ZZZ $43.83

15271 2 00 00 00 00 ZZZ $842.40

15271 8 00 00 00 00 ZZZ $168.00

15272 2 00 00 00 00 ZZZ $508.80

15272 8 00 00 00 00 ZZZ $102.00

15273 2 00 00 00 00 ZZZ $842.40

15273 8 00 00 00 00 ZZZ $168.00

Page 19: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

15274 2 00 00 00 00 ZZZ $508.80

15274 8 00 00 00 00 ZZZ $102.00

15275 2 00 00 00 00 ZZZ $1,187.20

15275 8 00 00 00 00 ZZZ $237.00

15276 2 00 00 00 00 ZZZ $737.60

15276 8 00 00 00 00 ZZZ $148.00

15277 2 00 00 00 00 ZZZ $1,187.20

15277 8 00 00 00 00 ZZZ $237.00

15278 2 00 00 00 00 ZZZ $737.60

15278 8 00 00 00 00 ZZZ $148.00

15570 2 00 00 00 00 ZZZ $447.68

15570 8 00 00 00 00 ZZZ $89.54

15572 2 00 00 00 00 ZZZ $482.90

15572 8 00 00 00 00 ZZZ $96.58

15574 2 00 00 00 00 ZZZ $689.70

15574 8 00 00 00 00 ZZZ $137.94

15576 2 00 00 00 00 ZZZ $707.75

15576 8 00 00 00 00 ZZZ $141.55

15600 2 00 00 00 00 ZZZ $192.50

15600 8 00 00 00 00 ZZZ $38.50

15610 2 00 00 00 00 ZZZ $261.00

15610 8 00 00 00 00 ZZZ $52.00

15620 2 00 00 00 00 ZZZ $337.70

15620 8 00 00 00 00 ZZZ $67.54

15630 2 00 00 00 00 ZZZ $374.00

15630 8 00 00 00 00 ZZZ $74.80

15650 2 00 00 00 00 ZZZ $381.70

15650 8 00 00 00 00 ZZZ $76.34

15731 2 00 00 00 00 ZZZ $1,118.49

15731 8 00 00 00 00 ZZZ $223.70

15732 2 00 00 00 00 ZZZ $1,461.71

15732 8 00 00 00 00 ZZZ $292.34

15734 2 00 00 00 00 ZZZ $1,599.74

15734 8 00 00 00 00 ZZZ $319.95

15736 2 00 00 00 00 ZZZ $1,422.78

15736 8 00 00 00 00 ZZZ $284.56

15738 2 00 00 00 00 ZZZ $1,348.46

15738 8 00 00 00 00 ZZZ $269.69

15740 2 00 00 00 00 ZZZ $544.19

15740 8 00 00 00 00 ZZZ $108.84

Page 20: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

15750 2 00 00 00 00 ZZZ $604.51

15750 8 00 00 00 00 ZZZ $120.90

15756 2 00 00 00 00 ZZZ $2,831.40

15756 8 00 00 00 00 ZZZ $566.28

15757 2 00 00 00 00 ZZZ $2,831.40

15757 8 00 00 00 00 ZZZ $566.28

15758 2 00 00 00 00 ZZZ $2,831.40

15758 8 00 00 00 00 ZZZ $566.28

15760 2 00 00 00 00 ZZZ $456.86

15760 8 00 00 00 00 ZZZ $91.37

15770 2 00 00 00 00 ZZZ $536.80

15770 8 00 00 00 00 ZZZ $107.36

15777 2 00 00 00 00 ZZZ $1,646.40

15777 8 00 00 00 00 ZZZ $329.00

15830 2 00 00 00 00 ZZZ $1,058.03

15830 8 00 00 00 00 ZZZ $211.61

15840 2 00 00 00 00 ZZZ $1,017.50

15840 8 00 00 00 00 ZZZ $203.50

15841 2 00 00 00 00 ZZZ $1,108.05

15841 8 00 00 00 00 ZZZ $221.61

15842 2 00 00 00 00 ZZZ $1,847.10

15842 8 00 00 00 00 ZZZ $369.42

15845 2 00 00 00 00 ZZZ $1,017.50

15845 8 00 00 00 00 ZZZ $203.50

15847 2 00 00 00 00 ZZZ $1,265.22

15847 8 00 00 00 00 ZZZ $253.04

15850 2 00 00 00 00 ZZZ $100.24

15850 8 00 00 00 00 ZZZ $20.05

15851 2 00 00 00 00 ZZZ $107.82

15851 8 00 00 00 00 ZZZ $21.56

15852 2 00 00 00 00 ZZZ $102.00

15852 8 00 00 00 00 ZZZ $20.00

15860 2 00 00 00 00 ZZZ $146.52

15860 8 00 00 00 00 ZZZ $29.30

15920 2 00 00 00 00 ZZZ $638.00

15920 8 00 00 00 00 ZZZ $82.11

15922 2 00 00 00 00 ZZZ $673.87

15922 8 00 00 00 00 ZZZ $134.77

15931 2 00 00 00 00 ZZZ $479.22

15931 8 00 00 00 00 ZZZ $95.84

Page 21: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

15933 2 00 00 00 00 ZZZ $743.25

15933 8 00 00 00 00 ZZZ $148.65

15934 2 00 00 00 00 ZZZ $838.81

15934 8 00 00 00 00 ZZZ $167.76

15935 2 00 00 00 00 ZZZ $1,097.17

15935 8 00 00 00 00 ZZZ $219.43

15936 2 00 00 00 00 ZZZ $973.29

15936 8 00 00 00 00 ZZZ $194.66

15937 2 00 00 00 00 ZZZ $1,199.80

15937 8 00 00 00 00 ZZZ $239.96

15940 2 00 00 00 00 ZZZ $514.60

15940 8 00 00 00 00 ZZZ $102.92

15941 2 00 00 00 00 ZZZ $768.02

15941 8 00 00 00 00 ZZZ $153.60

15944 2 00 00 00 00 ZZZ $877.73

15944 8 00 00 00 00 ZZZ $175.55

15945 2 00 00 00 00 ZZZ $1,012.23

15945 8 00 00 00 00 ZZZ $202.45

15946 2 00 00 00 00 ZZZ $1,635.14

15946 8 00 00 00 00 ZZZ $327.03

15950 2 00 00 00 00 ZZZ $428.25

15950 8 00 00 00 00 ZZZ $85.65

15951 2 00 00 00 00 ZZZ $775.09

15951 8 00 00 00 00 ZZZ $155.02

15952 2 00 00 00 00 ZZZ $771.56

15952 8 00 00 00 00 ZZZ $154.31

15953 2 00 00 00 00 ZZZ $920.21

15953 8 00 00 00 00 ZZZ $184.04

15956 2 00 00 00 00 ZZZ $1,422.78

15956 8 00 00 00 00 ZZZ $284.56

15958 2 00 00 00 00 ZZZ $1,461.20

15958 8 00 00 00 00 ZZZ $292.24

15999 2 00 00 00 00 ZZZ $0.00

15999 8 00 00 00 00 ZZZ $0.00

16000 2 00 00 00 00 ZZZ $42.48

16000 8 00 00 00 00 ZZZ $8.50

16020 2 00 00 00 00 ZZZ $40.65

16020 8 00 00 00 00 ZZZ $8.13

16025 2 00 00 00 00 ZZZ $80.30

16025 8 00 00 00 00 ZZZ $16.06

Page 22: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

16030 2 00 00 00 00 ZZZ $100.18

16030 8 00 00 00 00 ZZZ $20.04

16035 2 00 00 00 00 ZZZ $203.25

16035 8 00 00 00 00 ZZZ $40.65

16036 2 00 00 00 00 ZZZ $95.71

16036 8 00 00 00 00 ZZZ $19.14

17000 2 00 00 00 00 ZZZ $44.00

17000 8 00 00 00 00 ZZZ $8.80

17003 2 00 00 00 00 ZZZ $11.97

17003 8 00 00 00 00 ZZZ $2.39

17004 2 00 00 00 00 ZZZ $216.17

17004 8 00 00 00 00 ZZZ $43.23

17106 2 00 00 00 00 ZZZ $274.65

17106 8 00 00 00 00 ZZZ $54.93

17107 2 00 00 00 00 ZZZ $542.21

17107 8 00 00 00 00 ZZZ $108.44

17108 2 00 00 00 00 ZZZ $952.06

17108 8 00 00 00 00 ZZZ $190.41

17110 2 00 00 00 00 ZZZ $49.50

17110 8 00 00 00 00 ZZZ $9.90

17111 2 00 00 00 00 ZZZ $64.77

17111 8 00 00 00 00 ZZZ $12.95

17250 2 00 00 00 00 ZZZ $27.54

17250 8 00 00 00 00 ZZZ $5.51

17260 2 00 00 00 00 ZZZ $102.10

17260 8 00 00 00 00 ZZZ $20.42

17261 2 00 00 00 00 ZZZ $119.90

17261 8 00 00 00 00 ZZZ $23.98

17262 2 00 00 00 00 ZZZ $156.20

17262 8 00 00 00 00 ZZZ $31.24

17263 2 00 00 00 00 ZZZ $182.30

17263 8 00 00 00 00 ZZZ $36.46

17264 2 00 00 00 00 ZZZ $200.48

17264 8 00 00 00 00 ZZZ $40.10

17266 2 00 00 00 00 ZZZ $297.81

17266 8 00 00 00 00 ZZZ $59.56

17270 2 00 00 00 00 ZZZ $105.60

17270 8 00 00 00 00 ZZZ $21.12

17271 2 00 00 00 00 ZZZ $127.60

17271 8 00 00 00 00 ZZZ $25.52

Page 23: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

17272 2 00 00 00 00 ZZZ $179.97

17272 8 00 00 00 00 ZZZ $35.99

17273 2 00 00 00 00 ZZZ $206.54

17273 8 00 00 00 00 ZZZ $41.31

17274 2 00 00 00 00 ZZZ $254.57

17274 8 00 00 00 00 ZZZ $50.91

17276 2 00 00 00 00 ZZZ $353.00

17276 8 00 00 00 00 ZZZ $71.00

17280 2 00 00 00 00 ZZZ $130.54

17280 8 00 00 00 00 ZZZ $26.11

17281 2 00 00 00 00 ZZZ $178.00

17281 8 00 00 00 00 ZZZ $36.00

17282 2 00 00 00 00 ZZZ $234.00

17282 8 00 00 00 00 ZZZ $47.00

17283 2 00 00 00 00 ZZZ $287.00

17283 8 00 00 00 00 ZZZ $57.00

17284 2 00 00 00 00 ZZZ $337.00

17284 8 00 00 00 00 ZZZ $67.00

17286 2 00 00 00 00 ZZZ $356.40

17286 8 00 00 00 00 ZZZ $71.28

17311 2 00 00 00 00 ZZZ $765.90

17311 8 00 00 00 00 ZZZ $153.18

17312 2 00 00 00 00 ZZZ $325.33

17312 8 00 00 00 00 ZZZ $65.07

17313 2 00 00 00 00 ZZZ $326.28

17313 8 00 00 00 00 ZZZ $65.26

17314 2 00 00 00 00 ZZZ $309.68

17314 8 00 00 00 00 ZZZ $61.94

17315 2 00 00 00 00 ZZZ $123.30

17315 8 00 00 00 00 ZZZ $24.66

17340 2 00 00 00 00 ZZZ $49.50

17340 8 00 00 00 00 ZZZ $9.90

17999 2 00 00 00 00 ZZZ $0.00

17999 8 00 00 00 00 ZZZ $0.00

19000 2 00 00 00 00 ZZZ $53.90

19000 8 00 00 00 00 ZZZ $10.78

19001 2 00 00 00 00 ZZZ $25.44

19001 8 00 00 00 00 ZZZ $5.09

19020 2 00 00 00 00 ZZZ $257.40

19020 8 00 00 00 00 ZZZ $51.48

Page 24: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

19030 2 00 00 00 00 ZZZ $171.78

19030 8 00 00 00 00 ZZZ $34.36

19081 2 00 00 00 00 ZZZ $663.93

19081 8 00 00 00 00 ZZZ $132.79

19082 2 00 00 00 00 ZZZ $517.52

19082 8 00 00 00 00 ZZZ $103.50

19083 2 00 00 00 00 ZZZ $656.26

19083 8 00 00 00 00 ZZZ $131.25

19084 2 00 00 00 00 ZZZ $509.03

19084 8 00 00 00 00 ZZZ $101.81

19085 2 00 00 00 00 ZZZ $973.85

19085 8 00 00 00 00 ZZZ $194.77

19086 2 00 00 00 00 ZZZ $755.70

19086 8 00 00 00 00 ZZZ $151.14

19100 2 00 00 00 00 ZZZ $97.90

19100 8 00 00 00 00 ZZZ $19.58

19101 2 00 00 00 00 ZZZ $290.40

19101 8 00 00 00 00 ZZZ $58.08

19105 2 00 00 00 00 ZZZ $1,658.98

19105 8 00 00 00 00 ZZZ $331.80

19110 2 00 00 00 00 ZZZ $255.18

19110 8 00 00 00 00 ZZZ $51.04

19112 2 00 00 00 00 ZZZ $226.33

19112 8 00 00 00 00 ZZZ $45.27

19120 2 00 00 00 00 ZZZ $359.70

19120 8 00 00 00 00 ZZZ $71.94

19125 2 00 00 00 00 ZZZ $279.05

19125 8 00 00 00 00 ZZZ $79.00

19126 2 00 00 00 00 ZZZ $213.07

19126 8 00 00 00 00 ZZZ $42.61

19260 2 00 00 00 00 ZZZ $891.00

19260 8 00 00 00 00 ZZZ $178.20

19271 2 00 00 00 00 ZZZ $1,271.60

19271 8 00 00 00 00 ZZZ $254.32

19272 2 00 00 00 00 ZZZ $1,399.20

19272 8 00 00 00 00 ZZZ $279.84

19281 2 00 00 00 00 ZZZ $253.72

19281 8 00 00 00 00 ZZZ $50.74

19282 2 00 00 00 00 ZZZ $168.88

19282 8 00 00 00 00 ZZZ $33.78

Page 25: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

19283 2 00 00 00 00 ZZZ $283.19

19283 8 00 00 00 00 ZZZ $56.64

19284 2 00 00 00 00 ZZZ $198.99

19284 8 00 00 00 00 ZZZ $39.80

19285 2 00 00 00 00 ZZZ $448.55

19285 8 00 00 00 00 ZZZ $89.71

19286 2 00 00 00 00 ZZZ $365.52

19286 8 00 00 00 00 ZZZ $73.10

19287 2 00 00 00 00 ZZZ $820.78

19287 8 00 00 00 00 ZZZ $164.16

19288 2 00 00 00 00 ZZZ $639.15

19288 8 00 00 00 00 ZZZ $127.83

19296 2 00 00 00 00 ZZZ $3,261.12

19296 8 00 00 00 00 ZZZ $652.23

19297 2 00 00 00 00 ZZZ $117.97

19297 8 00 00 00 00 ZZZ $23.59

19298 2 00 00 00 00 ZZZ $1,154.31

19298 8 00 00 00 00 ZZZ $230.87

19300 2 00 00 00 00 ZZZ $615.56

19300 8 00 00 00 00 ZZZ $123.11

19301 2 00 00 00 00 ZZZ $483.73

19301 8 00 00 00 00 ZZZ $96.75

19302 2 00 00 00 00 ZZZ $1,026.73

19302 8 00 00 00 00 ZZZ $205.35

19303 2 00 00 00 00 ZZZ $711.36

19303 8 00 00 00 00 ZZZ $142.27

19304 2 00 00 00 00 ZZZ $641.18

19304 8 00 00 00 00 ZZZ $128.24

19305 2 00 00 00 00 ZZZ $1,203.14

19305 8 00 00 00 00 ZZZ $240.63

19306 2 00 00 00 00 ZZZ $1,233.98

19306 8 00 00 00 00 ZZZ $246.80

19307 2 00 00 00 00 ZZZ $1,248.20

19307 8 00 00 00 00 ZZZ $249.64

19318 2 00 00 00 00 ZZZ $1,343.10

19318 8 00 00 00 00 ZZZ $268.62

19324 2 00 00 00 00 ZZZ $392.15

19324 8 00 00 00 00 ZZZ $78.43

19325 2 00 00 00 00 ZZZ $620.79

19325 8 00 00 00 00 ZZZ $124.16

Page 26: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

19328 2 00 00 00 00 ZZZ $404.89

19328 8 00 00 00 00 ZZZ $80.98

19330 2 00 00 00 00 ZZZ $508.20

19330 8 00 00 00 00 ZZZ $101.64

19340 2 00 00 00 00 ZZZ $710.00

19340 8 00 00 00 00 ZZZ $142.00

19342 2 00 00 00 00 ZZZ $781.00

19342 8 00 00 00 00 ZZZ $156.20

19350 2 00 00 00 00 ZZZ $511.50

19350 8 00 00 00 00 ZZZ $102.30

19355 2 00 00 00 00 ZZZ $451.09

19355 8 00 00 00 00 ZZZ $90.22

19357 2 00 00 00 00 ZZZ $1,288.29

19357 8 00 00 00 00 ZZZ $257.66

19361 2 00 00 00 00 ZZZ $1,727.15

19361 8 00 00 00 00 ZZZ $345.43

19364 2 00 00 00 00 ZZZ $1,974.91

19364 8 00 00 00 00 ZZZ $394.98

19366 2 00 00 00 00 ZZZ $1,624.51

19366 8 00 00 00 00 ZZZ $324.90

19367 2 00 00 00 00 ZZZ $2,035.07

19367 8 00 00 00 00 ZZZ $407.01

19368 2 00 00 00 00 ZZZ $2,304.05

19368 8 00 00 00 00 ZZZ $460.81

19369 2 00 00 00 00 ZZZ $2,201.42

19369 8 00 00 00 00 ZZZ $440.28

19370 2 00 00 00 00 ZZZ $616.54

19370 8 00 00 00 00 ZZZ $123.31

19371 2 00 00 00 00 ZZZ $753.86

19371 8 00 00 00 00 ZZZ $150.77

19380 2 00 00 00 00 ZZZ $753.86

19380 8 00 00 00 00 ZZZ $150.77

19499 2 00 00 00 00 ZZZ $0.00

19499 8 00 00 00 00 ZZZ $0.00

20005 2 00 00 00 00 ZZZ $289.00

20005 8 00 00 00 00 ZZZ $58.00

20100 2 00 00 00 00 ZZZ $581.14

20100 8 00 00 00 00 ZZZ $116.23

20101 2 00 00 00 00 ZZZ $183.34

20101 8 00 00 00 00 ZZZ $36.67

Page 27: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

20102 2 00 00 00 00 ZZZ $225.09

20102 8 00 00 00 00 ZZZ $45.02

20103 2 00 00 00 00 ZZZ $302.25

20103 8 00 00 00 00 ZZZ $60.45

20150 2 00 00 00 00 ZZZ $1,132.56

20150 8 00 00 00 00 ZZZ $226.51

20200 2 00 00 00 00 ZZZ $108.90

20200 8 00 00 00 00 ZZZ $21.78

20205 2 00 00 00 00 ZZZ $156.20

20205 8 00 00 00 00 ZZZ $31.24

20206 2 00 00 00 00 ZZZ $77.10

20206 8 00 00 00 00 ZZZ $15.42

20220 2 00 00 00 00 ZZZ $116.60

20220 8 00 00 00 00 ZZZ $23.32

20225 2 00 00 00 00 ZZZ $175.00

20225 8 00 00 00 00 ZZZ $35.00

20240 2 00 00 00 00 ZZZ $195.80

20240 8 00 00 00 00 ZZZ $39.16

20245 2 00 00 00 00 ZZZ $290.40

20245 8 00 00 00 00 ZZZ $58.08

20250 2 00 00 00 00 ZZZ $381.70

20250 8 00 00 00 00 ZZZ $76.34

20251 2 00 00 00 00 ZZZ $381.70

20251 8 00 00 00 00 ZZZ $76.34

20500 2 00 00 00 00 ZZZ $102.02

20500 8 00 00 00 00 ZZZ $20.40

20501 2 00 00 00 00 ZZZ $179.39

20501 8 00 00 00 00 ZZZ $35.88

20520 2 00 00 00 00 ZZZ $121.69

20520 8 00 00 00 00 ZZZ $24.34

20525 2 00 00 00 00 ZZZ $201.94

20525 8 00 00 00 00 ZZZ $40.39

20526 2 00 00 00 00 ZZZ $70.14

20526 8 00 00 00 00 ZZZ $14.03

20550 2 00 00 00 00 ZZZ $52.19

20550 8 00 00 00 00 ZZZ $10.44

20551 2 00 00 00 00 ZZZ $70.14

20551 8 00 00 00 00 ZZZ $14.03

20552 2 00 00 00 00 ZZZ $70.14

20552 8 00 00 00 00 ZZZ $14.03

Page 28: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

20553 2 00 00 00 00 ZZZ $70.14

20553 8 00 00 00 00 ZZZ $14.03

20555 2 00 00 00 00 ZZZ $408.32

20555 8 00 00 00 00 ZZZ $81.66

20600 2 00 00 00 00 ZZZ $44.00

20600 8 00 00 00 00 ZZZ $8.80

20604 2 00 00 00 00 ZZZ $90.42

20604 8 00 00 00 00 ZZZ $18.08

20605 2 00 00 00 00 ZZZ $58.30

20605 8 00 00 00 00 ZZZ $11.66

20606 2 00 00 00 00 ZZZ $99.61

20606 8 00 00 00 00 ZZZ $19.92

20610 2 00 00 00 00 ZZZ $67.10

20610 8 00 00 00 00 ZZZ $13.42

20611 2 00 00 00 00 ZZZ $113.78

20611 8 00 00 00 00 ZZZ $22.76

20612 2 00 00 00 00 ZZZ $63.12

20612 8 00 00 00 00 ZZZ $12.62

20615 2 00 00 00 00 ZZZ $119.85

20615 8 00 00 00 00 ZZZ $23.97

20650 2 00 00 00 00 ZZZ $156.20

20650 8 00 00 00 00 ZZZ $31.24

20660 2 00 00 00 00 ZZZ $195.80

20660 8 00 00 00 00 ZZZ $39.16

20661 2 00 00 00 00 ZZZ $283.77

20661 8 00 00 00 00 ZZZ $56.75

20662 2 00 00 00 00 ZZZ $333.07

20662 8 00 00 00 00 ZZZ $66.61

20663 2 00 00 00 00 ZZZ $276.95

20663 8 00 00 00 00 ZZZ $55.39

20664 2 00 00 00 00 ZZZ $516.91

20664 8 00 00 00 00 ZZZ $103.38

20665 2 00 00 00 00 ZZZ $73.43

20665 8 00 00 00 00 ZZZ $14.69

20670 2 00 00 00 00 ZZZ $156.20

20670 8 00 00 00 00 ZZZ $31.24

20680 2 00 00 00 00 ZZZ $309.10

20680 8 00 00 00 00 ZZZ $61.82

20690 2 00 00 00 00 ZZZ $316.11

20690 8 00 00 00 00 ZZZ $63.22

Page 29: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

20692 2 00 00 00 00 ZZZ $528.76

20692 8 00 00 00 00 ZZZ $105.75

20693 2 00 00 00 00 ZZZ $343.31

20693 8 00 00 00 00 ZZZ $68.66

20694 2 00 00 00 00 ZZZ $250.98

20694 8 00 00 00 00 ZZZ $50.20

20696 2 00 00 00 00 ZZZ $1,334.51

20696 8 00 00 00 00 ZZZ $266.90

20697 2 00 00 00 00 ZZZ $1,059.03

20697 8 00 00 00 00 ZZZ $211.81

20802 2 00 00 00 00 ZZZ $3,443.69

20802 8 00 00 00 00 ZZZ $688.74

20805 2 00 00 00 00 ZZZ $4,211.71

20805 8 00 00 00 00 ZZZ $842.34

20808 2 00 00 00 00 ZZZ $5,238.09

20808 8 00 00 00 00 ZZZ $1,047.62

20816 2 00 00 00 00 ZZZ $2,583.66

20816 8 00 00 00 00 ZZZ $516.73

20822 2 00 00 00 00 ZZZ $2,134.17

20822 8 00 00 00 00 ZZZ $426.83

20824 2 00 00 00 00 ZZZ $2,583.66

20824 8 00 00 00 00 ZZZ $516.73

20827 2 00 00 00 00 ZZZ $3,022.50

20827 8 00 00 00 00 ZZZ $604.50

20838 2 00 00 00 00 ZZZ $3,443.69

20838 8 00 00 00 00 ZZZ $688.74

20900 2 00 00 00 00 ZZZ $270.65

20900 8 00 00 00 00 ZZZ $54.13

20902 2 00 00 00 00 ZZZ $392.08

20902 8 00 00 00 00 ZZZ $78.42

20910 2 00 00 00 00 ZZZ $290.40

20910 8 00 00 00 00 ZZZ $58.08

20912 2 00 00 00 00 ZZZ $327.30

20912 8 00 00 00 00 ZZZ $65.46

20920 2 00 00 00 00 ZZZ $274.06

20920 8 00 00 00 00 ZZZ $54.81

20922 2 00 00 00 00 ZZZ $377.91

20922 8 00 00 00 00 ZZZ $75.58

20924 2 00 00 00 00 ZZZ $508.20

20924 8 00 00 00 00 ZZZ $101.64

Page 30: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

20926 2 00 00 00 00 ZZZ $330.56

20926 8 00 00 00 00 ZZZ $66.11

20931 2 00 00 00 00 ZZZ $142.27

20931 8 00 00 00 00 ZZZ $28.45

20937 2 00 00 00 00 ZZZ $218.72

20937 8 00 00 00 00 ZZZ $43.74

20938 2 00 00 00 00 ZZZ $236.42

20938 8 00 00 00 00 ZZZ $47.28

20950 2 00 00 00 00 ZZZ $130.54

20950 8 00 00 00 00 ZZZ $26.11

20955 2 00 00 00 00 ZZZ $3,270.27

20955 8 00 00 00 00 ZZZ $654.05

20956 2 00 00 00 00 ZZZ $2,852.64

20956 8 00 00 00 00 ZZZ $570.53

20957 2 00 00 00 00 ZZZ $2,955.27

20957 8 00 00 00 00 ZZZ $591.05

20962 2 00 00 00 00 ZZZ $2,852.64

20962 8 00 00 00 00 ZZZ $570.53

20969 2 00 00 00 00 ZZZ $3,663.12

20969 8 00 00 00 00 ZZZ $732.62

20970 2 00 00 00 00 ZZZ $3,588.81

20970 8 00 00 00 00 ZZZ $717.76

20972 2 00 00 00 00 ZZZ $3,617.12

20972 8 00 00 00 00 ZZZ $723.42

20973 2 00 00 00 00 ZZZ $3,854.25

20973 8 00 00 00 00 ZZZ $770.85

20974 2 00 00 00 00 ZZZ $157.36

20974 8 00 00 00 00 ZZZ $31.47

20975 2 00 00 00 00 ZZZ $243.24

20975 8 00 00 00 00 ZZZ $48.65

20979 2 00 00 00 00 ZZZ $17.74

20979 8 00 00 00 00 ZZZ $3.55

20982 2 00 00 00 00 ZZZ $375.49

20982 8 00 00 00 00 ZZZ $75.10

20983 2 00 00 00 00 ZZZ $6,353.06

20983 8 00 00 00 00 ZZZ $1,270.61

20985 2 00 00 00 00 ZZZ $188.27

20985 8 00 00 00 00 ZZZ $37.65

20999 2 00 00 00 00 ZZZ $0.00

20999 8 00 00 00 00 ZZZ $0.00

Page 31: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21010 2 00 00 00 00 ZZZ $509.31

21010 8 00 00 00 00 ZZZ $101.86

21011 2 00 00 00 00 ZZZ $402.63

21011 8 00 00 00 00 ZZZ $80.53

21012 2 00 00 00 00 ZZZ $431.08

21012 8 00 00 00 00 ZZZ $86.22

21013 2 00 00 00 00 ZZZ $625.52

21013 8 00 00 00 00 ZZZ $125.10

21014 2 00 00 00 00 ZZZ $665.83

21014 8 00 00 00 00 ZZZ $133.17

21015 2 00 00 00 00 ZZZ $511.07

21015 8 00 00 00 00 ZZZ $102.21

21016 2 00 00 00 00 ZZZ $1,338.78

21016 8 00 00 00 00 ZZZ $267.76

21025 2 00 00 00 00 ZZZ $432.99

21025 8 00 00 00 00 ZZZ $86.60

21026 2 00 00 00 00 ZZZ $246.00

21026 8 00 00 00 00 ZZZ $49.20

21029 2 00 00 00 00 ZZZ $416.99

21029 8 00 00 00 00 ZZZ $83.40

21030 2 00 00 00 00 ZZZ $295.83

21030 8 00 00 00 00 ZZZ $59.17

21031 2 00 00 00 00 ZZZ $184.89

21031 8 00 00 00 00 ZZZ $36.98

21032 2 00 00 00 00 ZZZ $203.50

21032 8 00 00 00 00 ZZZ $40.70

21034 2 00 00 00 00 ZZZ $679.78

21034 8 00 00 00 00 ZZZ $135.96

21040 2 00 00 00 00 ZZZ $239.80

21040 8 00 00 00 00 ZZZ $47.96

21044 2 00 00 00 00 ZZZ $1,013.61

21044 8 00 00 00 00 ZZZ $202.72

21045 2 00 00 00 00 ZZZ $1,391.73

21045 8 00 00 00 00 ZZZ $278.35

21046 2 00 00 00 00 ZZZ $1,007.82

21046 8 00 00 00 00 ZZZ $201.56

21047 2 00 00 00 00 ZZZ $1,243.79

21047 8 00 00 00 00 ZZZ $248.76

21048 2 00 00 00 00 ZZZ $1,037.11

21048 8 00 00 00 00 ZZZ $207.42

Page 32: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21049 2 00 00 00 00 ZZZ $1,178.20

21049 8 00 00 00 00 ZZZ $235.64

21050 2 00 00 00 00 ZZZ $953.70

21050 8 00 00 00 00 ZZZ $190.74

21060 2 00 00 00 00 ZZZ $1,029.93

21060 8 00 00 00 00 ZZZ $205.99

21070 2 00 00 00 00 ZZZ $635.80

21070 8 00 00 00 00 ZZZ $127.16

21076 2 00 00 00 00 ZZZ $1,139.64

21076 8 00 00 00 00 ZZZ $227.93

21077 2 00 00 00 00 ZZZ $2,866.80

21077 8 00 00 00 00 ZZZ $573.36

21079 2 00 00 00 00 ZZZ $2,105.85

21079 8 00 00 00 00 ZZZ $421.17

21080 2 00 00 00 00 ZZZ $2,364.22

21080 8 00 00 00 00 ZZZ $472.84

21081 2 00 00 00 00 ZZZ $2,155.41

21081 8 00 00 00 00 ZZZ $431.08

21082 2 00 00 00 00 ZZZ $1,965.20

21082 8 00 00 00 00 ZZZ $393.04

21083 2 00 00 00 00 ZZZ $1,483.16

21083 8 00 00 00 00 ZZZ $296.63

21084 2 00 00 00 00 ZZZ $2,123.61

21084 8 00 00 00 00 ZZZ $424.72

21085 2 00 00 00 00 ZZZ $1,060.70

21085 8 00 00 00 00 ZZZ $212.14

21086 2 00 00 00 00 ZZZ $2,350.06

21086 8 00 00 00 00 ZZZ $470.01

21087 2 00 00 00 00 ZZZ $2,348.92

21087 8 00 00 00 00 ZZZ $469.78

21088 2 00 00 00 00 ZZZ $0.00

21088 8 00 00 00 00 ZZZ $0.00

21089 2 00 00 00 00 ZZZ $0.00

21089 8 00 00 00 00 ZZZ $0.00

21100 2 00 00 00 00 ZZZ $272.80

21100 8 00 00 00 00 ZZZ $54.56

21110 2 00 00 00 00 ZZZ $389.40

21110 8 00 00 00 00 ZZZ $77.88

21116 2 00 00 00 00 ZZZ $123.26

21116 8 00 00 00 00 ZZZ $24.65

Page 33: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21120 2 00 00 00 00 ZZZ $360.80

21120 8 00 00 00 00 ZZZ $72.16

21121 2 00 00 00 00 ZZZ $568.40

21121 8 00 00 00 00 ZZZ $113.68

21122 2 00 00 00 00 ZZZ $625.74

21122 8 00 00 00 00 ZZZ $125.15

21123 2 00 00 00 00 ZZZ $817.56

21123 8 00 00 00 00 ZZZ $163.51

21125 2 00 00 00 00 ZZZ $1,040.88

21125 8 00 00 00 00 ZZZ $208.18

21127 2 00 00 00 00 ZZZ $1,180.00

21127 8 00 00 00 00 ZZZ $236.00

21137 2 00 00 00 00 ZZZ $1,055.45

21137 8 00 00 00 00 ZZZ $211.09

21138 2 00 00 00 00 ZZZ $1,180.00

21138 8 00 00 00 00 ZZZ $236.00

21139 2 00 00 00 00 ZZZ $1,237.86

21139 8 00 00 00 00 ZZZ $247.57

21141 2 00 00 00 00 ZZZ $1,224.59

21141 8 00 00 00 00 ZZZ $244.92

21142 2 00 00 00 00 ZZZ $1,270.59

21142 8 00 00 00 00 ZZZ $254.12

21143 2 00 00 00 00 ZZZ $1,320.14

21143 8 00 00 00 00 ZZZ $264.03

21145 2 00 00 00 00 ZZZ $1,440.47

21145 8 00 00 00 00 ZZZ $288.09

21146 2 00 00 00 00 ZZZ $1,490.03

21146 8 00 00 00 00 ZZZ $298.01

21147 2 00 00 00 00 ZZZ $1,546.66

21147 8 00 00 00 00 ZZZ $309.33

21150 2 00 00 00 00 ZZZ $1,858.11

21150 8 00 00 00 00 ZZZ $371.62

21151 2 00 00 00 00 ZZZ $2,081.08

21151 8 00 00 00 00 ZZZ $416.22

21154 2 00 00 00 00 ZZZ $2,229.73

21154 8 00 00 00 00 ZZZ $445.95

21155 2 00 00 00 00 ZZZ $2,527.03

21155 8 00 00 00 00 ZZZ $505.41

21159 2 00 00 00 00 ZZZ $3,121.09

21159 8 00 00 00 00 ZZZ $624.22

Page 34: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21160 2 00 00 00 00 ZZZ $3,417.50

21160 8 00 00 00 00 ZZZ $683.50

21172 2 00 00 00 00 ZZZ $2,042.15

21172 8 00 00 00 00 ZZZ $408.43

21175 2 00 00 00 00 ZZZ $2,452.70

21175 8 00 00 00 00 ZZZ $490.54

21179 2 00 00 00 00 ZZZ $1,635.14

21179 8 00 00 00 00 ZZZ $327.03

21180 2 00 00 00 00 ZZZ $1,858.11

21180 8 00 00 00 00 ZZZ $371.62

21181 2 00 00 00 00 ZZZ $714.92

21181 8 00 00 00 00 ZZZ $142.98

21182 2 00 00 00 00 ZZZ $2,378.38

21182 8 00 00 00 00 ZZZ $475.68

21183 2 00 00 00 00 ZZZ $2,601.35

21183 8 00 00 00 00 ZZZ $520.27

21184 2 00 00 00 00 ZZZ $2,824.33

21184 8 00 00 00 00 ZZZ $564.87

21188 2 00 00 00 00 ZZZ $1,635.14

21188 8 00 00 00 00 ZZZ $327.03

21193 2 00 00 00 00 ZZZ $1,235.20

21193 8 00 00 00 00 ZZZ $247.04

21194 2 00 00 00 00 ZZZ $1,974.38

21194 8 00 00 00 00 ZZZ $394.88

21195 2 00 00 00 00 ZZZ $1,238.74

21195 8 00 00 00 00 ZZZ $247.75

21196 2 00 00 00 00 ZZZ $1,366.16

21196 8 00 00 00 00 ZZZ $819.69

21198 2 00 00 00 00 ZZZ $1,235.20

21198 8 00 00 00 00 ZZZ $247.04

21199 2 00 00 00 00 ZZZ $1,135.71

21199 8 00 00 00 00 ZZZ $227.14

21206 2 00 00 00 00 ZZZ $953.70

21206 8 00 00 00 00 ZZZ $190.74

21208 2 00 00 00 00 ZZZ $1,180.00

21208 8 00 00 00 00 ZZZ $236.00

21209 2 00 00 00 00 ZZZ $762.89

21209 8 00 00 00 00 ZZZ $152.58

21210 2 00 00 00 00 ZZZ $985.63

21210 8 00 00 00 00 ZZZ $197.13

Page 35: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21215 2 00 00 00 00 ZZZ $1,027.59

21215 8 00 00 00 00 ZZZ $205.52

21230 2 00 00 00 00 ZZZ $891.00

21230 8 00 00 00 00 ZZZ $178.20

21235 2 00 00 00 00 ZZZ $421.19

21235 8 00 00 00 00 ZZZ $84.24

21240 2 00 00 00 00 ZZZ $763.44

21240 8 00 00 00 00 ZZZ $152.69

21242 2 00 00 00 00 ZZZ $1,235.20

21242 8 00 00 00 00 ZZZ $247.04

21243 2 00 00 00 00 ZZZ $1,447.56

21243 8 00 00 00 00 ZZZ $289.51

21244 2 00 00 00 00 ZZZ $1,121.95

21244 8 00 00 00 00 ZZZ $224.39

21245 2 00 00 00 00 ZZZ $983.92

21245 8 00 00 00 00 ZZZ $196.78

21246 2 00 00 00 00 ZZZ $888.35

21246 8 00 00 00 00 ZZZ $177.67

21247 2 00 00 00 00 ZZZ $2,084.62

21247 8 00 00 00 00 ZZZ $416.92

21248 2 00 00 00 00 ZZZ $1,084.47

21248 8 00 00 00 00 ZZZ $216.89

21249 2 00 00 00 00 ZZZ $1,631.27

21249 8 00 00 00 00 ZZZ $326.25

21255 2 00 00 00 00 ZZZ $1,539.57

21255 8 00 00 00 00 ZZZ $307.91

21256 2 00 00 00 00 ZZZ $1,490.03

21256 8 00 00 00 00 ZZZ $298.01

21260 2 00 00 00 00 ZZZ $1,454.20

21260 8 00 00 00 00 ZZZ $290.84

21261 2 00 00 00 00 ZZZ $2,017.38

21261 8 00 00 00 00 ZZZ $403.48

21263 2 00 00 00 00 ZZZ $2,501.84

21263 8 00 00 00 00 ZZZ $500.37

21267 2 00 00 00 00 ZZZ $1,419.24

21267 8 00 00 00 00 ZZZ $283.85

21268 2 00 00 00 00 ZZZ $1,705.92

21268 8 00 00 00 00 ZZZ $341.18

21270 2 00 00 00 00 ZZZ $849.42

21270 8 00 00 00 00 ZZZ $169.88

Page 36: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21275 2 00 00 00 00 ZZZ $852.96

21275 8 00 00 00 00 ZZZ $170.59

21280 2 00 00 00 00 ZZZ $554.25

21280 8 00 00 00 00 ZZZ $110.85

21282 2 00 00 00 00 ZZZ $353.93

21282 8 00 00 00 00 ZZZ $70.79

21295 2 00 00 00 00 ZZZ $105.17

21295 8 00 00 00 00 ZZZ $21.03

21296 2 00 00 00 00 ZZZ $322.07

21296 8 00 00 00 00 ZZZ $64.41

21299 2 00 00 00 00 ZZZ $0.00

21299 8 00 00 00 00 ZZZ $0.00

21310 2 00 00 00 00 ZZZ $103.04

21310 8 00 00 00 00 ZZZ $20.61

21315 2 00 00 00 00 ZZZ $108.90

21315 8 00 00 00 00 ZZZ $21.78

21320 2 00 00 00 00 ZZZ $277.00

21320 8 00 00 00 00 ZZZ $55.00

21325 2 00 00 00 00 ZZZ $345.40

21325 8 00 00 00 00 ZZZ $69.08

21330 2 00 00 00 00 ZZZ $471.90

21330 8 00 00 00 00 ZZZ $94.38

21335 2 00 00 00 00 ZZZ $957.00

21335 8 00 00 00 00 ZZZ $191.00

21336 2 00 00 00 00 ZZZ $285.08

21336 8 00 00 00 00 ZZZ $57.02

21337 2 00 00 00 00 ZZZ $178.60

21337 8 00 00 00 00 ZZZ $35.72

21338 2 00 00 00 00 ZZZ $327.83

21338 8 00 00 00 00 ZZZ $65.57

21339 2 00 00 00 00 ZZZ $410.96

21339 8 00 00 00 00 ZZZ $82.19

21340 2 00 00 00 00 ZZZ $635.80

21340 8 00 00 00 00 ZZZ $127.16

21343 2 00 00 00 00 ZZZ $621.82

21343 8 00 00 00 00 ZZZ $124.36

21344 2 00 00 00 00 ZZZ $1,182.12

21344 8 00 00 00 00 ZZZ $236.42

21345 2 00 00 00 00 ZZZ $635.80

21345 8 00 00 00 00 ZZZ $127.16

Page 37: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21346 2 00 00 00 00 ZZZ $891.00

21346 8 00 00 00 00 ZZZ $178.20

21347 2 00 00 00 00 ZZZ $1,110.12

21347 8 00 00 00 00 ZZZ $222.02

21348 2 00 00 00 00 ZZZ $1,203.35

21348 8 00 00 00 00 ZZZ $240.67

21355 2 00 00 00 00 ZZZ $175.98

21355 8 00 00 00 00 ZZZ $35.20

21356 2 00 00 00 00 ZZZ $492.47

21356 8 00 00 00 00 ZZZ $98.49

21360 2 00 00 00 00 ZZZ $609.40

21360 8 00 00 00 00 ZZZ $121.88

21365 2 00 00 00 00 ZZZ $1,197.90

21365 8 00 00 00 00 ZZZ $239.58

21366 2 00 00 00 00 ZZZ $1,289.20

21366 8 00 00 00 00 ZZZ $257.84

21385 2 00 00 00 00 ZZZ $834.90

21385 8 00 00 00 00 ZZZ $166.98

21386 2 00 00 00 00 ZZZ $834.90

21386 8 00 00 00 00 ZZZ $166.98

21387 2 00 00 00 00 ZZZ $1,069.44

21387 8 00 00 00 00 ZZZ $213.89

21390 2 00 00 00 00 ZZZ $834.90

21390 8 00 00 00 00 ZZZ $166.98

21395 2 00 00 00 00 ZZZ $980.10

21395 8 00 00 00 00 ZZZ $196.02

21400 2 00 00 00 00 ZZZ $225.54

21400 8 00 00 00 00 ZZZ $45.11

21401 2 00 00 00 00 ZZZ $414.37

21401 8 00 00 00 00 ZZZ $82.87

21406 2 00 00 00 00 ZZZ $621.03

21406 8 00 00 00 00 ZZZ $124.21

21407 2 00 00 00 00 ZZZ $763.40

21407 8 00 00 00 00 ZZZ $152.68

21408 2 00 00 00 00 ZZZ $943.89

21408 8 00 00 00 00 ZZZ $188.78

21421 2 00 00 00 00 ZZZ $407.00

21421 8 00 00 00 00 ZZZ $81.40

21422 2 00 00 00 00 ZZZ $635.80

21422 8 00 00 00 00 ZZZ $127.16

Page 38: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21423 2 00 00 00 00 ZZZ $852.96

21423 8 00 00 00 00 ZZZ $170.59

21431 2 00 00 00 00 ZZZ $385.00

21431 8 00 00 00 00 ZZZ $77.00

21432 2 00 00 00 00 ZZZ $635.80

21432 8 00 00 00 00 ZZZ $127.16

21433 2 00 00 00 00 ZZZ $1,180.70

21433 8 00 00 00 00 ZZZ $236.14

21435 2 00 00 00 00 ZZZ $1,399.20

21435 8 00 00 00 00 ZZZ $279.84

21436 2 00 00 00 00 ZZZ $1,773.17

21436 8 00 00 00 00 ZZZ $354.63

21440 2 00 00 00 00 ZZZ $254.10

21440 8 00 00 00 00 ZZZ $50.82

21445 2 00 00 00 00 ZZZ $482.90

21445 8 00 00 00 00 ZZZ $96.58

21450 2 00 00 00 00 ZZZ $254.10

21450 8 00 00 00 00 ZZZ $50.82

21451 2 00 00 00 00 ZZZ $458.69

21451 8 00 00 00 00 ZZZ $91.74

21452 2 00 00 00 00 ZZZ $170.47

21452 8 00 00 00 00 ZZZ $34.09

21453 2 00 00 00 00 ZZZ $510.36

21453 8 00 00 00 00 ZZZ $102.07

21454 2 00 00 00 00 ZZZ $618.23

21454 8 00 00 00 00 ZZZ $123.65

21461 2 00 00 00 00 ZZZ $711.70

21461 8 00 00 00 00 ZZZ $142.34

21462 2 00 00 00 00 ZZZ $974.00

21462 8 00 00 00 00 ZZZ $195.00

21465 2 00 00 00 00 ZZZ $1,222.71

21465 8 00 00 00 00 ZZZ $244.54

21470 2 00 00 00 00 ZZZ $1,410.38

21470 8 00 00 00 00 ZZZ $282.08

21480 2 00 00 00 00 ZZZ $48.78

21480 8 00 00 00 00 ZZZ $9.76

21485 2 00 00 00 00 ZZZ $189.35

21485 8 00 00 00 00 ZZZ $37.87

21490 2 00 00 00 00 ZZZ $515.87

21490 8 00 00 00 00 ZZZ $103.17

Page 39: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21499 2 00 00 00 00 ZZZ $0.00

21499 8 00 00 00 00 ZZZ $0.00

21501 2 00 00 00 00 ZZZ $187.52

21501 8 00 00 00 00 ZZZ $37.50

21502 2 00 00 00 00 ZZZ $381.70

21502 8 00 00 00 00 ZZZ $76.34

21510 2 00 00 00 00 ZZZ $381.70

21510 8 00 00 00 00 ZZZ $76.34

21550 2 00 00 00 00 ZZZ $98.35

21550 8 00 00 00 00 ZZZ $19.67

21552 2 00 00 00 00 ZZZ $575.73

21552 8 00 00 00 00 ZZZ $115.15

21554 2 00 00 00 00 ZZZ $945.63

21554 8 00 00 00 00 ZZZ $189.13

21555 2 00 00 00 00 ZZZ $201.15

21555 8 00 00 00 00 ZZZ $40.23

21556 2 00 00 00 00 ZZZ $257.01

21556 8 00 00 00 00 ZZZ $51.40

21557 2 00 00 00 00 ZZZ $745.80

21557 8 00 00 00 00 ZZZ $149.16

21558 2 00 00 00 00 ZZZ $1,775.08

21558 8 00 00 00 00 ZZZ $355.02

21600 2 00 00 00 00 ZZZ $375.82

21600 8 00 00 00 00 ZZZ $75.16

21610 2 00 00 00 00 ZZZ $871.20

21610 8 00 00 00 00 ZZZ $174.24

21615 2 00 00 00 00 ZZZ $1,089.00

21615 8 00 00 00 00 ZZZ $218.00

21616 2 00 00 00 00 ZZZ $953.70

21616 8 00 00 00 00 ZZZ $190.74

21620 2 00 00 00 00 ZZZ $730.13

21620 8 00 00 00 00 ZZZ $146.03

21627 2 00 00 00 00 ZZZ $494.79

21627 8 00 00 00 00 ZZZ $98.96

21630 2 00 00 00 00 ZZZ $867.03

21630 8 00 00 00 00 ZZZ $173.41

21632 2 00 00 00 00 ZZZ $1,145.10

21632 8 00 00 00 00 ZZZ $229.02

21685 2 00 00 00 00 ZZZ $1,014.43

21685 8 00 00 00 00 ZZZ $202.89

Page 40: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21700 2 00 00 00 00 ZZZ $573.10

21700 8 00 00 00 00 ZZZ $114.62

21705 2 00 00 00 00 ZZZ $726.00

21705 8 00 00 00 00 ZZZ $145.20

21720 2 00 00 00 00 ZZZ $475.20

21720 8 00 00 00 00 ZZZ $95.04

21725 2 00 00 00 00 ZZZ $577.50

21725 8 00 00 00 00 ZZZ $115.50

21740 2 00 00 00 00 ZZZ $1,470.06

21740 8 00 00 00 00 ZZZ $294.01

21742 2 00 00 00 00 ZZZ $0.00

21742 8 00 00 00 00 ZZZ $0.00

21743 2 00 00 00 00 ZZZ $0.00

21743 8 00 00 00 00 ZZZ $0.00

21750 2 00 00 00 00 ZZZ $775.09

21750 8 00 00 00 00 ZZZ $155.02

21811 2 00 00 00 00 ZZZ $715.50

21811 8 00 00 00 00 ZZZ $143.10

21812 2 00 00 00 00 ZZZ $857.95

21812 8 00 00 00 00 ZZZ $171.59

21813 2 00 00 00 00 ZZZ $1,173.01

21813 8 00 00 00 00 ZZZ $234.60

21820 2 00 00 00 00 ZZZ $85.50

21820 8 00 00 00 00 ZZZ $17.10

21825 2 00 00 00 00 ZZZ $635.80

21825 8 00 00 00 00 ZZZ $127.16

21899 2 00 00 00 00 ZZZ $0.00

21899 8 00 00 00 00 ZZZ $0.00

21920 2 00 00 00 00 ZZZ $98.61

21920 8 00 00 00 00 ZZZ $19.72

21925 2 00 00 00 00 ZZZ $296.88

21925 8 00 00 00 00 ZZZ $59.38

21930 2 00 00 00 00 ZZZ $240.49

21930 8 00 00 00 00 ZZZ $48.10

21931 2 00 00 00 00 ZZZ $602.76

21931 8 00 00 00 00 ZZZ $120.55

21932 2 00 00 00 00 ZZZ $866.44

21932 8 00 00 00 00 ZZZ $173.29

21933 2 00 00 00 00 ZZZ $955.59

21933 8 00 00 00 00 ZZZ $191.12

Page 41: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

21935 2 00 00 00 00 ZZZ $762.65

21935 8 00 00 00 00 ZZZ $152.53

21936 2 00 00 00 00 ZZZ $1,849.06

21936 8 00 00 00 00 ZZZ $369.81

22010 2 00 00 00 00 ZZZ $695.05

22010 8 00 00 00 00 ZZZ $139.01

22015 2 00 00 00 00 ZZZ $688.93

22015 8 00 00 00 00 ZZZ $137.79

22100 2 00 00 00 00 ZZZ $506.69

22100 8 00 00 00 00 ZZZ $101.34

22101 2 00 00 00 00 ZZZ $513.77

22101 8 00 00 00 00 ZZZ $102.75

22102 2 00 00 00 00 ZZZ $490.60

22102 8 00 00 00 00 ZZZ $98.12

22103 2 00 00 00 00 ZZZ $183.34

22103 8 00 00 00 00 ZZZ $36.67

22110 2 00 00 00 00 ZZZ $658.01

22110 8 00 00 00 00 ZZZ $131.60

22112 2 00 00 00 00 ZZZ $649.62

22112 8 00 00 00 00 ZZZ $129.92

22114 2 00 00 00 00 ZZZ $632.84

22114 8 00 00 00 00 ZZZ $126.57

22116 2 00 00 00 00 ZZZ $181.92

22116 8 00 00 00 00 ZZZ $36.38

22206 2 00 00 00 00 ZZZ $2,890.97

22206 8 00 00 00 00 ZZZ $578.19

22207 2 00 00 00 00 ZZZ $2,853.98

22207 8 00 00 00 00 ZZZ $570.80

22208 2 00 00 00 00 ZZZ $733.18

22208 8 00 00 00 00 ZZZ $146.64

22210 2 00 00 00 00 ZZZ $1,145.10

22210 8 00 00 00 00 ZZZ $229.02

22212 2 00 00 00 00 ZZZ $1,145.10

22212 8 00 00 00 00 ZZZ $229.02

22214 2 00 00 00 00 ZZZ $1,145.10

22214 8 00 00 00 00 ZZZ $229.02

22216 2 00 00 00 00 ZZZ $445.95

22216 8 00 00 00 00 ZZZ $89.19

22220 2 00 00 00 00 ZZZ $1,073.69

22220 8 00 00 00 00 ZZZ $214.74

Page 42: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

22222 2 00 00 00 00 ZZZ $1,017.50

22222 8 00 00 00 00 ZZZ $203.50

22224 2 00 00 00 00 ZZZ $1,031.47

22224 8 00 00 00 00 ZZZ $206.29

22226 2 00 00 00 00 ZZZ $445.94

22226 8 00 00 00 00 ZZZ $89.19

22310 2 00 00 00 00 ZZZ $209.15

22310 8 00 00 00 00 ZZZ $41.83

22315 2 00 00 00 00 ZZZ $475.20

22315 8 00 00 00 00 ZZZ $95.04

22318 2 00 00 00 00 ZZZ $1,645.60

22318 8 00 00 00 00 ZZZ $329.12

22319 2 00 00 00 00 ZZZ $1,858.89

22319 8 00 00 00 00 ZZZ $371.78

22325 2 00 00 00 00 ZZZ $1,271.60

22325 8 00 00 00 00 ZZZ $254.32

22326 2 00 00 00 00 ZZZ $1,271.60

22326 8 00 00 00 00 ZZZ $254.32

22327 2 00 00 00 00 ZZZ $1,271.60

22327 8 00 00 00 00 ZZZ $254.32

22328 2 00 00 00 00 ZZZ $361.71

22328 8 00 00 00 00 ZZZ $72.34

22505 2 00 00 00 00 ZZZ $124.05

22505 8 00 00 00 00 ZZZ $24.81

22510 2 00 00 00 00 ZZZ $1,551.24

22510 8 00 00 00 00 ZZZ $310.25

22511 2 00 00 00 00 ZZZ $1,534.72

22511 8 00 00 00 00 ZZZ $306.95

22512 2 00 00 00 00 ZZZ $857.08

22512 8 00 00 00 00 ZZZ $171.42

22513 2 00 00 00 00 ZZZ $6,446.48

22513 8 00 00 00 00 ZZZ $1,289.30

22514 2 00 00 00 00 ZZZ $6,419.73

22514 8 00 00 00 00 ZZZ $1,283.96

22515 2 00 00 00 00 ZZZ $3,891.40

22515 8 00 00 00 00 ZZZ $778.28

22532 2 00 00 00 00 ZZZ $1,787.93

22532 8 00 00 00 00 ZZZ $357.59

22533 2 00 00 00 00 ZZZ $1,667.05

22533 8 00 00 00 00 ZZZ $333.41

Page 43: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

22534 2 00 00 00 00 ZZZ $421.20

22534 8 00 00 00 00 ZZZ $84.24

22548 2 00 00 00 00 ZZZ $1,353.78

22548 8 00 00 00 00 ZZZ $270.76

22551 2 00 00 00 00 ZZZ $2,198.17

22551 8 00 00 00 00 ZZZ $439.63

22552 2 00 00 00 00 ZZZ $516.98

22552 8 00 00 00 00 ZZZ $103.40

22554 2 00 00 00 00 ZZZ $1,029.63

22554 8 00 00 00 00 ZZZ $205.93

22556 2 00 00 00 00 ZZZ $1,224.49

22556 8 00 00 00 00 ZZZ $244.90

22558 2 00 00 00 00 ZZZ $1,136.37

22558 8 00 00 00 00 ZZZ $227.27

22585 2 00 00 00 00 ZZZ $501.67

22585 8 00 00 00 00 ZZZ $100.33

22586 2 00 00 00 00 ZZZ $1,863.52

22586 8 00 00 00 00 ZZZ $372.70

22590 2 00 00 00 00 ZZZ $1,129.55

22590 8 00 00 00 00 ZZZ $225.91

22595 2 00 00 00 00 ZZZ $1,844.70

22595 8 00 00 00 00 ZZZ $368.94

22600 2 00 00 00 00 ZZZ $1,003.20

22600 8 00 00 00 00 ZZZ $200.64

22610 2 00 00 00 00 ZZZ $890.37

22610 8 00 00 00 00 ZZZ $178.07

22612 2 00 00 00 00 ZZZ $1,109.36

22612 8 00 00 00 00 ZZZ $221.87

22614 2 00 00 00 00 ZZZ $483.46

22614 8 00 00 00 00 ZZZ $96.69

22630 2 00 00 00 00 ZZZ $1,092.84

22630 8 00 00 00 00 ZZZ $218.57

22632 2 00 00 00 00 ZZZ $410.55

22632 8 00 00 00 00 ZZZ $82.11

22633 2 00 00 00 00 ZZZ $1,965.50

22633 8 00 00 00 00 ZZZ $393.00

22634 2 00 00 00 00 ZZZ $1,187.20

22634 8 00 00 00 00 ZZZ $237.00

22800 2 00 00 00 00 ZZZ $1,808.00

22800 8 00 00 00 00 ZZZ $362.00

Page 44: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

22802 2 00 00 00 00 ZZZ $2,607.00

22802 8 00 00 00 00 ZZZ $521.40

22804 2 00 00 00 00 ZZZ $2,523.49

22804 8 00 00 00 00 ZZZ $504.70

22808 2 00 00 00 00 ZZZ $1,730.70

22808 8 00 00 00 00 ZZZ $346.14

22810 2 00 00 00 00 ZZZ $1,459.70

22810 8 00 00 00 00 ZZZ $291.94

22812 2 00 00 00 00 ZZZ $1,678.60

22812 8 00 00 00 00 ZZZ $335.72

22818 2 00 00 00 00 ZZZ $2,678.59

22818 8 00 00 00 00 ZZZ $535.72

22819 2 00 00 00 00 ZZZ $2,868.77

22819 8 00 00 00 00 ZZZ $573.75

22830 2 00 00 00 00 ZZZ $611.33

22830 8 00 00 00 00 ZZZ $122.27

22840 2 00 00 00 00 ZZZ $804.44

22840 8 00 00 00 00 ZZZ $160.89

22841 2 00 00 00 00 ZZZ $0.00

22841 8 00 00 00 00 ZZZ $0.00

22842 2 00 00 00 00 ZZZ $625.74

22842 8 00 00 00 00 ZZZ $125.15

22843 2 00 00 00 00 ZZZ $778.64

22843 8 00 00 00 00 ZZZ $155.73

22844 2 00 00 00 00 ZZZ $952.06

22844 8 00 00 00 00 ZZZ $190.41

22845 2 00 00 00 00 ZZZ $862.61

22845 8 00 00 00 00 ZZZ $172.52

22846 2 00 00 00 00 ZZZ $649.10

22846 8 00 00 00 00 ZZZ $129.82

22847 2 00 00 00 00 ZZZ $722.01

22847 8 00 00 00 00 ZZZ $144.40

22848 2 00 00 00 00 ZZZ $470.72

22848 8 00 00 00 00 ZZZ $94.14

22849 2 00 00 00 00 ZZZ $1,291.83

22849 8 00 00 00 00 ZZZ $258.37

22850 2 00 00 00 00 ZZZ $519.80

22850 8 00 00 00 00 ZZZ $103.96

22852 2 00 00 00 00 ZZZ $509.31

22852 8 00 00 00 00 ZZZ $101.86

Page 45: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

22853 2 00 00 00 00 ZZZ $300.40

22853 8 00 00 00 00 ZZZ $60.08

22854 2 00 00 00 00 ZZZ $388.88

22854 8 00 00 00 00 ZZZ $77.78

22855 2 00 00 00 00 ZZZ $710.99

22855 8 00 00 00 00 ZZZ $142.20

22856 2 00 00 00 00 ZZZ $1,836.12

22856 8 00 00 00 00 ZZZ $367.22

22857 2 00 00 00 00 ZZZ $1,727.56

22857 8 00 00 00 00 ZZZ $345.51

22858 2 00 00 00 00 ZZZ $540.71

22858 8 00 00 00 00 ZZZ $108.15

22859 2 00 00 00 00 ZZZ $388.88

22859 8 00 00 00 00 ZZZ $77.78

22861 2 00 00 00 00 ZZZ $2,268.59

22861 8 00 00 00 00 ZZZ $453.72

22862 2 00 00 00 00 ZZZ $2,114.39

22862 8 00 00 00 00 ZZZ $422.88

22864 2 00 00 00 00 ZZZ $2,112.06

22864 8 00 00 00 00 ZZZ $422.41

22865 2 00 00 00 00 ZZZ $2,057.72

22865 8 00 00 00 00 ZZZ $411.54

22899 2 00 00 00 00 ZZZ $0.00

22899 8 00 00 00 00 ZZZ $0.00

22900 2 00 00 00 00 ZZZ $334.40

22900 8 00 00 00 00 ZZZ $66.88

22901 2 00 00 00 00 ZZZ $852.68

22901 8 00 00 00 00 ZZZ $170.54

22902 2 00 00 00 00 ZZZ $537.79

22902 8 00 00 00 00 ZZZ $107.56

22903 2 00 00 00 00 ZZZ $563.40

22903 8 00 00 00 00 ZZZ $112.68

22904 2 00 00 00 00 ZZZ $1,335.46

22904 8 00 00 00 00 ZZZ $267.09

22905 2 00 00 00 00 ZZZ $1,730.98

22905 8 00 00 00 00 ZZZ $346.20

22999 2 00 00 00 00 ZZZ $0.00

22999 8 00 00 00 00 ZZZ $0.00

23000 2 00 00 00 00 ZZZ $330.00

23000 8 00 00 00 00 ZZZ $66.00

Page 46: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

23020 2 00 00 00 00 ZZZ $711.70

23020 8 00 00 00 00 ZZZ $142.34

23030 2 00 00 00 00 ZZZ $196.17

23030 8 00 00 00 00 ZZZ $39.23

23031 2 00 00 00 00 ZZZ $152.37

23031 8 00 00 00 00 ZZZ $30.47

23035 2 00 00 00 00 ZZZ $520.85

23035 8 00 00 00 00 ZZZ $104.17

23040 2 00 00 00 00 ZZZ $595.10

23040 8 00 00 00 00 ZZZ $119.02

23044 2 00 00 00 00 ZZZ $422.24

23044 8 00 00 00 00 ZZZ $84.45

23065 2 00 00 00 00 ZZZ $105.43

23065 8 00 00 00 00 ZZZ $21.09

23066 2 00 00 00 00 ZZZ $220.04

23066 8 00 00 00 00 ZZZ $44.01

23071 2 00 00 00 00 ZZZ $535.42

23071 8 00 00 00 00 ZZZ $107.08

23073 2 00 00 00 00 ZZZ $887.78

23073 8 00 00 00 00 ZZZ $177.56

23075 2 00 00 00 00 ZZZ $150.80

23075 8 00 00 00 00 ZZZ $30.16

23076 2 00 00 00 00 ZZZ $635.80

23076 8 00 00 00 00 ZZZ $127.16

23077 2 00 00 00 00 ZZZ $745.80

23077 8 00 00 00 00 ZZZ $149.16

23078 2 00 00 00 00 ZZZ $1,801.16

23078 8 00 00 00 00 ZZZ $360.23

23100 2 00 00 00 00 ZZZ $522.50

23100 8 00 00 00 00 ZZZ $104.50

23101 2 00 00 00 00 ZZZ $359.70

23101 8 00 00 00 00 ZZZ $71.94

23105 2 00 00 00 00 ZZZ $834.90

23105 8 00 00 00 00 ZZZ $166.98

23106 2 00 00 00 00 ZZZ $769.30

23106 8 00 00 00 00 ZZZ $153.86

23107 2 00 00 00 00 ZZZ $507.47

23107 8 00 00 00 00 ZZZ $101.49

23120 2 00 00 00 00 ZZZ $385.00

23120 8 00 00 00 00 ZZZ $77.00

Page 47: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

23125 2 00 00 00 00 ZZZ $595.10

23125 8 00 00 00 00 ZZZ $119.02

23130 2 00 00 00 00 ZZZ $482.90

23130 8 00 00 00 00 ZZZ $96.58

23140 2 00 00 00 00 ZZZ $432.30

23140 8 00 00 00 00 ZZZ $86.46

23145 2 00 00 00 00 ZZZ $544.50

23145 8 00 00 00 00 ZZZ $108.90

23146 2 00 00 00 00 ZZZ $745.98

23146 8 00 00 00 00 ZZZ $149.20

23150 2 00 00 00 00 ZZZ $508.20

23150 8 00 00 00 00 ZZZ $101.64

23155 2 00 00 00 00 ZZZ $826.10

23155 8 00 00 00 00 ZZZ $165.22

23156 2 00 00 00 00 ZZZ $763.40

23156 8 00 00 00 00 ZZZ $152.68

23170 2 00 00 00 00 ZZZ $384.47

23170 8 00 00 00 00 ZZZ $76.89

23172 2 00 00 00 00 ZZZ $380.54

23172 8 00 00 00 00 ZZZ $76.11

23174 2 00 00 00 00 ZZZ $711.70

23174 8 00 00 00 00 ZZZ $142.34

23180 2 00 00 00 00 ZZZ $483.08

23180 8 00 00 00 00 ZZZ $96.62

23182 2 00 00 00 00 ZZZ $527.14

23182 8 00 00 00 00 ZZZ $105.43

23184 2 00 00 00 00 ZZZ $711.70

23184 8 00 00 00 00 ZZZ $142.34

23190 2 00 00 00 00 ZZZ $391.29

23190 8 00 00 00 00 ZZZ $78.26

23195 2 00 00 00 00 ZZZ $826.10

23195 8 00 00 00 00 ZZZ $165.22

23200 2 00 00 00 00 ZZZ $763.40

23200 8 00 00 00 00 ZZZ $152.68

23210 2 00 00 00 00 ZZZ $1,160.47

23210 8 00 00 00 00 ZZZ $232.09

23220 2 00 00 00 00 ZZZ $1,271.60

23220 8 00 00 00 00 ZZZ $254.32

23330 2 00 00 00 00 ZZZ $159.50

23330 8 00 00 00 00 ZZZ $31.90

Page 48: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

23333 2 00 00 00 00 ZZZ $593.76

23333 8 00 00 00 00 ZZZ $118.75

23334 2 00 00 00 00 ZZZ $1,376.68

23334 8 00 00 00 00 ZZZ $275.34

23335 2 00 00 00 00 ZZZ $1,645.18

23335 8 00 00 00 00 ZZZ $329.04

23350 2 00 00 00 00 ZZZ $148.70

23350 8 00 00 00 00 ZZZ $29.74

23395 2 00 00 00 00 ZZZ $1,107.70

23395 8 00 00 00 00 ZZZ $221.54

23397 2 00 00 00 00 ZZZ $1,486.38

23397 8 00 00 00 00 ZZZ $297.28

23400 2 00 00 00 00 ZZZ $1,107.70

23400 8 00 00 00 00 ZZZ $221.54

23405 2 00 00 00 00 ZZZ $476.26

23405 8 00 00 00 00 ZZZ $95.25

23406 2 00 00 00 00 ZZZ $711.70

23406 8 00 00 00 00 ZZZ $142.34

23410 2 00 00 00 00 ZZZ $834.90

23410 8 00 00 00 00 ZZZ $166.98

23412 2 00 00 00 00 ZZZ $834.90

23412 8 00 00 00 00 ZZZ $166.98

23415 2 00 00 00 00 ZZZ $522.50

23415 8 00 00 00 00 ZZZ $104.50

23420 2 00 00 00 00 ZZZ $1,052.70

23420 8 00 00 00 00 ZZZ $210.54

23430 2 00 00 00 00 ZZZ $661.10

23430 8 00 00 00 00 ZZZ $132.22

23440 2 00 00 00 00 ZZZ $595.10

23440 8 00 00 00 00 ZZZ $119.02

23450 2 00 00 00 00 ZZZ $1,252.90

23450 8 00 00 00 00 ZZZ $250.58

23455 2 00 00 00 00 ZZZ $1,325.50

23455 8 00 00 00 00 ZZZ $265.10

23460 2 00 00 00 00 ZZZ $1,144.00

23460 8 00 00 00 00 ZZZ $228.80

23462 2 00 00 00 00 ZZZ $1,465.39

23462 8 00 00 00 00 ZZZ $293.08

23465 2 00 00 00 00 ZZZ $962.50

23465 8 00 00 00 00 ZZZ $192.50

Page 49: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

23466 2 00 00 00 00 ZZZ $794.12

23466 8 00 00 00 00 ZZZ $158.82

23470 2 00 00 00 00 ZZZ $1,017.50

23470 8 00 00 00 00 ZZZ $203.50

23472 2 00 00 00 00 ZZZ $1,633.50

23472 8 00 00 00 00 ZZZ $326.70

23473 2 00 00 00 00 ZZZ $1,897.01

23473 8 00 00 00 00 ZZZ $379.40

23474 2 00 00 00 00 ZZZ $2,052.91

23474 8 00 00 00 00 ZZZ $410.58

23480 2 00 00 00 00 ZZZ $552.06

23480 8 00 00 00 00 ZZZ $110.41

23485 2 00 00 00 00 ZZZ $704.17

23485 8 00 00 00 00 ZZZ $140.83

23490 2 00 00 00 00 ZZZ $618.41

23490 8 00 00 00 00 ZZZ $123.68

23491 2 00 00 00 00 ZZZ $745.87

23491 8 00 00 00 00 ZZZ $149.17

23500 2 00 00 00 00 ZZZ $125.10

23500 8 00 00 00 00 ZZZ $25.02

23505 2 00 00 00 00 ZZZ $221.10

23505 8 00 00 00 00 ZZZ $44.22

23515 2 00 00 00 00 ZZZ $511.50

23515 8 00 00 00 00 ZZZ $102.30

23520 2 00 00 00 00 ZZZ $124.57

23520 8 00 00 00 00 ZZZ $24.91

23525 2 00 00 00 00 ZZZ $190.67

23525 8 00 00 00 00 ZZZ $38.13

23530 2 00 00 00 00 ZZZ $595.10

23530 8 00 00 00 00 ZZZ $119.02

23532 2 00 00 00 00 ZZZ $661.10

23532 8 00 00 00 00 ZZZ $132.22

23540 2 00 00 00 00 ZZZ $133.23

23540 8 00 00 00 00 ZZZ $26.65

23545 2 00 00 00 00 ZZZ $176.76

23545 8 00 00 00 00 ZZZ $35.35

23550 2 00 00 00 00 ZZZ $742.72

23550 8 00 00 00 00 ZZZ $148.54

23552 2 00 00 00 00 ZZZ $891.00

23552 8 00 00 00 00 ZZZ $178.00

Page 50: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

23570 2 00 00 00 00 ZZZ $130.34

23570 8 00 00 00 00 ZZZ $26.07

23575 2 00 00 00 00 ZZZ $228.80

23575 8 00 00 00 00 ZZZ $45.76

23585 2 00 00 00 00 ZZZ $661.10

23585 8 00 00 00 00 ZZZ $132.22

23600 2 00 00 00 00 ZZZ $189.35

23600 8 00 00 00 00 ZZZ $37.87

23605 2 00 00 00 00 ZZZ $319.00

23605 8 00 00 00 00 ZZZ $63.80

23615 2 00 00 00 00 ZZZ $715.00

23615 8 00 00 00 00 ZZZ $143.00

23616 2 00 00 00 00 ZZZ $1,214.40

23616 8 00 00 00 00 ZZZ $242.88

23620 2 00 00 00 00 ZZZ $170.21

23620 8 00 00 00 00 ZZZ $34.04

23625 2 00 00 00 00 ZZZ $254.10

23625 8 00 00 00 00 ZZZ $50.82

23630 2 00 00 00 00 ZZZ $490.60

23630 8 00 00 00 00 ZZZ $98.12

23650 2 00 00 00 00 ZZZ $186.73

23650 8 00 00 00 00 ZZZ $37.35

23655 2 00 00 00 00 ZZZ $265.10

23655 8 00 00 00 00 ZZZ $53.02

23660 2 00 00 00 00 ZZZ $825.00

23660 8 00 00 00 00 ZZZ $165.00

23665 2 00 00 00 00 ZZZ $262.52

23665 8 00 00 00 00 ZZZ $52.50

23670 2 00 00 00 00 ZZZ $744.70

23670 8 00 00 00 00 ZZZ $148.94

23675 2 00 00 00 00 ZZZ $327.83

23675 8 00 00 00 00 ZZZ $65.57

23680 2 00 00 00 00 ZZZ $980.10

23680 8 00 00 00 00 ZZZ $196.02

23700 2 00 00 00 00 ZZZ $141.10

23700 8 00 00 00 00 ZZZ $28.22

23800 2 00 00 00 00 ZZZ $1,197.90

23800 8 00 00 00 00 ZZZ $239.58

23802 2 00 00 00 00 ZZZ $1,325.50

23802 8 00 00 00 00 ZZZ $265.10

Page 51: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

23900 2 00 00 00 00 ZZZ $1,415.70

23900 8 00 00 00 00 ZZZ $283.14

23920 2 00 00 00 00 ZZZ $1,107.70

23920 8 00 00 00 00 ZZZ $221.54

23921 2 00 00 00 00 ZZZ $359.70

23921 8 00 00 00 00 ZZZ $71.94

23929 2 00 00 00 00 ZZZ $0.00

23929 8 00 00 00 00 ZZZ $0.00

23930 2 00 00 00 00 ZZZ $172.83

23930 8 00 00 00 00 ZZZ $34.57

23931 2 00 00 00 00 ZZZ $122.74

23931 8 00 00 00 00 ZZZ $24.55

23935 2 00 00 00 00 ZZZ $381.70

23935 8 00 00 00 00 ZZZ $76.34

24000 2 00 00 00 00 ZZZ $544.50

24000 8 00 00 00 00 ZZZ $108.90

24006 2 00 00 00 00 ZZZ $779.90

24006 8 00 00 00 00 ZZZ $155.98

24065 2 00 00 00 00 ZZZ $132.18

24065 8 00 00 00 00 ZZZ $26.44

24066 2 00 00 00 00 ZZZ $283.77

24066 8 00 00 00 00 ZZZ $56.75

24071 2 00 00 00 00 ZZZ $519.77

24071 8 00 00 00 00 ZZZ $103.95

24073 2 00 00 00 00 ZZZ $892.05

24073 8 00 00 00 00 ZZZ $178.41

24075 2 00 00 00 00 ZZZ $228.95

24075 8 00 00 00 00 ZZZ $45.79

24076 2 00 00 00 00 ZZZ $315.70

24076 8 00 00 00 00 ZZZ $63.14

24077 2 00 00 00 00 ZZZ $745.80

24077 8 00 00 00 00 ZZZ $149.16

24079 2 00 00 00 00 ZZZ $1,660.79

24079 8 00 00 00 00 ZZZ $332.16

24100 2 00 00 00 00 ZZZ $407.00

24100 8 00 00 00 00 ZZZ $81.40

24101 2 00 00 00 00 ZZZ $626.62

24101 8 00 00 00 00 ZZZ $125.32

24102 2 00 00 00 00 ZZZ $711.70

24102 8 00 00 00 00 ZZZ $142.34

Page 52: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

24105 2 00 00 00 00 ZZZ $381.38

24105 8 00 00 00 00 ZZZ $76.28

24110 2 00 00 00 00 ZZZ $711.70

24110 8 00 00 00 00 ZZZ $142.34

24115 2 00 00 00 00 ZZZ $951.59

24115 8 00 00 00 00 ZZZ $190.32

24116 2 00 00 00 00 ZZZ $762.30

24116 8 00 00 00 00 ZZZ $152.46

24120 2 00 00 00 00 ZZZ $490.60

24120 8 00 00 00 00 ZZZ $98.12

24125 2 00 00 00 00 ZZZ $710.00

24125 8 00 00 00 00 ZZZ $142.00

24126 2 00 00 00 00 ZZZ $595.10

24126 8 00 00 00 00 ZZZ $119.02

24130 2 00 00 00 00 ZZZ $490.60

24130 8 00 00 00 00 ZZZ $98.12

24134 2 00 00 00 00 ZZZ $635.80

24134 8 00 00 00 00 ZZZ $127.16

24136 2 00 00 00 00 ZZZ $635.80

24136 8 00 00 00 00 ZZZ $127.16

24138 2 00 00 00 00 ZZZ $635.80

24138 8 00 00 00 00 ZZZ $127.16

24140 2 00 00 00 00 ZZZ $711.70

24140 8 00 00 00 00 ZZZ $142.34

24145 2 00 00 00 00 ZZZ $544.50

24145 8 00 00 00 00 ZZZ $108.90

24147 2 00 00 00 00 ZZZ $434.04

24147 8 00 00 00 00 ZZZ $86.81

24149 2 00 00 00 00 ZZZ $1,153.80

24149 8 00 00 00 00 ZZZ $230.76

24150 2 00 00 00 00 ZZZ $1,271.60

24150 8 00 00 00 00 ZZZ $254.32

24152 2 00 00 00 00 ZZZ $1,097.41

24152 8 00 00 00 00 ZZZ $219.48

24155 2 00 00 00 00 ZZZ $853.60

24155 8 00 00 00 00 ZZZ $170.72

24160 2 00 00 00 00 ZZZ $383.69

24160 8 00 00 00 00 ZZZ $76.74

24164 2 00 00 00 00 ZZZ $388.30

24164 8 00 00 00 00 ZZZ $77.66

Page 53: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

24200 2 00 00 00 00 ZZZ $116.71

24200 8 00 00 00 00 ZZZ $23.34

24201 2 00 00 00 00 ZZZ $268.29

24201 8 00 00 00 00 ZZZ $53.66

24220 2 00 00 00 00 ZZZ $176.76

24220 8 00 00 00 00 ZZZ $35.35

24300 2 00 00 00 00 ZZZ $401.39

24300 8 00 00 00 00 ZZZ $80.28

24301 2 00 00 00 00 ZZZ $517.96

24301 8 00 00 00 00 ZZZ $103.59

24305 2 00 00 00 00 ZZZ $359.70

24305 8 00 00 00 00 ZZZ $71.94

24310 2 00 00 00 00 ZZZ $304.48

24310 8 00 00 00 00 ZZZ $60.90

24320 2 00 00 00 00 ZZZ $635.80

24320 8 00 00 00 00 ZZZ $127.16

24330 2 00 00 00 00 ZZZ $711.70

24330 8 00 00 00 00 ZZZ $142.34

24331 2 00 00 00 00 ZZZ $962.50

24331 8 00 00 00 00 ZZZ $192.50

24332 2 00 00 00 00 ZZZ $554.86

24332 8 00 00 00 00 ZZZ $110.97

24340 2 00 00 00 00 ZZZ $595.10

24340 8 00 00 00 00 ZZZ $119.02

24341 2 00 00 00 00 ZZZ $637.77

24341 8 00 00 00 00 ZZZ $127.55

24342 2 00 00 00 00 ZZZ $853.60

24342 8 00 00 00 00 ZZZ $170.72

24343 2 00 00 00 00 ZZZ $733.08

24343 8 00 00 00 00 ZZZ $146.62

24344 2 00 00 00 00 ZZZ $1,106.41

24344 8 00 00 00 00 ZZZ $221.28

24345 2 00 00 00 00 ZZZ $733.08

24345 8 00 00 00 00 ZZZ $146.62

24346 2 00 00 00 00 ZZZ $1,106.41

24346 8 00 00 00 00 ZZZ $221.28

24357 2 00 00 00 00 ZZZ $537.79

24357 8 00 00 00 00 ZZZ $107.56

24358 2 00 00 00 00 ZZZ $632.64

24358 8 00 00 00 00 ZZZ $126.53

Page 54: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

24359 2 00 00 00 00 ZZZ $781.07

24359 8 00 00 00 00 ZZZ $156.21

24360 2 00 00 00 00 ZZZ $1,017.50

24360 8 00 00 00 00 ZZZ $203.50

24361 2 00 00 00 00 ZZZ $1,259.50

24361 8 00 00 00 00 ZZZ $251.90

24362 2 00 00 00 00 ZZZ $1,017.50

24362 8 00 00 00 00 ZZZ $203.50

24363 2 00 00 00 00 ZZZ $1,259.50

24363 8 00 00 00 00 ZZZ $251.90

24365 2 00 00 00 00 ZZZ $490.60

24365 8 00 00 00 00 ZZZ $98.12

24366 2 00 00 00 00 ZZZ $544.50

24366 8 00 00 00 00 ZZZ $108.90

24370 2 00 00 00 00 ZZZ $1,791.02

24370 8 00 00 00 00 ZZZ $358.20

24371 2 00 00 00 00 ZZZ $2,070.14

24371 8 00 00 00 00 ZZZ $414.03

24400 2 00 00 00 00 ZZZ $711.70

24400 8 00 00 00 00 ZZZ $142.34

24410 2 00 00 00 00 ZZZ $980.10

24410 8 00 00 00 00 ZZZ $196.02

24420 2 00 00 00 00 ZZZ $753.74

24420 8 00 00 00 00 ZZZ $150.75

24430 2 00 00 00 00 ZZZ $943.80

24430 8 00 00 00 00 ZZZ $188.76

24435 2 00 00 00 00 ZZZ $1,107.70

24435 8 00 00 00 00 ZZZ $221.54

24470 2 00 00 00 00 ZZZ $490.60

24470 8 00 00 00 00 ZZZ $98.12

24495 2 00 00 00 00 ZZZ $925.00

24495 8 00 00 00 00 ZZZ $185.00

24498 2 00 00 00 00 ZZZ $641.23

24498 8 00 00 00 00 ZZZ $128.25

24500 2 00 00 00 00 ZZZ $217.41

24500 8 00 00 00 00 ZZZ $43.48

24505 2 00 00 00 00 ZZZ $344.61

24505 8 00 00 00 00 ZZZ $68.92

24515 2 00 00 00 00 ZZZ $781.00

24515 8 00 00 00 00 ZZZ $156.20

Page 55: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

24516 2 00 00 00 00 ZZZ $781.00

24516 8 00 00 00 00 ZZZ $156.20

24530 2 00 00 00 00 ZZZ $240.75

24530 8 00 00 00 00 ZZZ $48.15

24535 2 00 00 00 00 ZZZ $421.30

24535 8 00 00 00 00 ZZZ $84.26

24538 2 00 00 00 00 ZZZ $506.69

24538 8 00 00 00 00 ZZZ $101.34

24545 2 00 00 00 00 ZZZ $781.00

24545 8 00 00 00 00 ZZZ $156.20

24546 2 00 00 00 00 ZZZ $781.00

24546 8 00 00 00 00 ZZZ $156.20

24560 2 00 00 00 00 ZZZ $197.22

24560 8 00 00 00 00 ZZZ $39.44

24565 2 00 00 00 00 ZZZ $328.87

24565 8 00 00 00 00 ZZZ $65.77

24566 2 00 00 00 00 ZZZ $420.14

24566 8 00 00 00 00 ZZZ $84.03

24575 2 00 00 00 00 ZZZ $519.80

24575 8 00 00 00 00 ZZZ $103.96

24576 2 00 00 00 00 ZZZ $196.17

24576 8 00 00 00 00 ZZZ $39.23

24577 2 00 00 00 00 ZZZ $347.49

24577 8 00 00 00 00 ZZZ $69.50

24579 2 00 00 00 00 ZZZ $744.70

24579 8 00 00 00 00 ZZZ $148.94

24582 2 00 00 00 00 ZZZ $460.79

24582 8 00 00 00 00 ZZZ $92.16

24586 2 00 00 00 00 ZZZ $980.10

24586 8 00 00 00 00 ZZZ $196.02

24587 2 00 00 00 00 ZZZ $1,144.00

24587 8 00 00 00 00 ZZZ $228.80

24600 2 00 00 00 00 ZZZ $258.07

24600 8 00 00 00 00 ZZZ $51.61

24605 2 00 00 00 00 ZZZ $330.00

24605 8 00 00 00 00 ZZZ $66.00

24615 2 00 00 00 00 ZZZ $544.50

24615 8 00 00 00 00 ZZZ $108.90

24620 2 00 00 00 00 ZZZ $333.59

24620 8 00 00 00 00 ZZZ $66.72

Page 56: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

24635 2 00 00 00 00 ZZZ $962.50

24635 8 00 00 00 00 ZZZ $192.50

24640 2 00 00 00 00 ZZZ $208.00

24640 8 00 00 00 00 ZZZ $42.00

24650 2 00 00 00 00 ZZZ $176.24

24650 8 00 00 00 00 ZZZ $35.25

24655 2 00 00 00 00 ZZZ $355.30

24655 8 00 00 00 00 ZZZ $71.06

24665 2 00 00 00 00 ZZZ $511.50

24665 8 00 00 00 00 ZZZ $102.30

24666 2 00 00 00 00 ZZZ $726.00

24666 8 00 00 00 00 ZZZ $145.20

24670 2 00 00 00 00 ZZZ $182.01

24670 8 00 00 00 00 ZZZ $36.40

24675 2 00 00 00 00 ZZZ $301.60

24675 8 00 00 00 00 ZZZ $60.32

24685 2 00 00 00 00 ZZZ $544.50

24685 8 00 00 00 00 ZZZ $108.90

24800 2 00 00 00 00 ZZZ $891.00

24800 8 00 00 00 00 ZZZ $178.20

24802 2 00 00 00 00 ZZZ $953.70

24802 8 00 00 00 00 ZZZ $190.74

24900 2 00 00 00 00 ZZZ $613.80

24900 8 00 00 00 00 ZZZ $122.76

24920 2 00 00 00 00 ZZZ $506.95

24920 8 00 00 00 00 ZZZ $101.39

24925 2 00 00 00 00 ZZZ $438.90

24925 8 00 00 00 00 ZZZ $87.78

24930 2 00 00 00 00 ZZZ $552.84

24930 8 00 00 00 00 ZZZ $110.57

24931 2 00 00 00 00 ZZZ $661.10

24931 8 00 00 00 00 ZZZ $132.22

24935 2 00 00 00 00 ZZZ $791.24

24935 8 00 00 00 00 ZZZ $158.25

24940 2 00 00 00 00 ZZZ $867.00

24940 8 00 00 00 00 ZZZ $174.00

24999 2 00 00 00 00 ZZZ $0.00

24999 8 00 00 00 00 ZZZ $0.00

25000 2 00 00 00 00 ZZZ $388.30

25000 8 00 00 00 00 ZZZ $77.66

Page 57: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25001 2 00 00 00 00 ZZZ $335.39

25001 8 00 00 00 00 ZZZ $67.08

25020 2 00 00 00 00 ZZZ $381.70

25020 8 00 00 00 00 ZZZ $76.34

25023 2 00 00 00 00 ZZZ $642.01

25023 8 00 00 00 00 ZZZ $128.40

25024 2 00 00 00 00 ZZZ $1,099.74

25024 8 00 00 00 00 ZZZ $219.95

25025 2 00 00 00 00 ZZZ $799.89

25025 8 00 00 00 00 ZZZ $159.98

25028 2 00 00 00 00 ZZZ $300.84

25028 8 00 00 00 00 ZZZ $60.17

25031 2 00 00 00 00 ZZZ $236.30

25031 8 00 00 00 00 ZZZ $47.26

25035 2 00 00 00 00 ZZZ $473.12

25035 8 00 00 00 00 ZZZ $94.62

25040 2 00 00 00 00 ZZZ $389.98

25040 8 00 00 00 00 ZZZ $78.00

25065 2 00 00 00 00 ZZZ $108.90

25065 8 00 00 00 00 ZZZ $21.78

25066 2 00 00 00 00 ZZZ $227.38

25066 8 00 00 00 00 ZZZ $45.48

25071 2 00 00 00 00 ZZZ $544.43

25071 8 00 00 00 00 ZZZ $108.89

25073 2 00 00 00 00 ZZZ $677.69

25073 8 00 00 00 00 ZZZ $135.54

25075 2 00 00 00 00 ZZZ $220.30

25075 8 00 00 00 00 ZZZ $44.06

25076 2 00 00 00 00 ZZZ $380.12

25076 8 00 00 00 00 ZZZ $76.02

25077 2 00 00 00 00 ZZZ $745.80

25077 8 00 00 00 00 ZZZ $149.16

25078 2 00 00 00 00 ZZZ $1,450.23

25078 8 00 00 00 00 ZZZ $290.05

25085 2 00 00 00 00 ZZZ $490.60

25085 8 00 00 00 00 ZZZ $98.12

25100 2 00 00 00 00 ZZZ $443.30

25100 8 00 00 00 00 ZZZ $88.66

25101 2 00 00 00 00 ZZZ $490.60

25101 8 00 00 00 00 ZZZ $98.12

Page 58: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25105 2 00 00 00 00 ZZZ $544.50

25105 8 00 00 00 00 ZZZ $108.90

25107 2 00 00 00 00 ZZZ $490.60

25107 8 00 00 00 00 ZZZ $98.12

25109 2 00 00 00 00 ZZZ $538.72

25109 8 00 00 00 00 ZZZ $107.74

25110 2 00 00 00 00 ZZZ $374.00

25110 8 00 00 00 00 ZZZ $74.80

25111 2 00 00 00 00 ZZZ $377.19

25111 8 00 00 00 00 ZZZ $75.44

25112 2 00 00 00 00 ZZZ $427.90

25112 8 00 00 00 00 ZZZ $85.58

25115 2 00 00 00 00 ZZZ $595.10

25115 8 00 00 00 00 ZZZ $119.02

25116 2 00 00 00 00 ZZZ $858.00

25116 8 00 00 00 00 ZZZ $172.00

25118 2 00 00 00 00 ZZZ $427.90

25118 8 00 00 00 00 ZZZ $85.58

25119 2 00 00 00 00 ZZZ $544.50

25119 8 00 00 00 00 ZZZ $108.90

25120 2 00 00 00 00 ZZZ $544.50

25120 8 00 00 00 00 ZZZ $108.90

25125 2 00 00 00 00 ZZZ $661.10

25125 8 00 00 00 00 ZZZ $132.22

25126 2 00 00 00 00 ZZZ $577.50

25126 8 00 00 00 00 ZZZ $115.50

25130 2 00 00 00 00 ZZZ $317.90

25130 8 00 00 00 00 ZZZ $63.58

25135 2 00 00 00 00 ZZZ $536.55

25135 8 00 00 00 00 ZZZ $107.31

25136 2 00 00 00 00 ZZZ $465.06

25136 8 00 00 00 00 ZZZ $93.01

25145 2 00 00 00 00 ZZZ $635.80

25145 8 00 00 00 00 ZZZ $127.16

25150 2 00 00 00 00 ZZZ $490.60

25150 8 00 00 00 00 ZZZ $98.12

25151 2 00 00 00 00 ZZZ $544.50

25151 8 00 00 00 00 ZZZ $108.90

25170 2 00 00 00 00 ZZZ $898.98

25170 8 00 00 00 00 ZZZ $179.80

Page 59: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25210 2 00 00 00 00 ZZZ $443.30

25210 8 00 00 00 00 ZZZ $88.66

25215 2 00 00 00 00 ZZZ $572.00

25215 8 00 00 00 00 ZZZ $114.40

25230 2 00 00 00 00 ZZZ $359.70

25230 8 00 00 00 00 ZZZ $71.94

25240 2 00 00 00 00 ZZZ $464.20

25240 8 00 00 00 00 ZZZ $92.84

25246 2 00 00 00 00 ZZZ $162.34

25246 8 00 00 00 00 ZZZ $32.47

25248 2 00 00 00 00 ZZZ $296.88

25248 8 00 00 00 00 ZZZ $59.38

25250 2 00 00 00 00 ZZZ $420.20

25250 8 00 00 00 00 ZZZ $84.04

25251 2 00 00 00 00 ZZZ $771.56

25251 8 00 00 00 00 ZZZ $154.31

25259 2 00 00 00 00 ZZZ $396.85

25259 8 00 00 00 00 ZZZ $79.37

25260 2 00 00 00 00 ZZZ $464.99

25260 8 00 00 00 00 ZZZ $93.00

25263 2 00 00 00 00 ZZZ $497.51

25263 8 00 00 00 00 ZZZ $99.50

25265 2 00 00 00 00 ZZZ $708.40

25265 8 00 00 00 00 ZZZ $141.68

25270 2 00 00 00 00 ZZZ $382.90

25270 8 00 00 00 00 ZZZ $76.58

25272 2 00 00 00 00 ZZZ $464.20

25272 8 00 00 00 00 ZZZ $92.84

25274 2 00 00 00 00 ZZZ $555.50

25274 8 00 00 00 00 ZZZ $111.10

25275 2 00 00 00 00 ZZZ $707.09

25275 8 00 00 00 00 ZZZ $141.42

25280 2 00 00 00 00 ZZZ $431.94

25280 8 00 00 00 00 ZZZ $86.39

25290 2 00 00 00 00 ZZZ $369.79

25290 8 00 00 00 00 ZZZ $73.96

25295 2 00 00 00 00 ZZZ $393.65

25295 8 00 00 00 00 ZZZ $78.73

25300 2 00 00 00 00 ZZZ $817.30

25300 8 00 00 00 00 ZZZ $163.46

Page 60: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25301 2 00 00 00 00 ZZZ $678.70

25301 8 00 00 00 00 ZZZ $135.74

25310 2 00 00 00 00 ZZZ $689.70

25310 8 00 00 00 00 ZZZ $137.94

25312 2 00 00 00 00 ZZZ $762.30

25312 8 00 00 00 00 ZZZ $152.46

25315 2 00 00 00 00 ZZZ $907.50

25315 8 00 00 00 00 ZZZ $181.50

25316 2 00 00 00 00 ZZZ $1,107.70

25316 8 00 00 00 00 ZZZ $221.54

25320 2 00 00 00 00 ZZZ $568.32

25320 8 00 00 00 00 ZZZ $113.66

25332 2 00 00 00 00 ZZZ $711.70

25332 8 00 00 00 00 ZZZ $142.34

25335 2 00 00 00 00 ZZZ $1,236.00

25335 8 00 00 00 00 ZZZ $247.20

25337 2 00 00 00 00 ZZZ $799.88

25337 8 00 00 00 00 ZZZ $159.98

25350 2 00 00 00 00 ZZZ $577.50

25350 8 00 00 00 00 ZZZ $115.50

25355 2 00 00 00 00 ZZZ $628.10

25355 8 00 00 00 00 ZZZ $125.62

25360 2 00 00 00 00 ZZZ $577.50

25360 8 00 00 00 00 ZZZ $115.50

25365 2 00 00 00 00 ZZZ $853.60

25365 8 00 00 00 00 ZZZ $170.72

25370 2 00 00 00 00 ZZZ $1,145.10

25370 8 00 00 00 00 ZZZ $229.02

25375 2 00 00 00 00 ZZZ $1,271.60

25375 8 00 00 00 00 ZZZ $254.32

25390 2 00 00 00 00 ZZZ $621.56

25390 8 00 00 00 00 ZZZ $124.31

25391 2 00 00 00 00 ZZZ $804.09

25391 8 00 00 00 00 ZZZ $160.82

25392 2 00 00 00 00 ZZZ $771.04

25392 8 00 00 00 00 ZZZ $154.21

25393 2 00 00 00 00 ZZZ $889.90

25393 8 00 00 00 00 ZZZ $177.98

25394 2 00 00 00 00 ZZZ $824.24

25394 8 00 00 00 00 ZZZ $164.85

Page 61: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25400 2 00 00 00 00 ZZZ $662.73

25400 8 00 00 00 00 ZZZ $132.55

25405 2 00 00 00 00 ZZZ $827.17

25405 8 00 00 00 00 ZZZ $165.43

25415 2 00 00 00 00 ZZZ $889.90

25415 8 00 00 00 00 ZZZ $177.98

25420 2 00 00 00 00 ZZZ $1,107.70

25420 8 00 00 00 00 ZZZ $221.54

25425 2 00 00 00 00 ZZZ $871.20

25425 8 00 00 00 00 ZZZ $174.24

25426 2 00 00 00 00 ZZZ $1,107.70

25426 8 00 00 00 00 ZZZ $221.54

25430 2 00 00 00 00 ZZZ $727.30

25430 8 00 00 00 00 ZZZ $145.46

25431 2 00 00 00 00 ZZZ $718.64

25431 8 00 00 00 00 ZZZ $143.73

25440 2 00 00 00 00 ZZZ $781.00

25440 8 00 00 00 00 ZZZ $156.20

25441 2 00 00 00 00 ZZZ $1,051.16

25441 8 00 00 00 00 ZZZ $210.23

25442 2 00 00 00 00 ZZZ $595.10

25442 8 00 00 00 00 ZZZ $119.02

25443 2 00 00 00 00 ZZZ $853.60

25443 8 00 00 00 00 ZZZ $170.72

25444 2 00 00 00 00 ZZZ $711.70

25444 8 00 00 00 00 ZZZ $142.34

25445 2 00 00 00 00 ZZZ $711.70

25445 8 00 00 00 00 ZZZ $142.34

25446 2 00 00 00 00 ZZZ $1,271.60

25446 8 00 00 00 00 ZZZ $254.32

25447 2 00 00 00 00 ZZZ $870.66

25447 8 00 00 00 00 ZZZ $174.13

25449 2 00 00 00 00 ZZZ $707.58

25449 8 00 00 00 00 ZZZ $141.52

25450 2 00 00 00 00 ZZZ $479.93

25450 8 00 00 00 00 ZZZ $95.99

25455 2 00 00 00 00 ZZZ $535.80

25455 8 00 00 00 00 ZZZ $107.16

25490 2 00 00 00 00 ZZZ $569.11

25490 8 00 00 00 00 ZZZ $113.82

Page 62: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25491 2 00 00 00 00 ZZZ $599.79

25491 8 00 00 00 00 ZZZ $119.96

25492 2 00 00 00 00 ZZZ $713.90

25500 2 00 00 00 00 ZZZ $180.70

25500 8 00 00 00 00 ZZZ $36.14

25505 2 00 00 00 00 ZZZ $318.91

25505 8 00 00 00 00 ZZZ $63.78

25515 2 00 00 00 00 ZZZ $650.10

25515 8 00 00 00 00 ZZZ $130.02

25520 2 00 00 00 00 ZZZ $385.00

25520 8 00 00 00 00 ZZZ $77.00

25525 2 00 00 00 00 ZZZ $687.50

25525 8 00 00 00 00 ZZZ $137.50

25526 2 00 00 00 00 ZZZ $770.52

25526 8 00 00 00 00 ZZZ $154.10

25530 2 00 00 00 00 ZZZ $172.83

25530 8 00 00 00 00 ZZZ $34.57

25535 2 00 00 00 00 ZZZ $314.45

25535 8 00 00 00 00 ZZZ $62.89

25545 2 00 00 00 00 ZZZ $817.30

25545 8 00 00 00 00 ZZZ $163.46

25560 2 00 00 00 00 ZZZ $180.44

25560 8 00 00 00 00 ZZZ $36.09

25565 2 00 00 00 00 ZZZ $449.90

25565 8 00 00 00 00 ZZZ $89.98

25574 2 00 00 00 00 ZZZ $917.33

25574 8 00 00 00 00 ZZZ $183.47

25575 2 00 00 00 00 ZZZ $1,031.79

25575 8 00 00 00 00 ZZZ $206.36

25600 2 00 00 00 00 ZZZ $198.00

25600 8 00 00 00 00 ZZZ $39.60

25605 2 00 00 00 00 ZZZ $374.00

25605 8 00 00 00 00 ZZZ $74.80

25606 2 00 00 00 00 ZZZ $857.90

25606 8 00 00 00 00 ZZZ $171.58

25607 2 00 00 00 00 ZZZ $817.59

25607 8 00 00 00 00 ZZZ $163.52

25608 2 00 00 00 00 ZZZ $854.44

25608 8 00 00 00 00 ZZZ $170.89

25609 2 00 00 00 00 ZZZ $1,095.14

Page 63: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25609 8 00 00 00 00 ZZZ $219.03

25622 2 00 00 00 00 ZZZ $189.09

25622 8 00 00 00 00 ZZZ $37.82

25624 2 00 00 00 00 ZZZ $298.19

25624 8 00 00 00 00 ZZZ $59.64

25628 2 00 00 00 00 ZZZ $464.20

25628 8 00 00 00 00 ZZZ $92.84

25630 2 00 00 00 00 ZZZ $197.48

25630 8 00 00 00 00 ZZZ $39.50

25635 2 00 00 00 00 ZZZ $287.44

25635 8 00 00 00 00 ZZZ $57.49

25645 2 00 00 00 00 ZZZ $464.20

25645 8 00 00 00 00 ZZZ $92.84

25650 2 00 00 00 00 ZZZ $209.28

25650 8 00 00 00 00 ZZZ $41.86

25651 2 00 00 00 00 ZZZ $432.33

25651 8 00 00 00 00 ZZZ $86.47

25652 2 00 00 00 00 ZZZ $638.19

25652 8 00 00 00 00 ZZZ $127.64

25660 2 00 00 00 00 ZZZ $319.00

25660 8 00 00 00 00 ZZZ $63.80

25670 2 00 00 00 00 ZZZ $544.50

25670 8 00 00 00 00 ZZZ $108.90

25671 2 00 00 00 00 ZZZ $595.39

25671 8 00 00 00 00 ZZZ $119.08

25675 2 00 00 00 00 ZZZ $275.90

25675 8 00 00 00 00 ZZZ $55.18

25676 2 00 00 00 00 ZZZ $464.20

25676 8 00 00 00 00 ZZZ $92.84

25680 2 00 00 00 00 ZZZ $449.90

25680 8 00 00 00 00 ZZZ $89.98

25685 2 00 00 00 00 ZZZ $834.90

25685 8 00 00 00 00 ZZZ $166.98

25690 2 00 00 00 00 ZZZ $530.20

25690 8 00 00 00 00 ZZZ $106.04

25695 2 00 00 00 00 ZZZ $715.00

25695 8 00 00 00 00 ZZZ $143.00

25800 2 00 00 00 00 ZZZ $661.10

25800 8 00 00 00 00 ZZZ $132.22

25805 2 00 00 00 00 ZZZ $762.30

Page 64: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

25805 8 00 00 00 00 ZZZ $152.46

25810 2 00 00 00 00 ZZZ $871.20

25810 8 00 00 00 00 ZZZ $174.24

25820 2 00 00 00 00 ZZZ $439.29

25820 8 00 00 00 00 ZZZ $87.86

25825 2 00 00 00 00 ZZZ $533.70

25825 8 00 00 00 00 ZZZ $106.74

25830 2 00 00 00 00 ZZZ $799.88

25830 8 00 00 00 00 ZZZ $159.98

25900 2 00 00 00 00 ZZZ $661.10

25900 8 00 00 00 00 ZZZ $132.22

25905 2 00 00 00 00 ZZZ $544.50

25905 8 00 00 00 00 ZZZ $108.90

25907 2 00 00 00 00 ZZZ $476.53

25907 8 00 00 00 00 ZZZ $95.31

25909 2 00 00 00 00 ZZZ $661.10

25909 8 00 00 00 00 ZZZ $132.22

25915 2 00 00 00 00 ZZZ $1,107.70

25915 8 00 00 00 00 ZZZ $221.54

25920 2 00 00 00 00 ZZZ $595.10

25920 8 00 00 00 00 ZZZ $119.02

25922 2 00 00 00 00 ZZZ $427.90

25922 8 00 00 00 00 ZZZ $85.58

25924 2 00 00 00 00 ZZZ $704.00

25924 8 00 00 00 00 ZZZ $140.80

25927 2 00 00 00 00 ZZZ $661.10

25927 8 00 00 00 00 ZZZ $132.22

25929 2 00 00 00 00 ZZZ $410.30

25929 8 00 00 00 00 ZZZ $82.06

25931 2 00 00 00 00 ZZZ $609.40

25931 8 00 00 00 00 ZZZ $121.88

25999 2 00 00 00 00 ZZZ $0.00

25999 8 00 00 00 00 ZZZ $0.00

26010 2 00 00 00 00 ZZZ $107.53

26010 8 00 00 00 00 ZZZ $21.51

26011 2 00 00 00 00 ZZZ $178.20

26011 8 00 00 00 00 ZZZ $35.64

26020 2 00 00 00 00 ZZZ $316.02

26020 8 00 00 00 00 ZZZ $63.20

26025 2 00 00 00 00 ZZZ $332.55

Page 65: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26025 8 00 00 00 00 ZZZ $66.51

26030 2 00 00 00 00 ZZZ $445.50

26030 8 00 00 00 00 ZZZ $89.10

26034 2 00 00 00 00 ZZZ $393.13

26034 8 00 00 00 00 ZZZ $78.63

26035 2 00 00 00 00 ZZZ $594.59

26035 8 00 00 00 00 ZZZ $118.92

26037 2 00 00 00 00 ZZZ $435.09

26037 8 00 00 00 00 ZZZ $87.02

26040 2 00 00 00 00 ZZZ $260.42

26040 8 00 00 00 00 ZZZ $52.08

26045 2 00 00 00 00 ZZZ $374.00

26045 8 00 00 00 00 ZZZ $74.80

26055 2 00 00 00 00 ZZZ $315.70

26055 8 00 00 00 00 ZZZ $63.14

26060 2 00 00 00 00 ZZZ $178.20

26060 8 00 00 00 00 ZZZ $35.64

26070 2 00 00 00 00 ZZZ $348.70

26070 8 00 00 00 00 ZZZ $69.74

26075 2 00 00 00 00 ZZZ $286.12

26075 8 00 00 00 00 ZZZ $57.22

26080 2 00 00 00 00 ZZZ $297.93

26080 8 00 00 00 00 ZZZ $59.59

26100 2 00 00 00 00 ZZZ $348.70

26100 8 00 00 00 00 ZZZ $69.74

26105 2 00 00 00 00 ZZZ $296.35

26105 8 00 00 00 00 ZZZ $59.27

26110 2 00 00 00 00 ZZZ $265.67

26110 8 00 00 00 00 ZZZ $53.13

26111 2 00 00 00 00 ZZZ $527.35

26111 8 00 00 00 00 ZZZ $105.47

26113 2 00 00 00 00 ZZZ $693.81

26113 8 00 00 00 00 ZZZ $138.76

26115 2 00 00 00 00 ZZZ $221.09

26115 8 00 00 00 00 ZZZ $44.22

26116 2 00 00 00 00 ZZZ $370.70

26116 8 00 00 00 00 ZZZ $74.14

26117 2 00 00 00 00 ZZZ $480.20

26117 8 00 00 00 00 ZZZ $96.04

26118 2 00 00 00 00 ZZZ $1,362.49

Page 66: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26118 8 00 00 00 00 ZZZ $272.50

26121 2 00 00 00 00 ZZZ $762.30

26121 8 00 00 00 00 ZZZ $152.46

26123 2 00 00 00 00 ZZZ $853.60

26123 8 00 00 00 00 ZZZ $170.72

26125 2 00 00 00 00 ZZZ $452.84

26125 8 00 00 00 00 ZZZ $90.57

26130 2 00 00 00 00 ZZZ $443.30

26130 8 00 00 00 00 ZZZ $88.66

26135 2 00 00 00 00 ZZZ $490.60

26135 8 00 00 00 00 ZZZ $98.12

26140 2 00 00 00 00 ZZZ $403.88

26140 8 00 00 00 00 ZZZ $80.78

26145 2 00 00 00 00 ZZZ $511.50

26145 8 00 00 00 00 ZZZ $102.30

26160 2 00 00 00 00 ZZZ $337.70

26160 8 00 00 00 00 ZZZ $67.54

26170 2 00 00 00 00 ZZZ $326.70

26170 8 00 00 00 00 ZZZ $65.34

26180 2 00 00 00 00 ZZZ $326.70

26180 8 00 00 00 00 ZZZ $65.34

26185 2 00 00 00 00 ZZZ $397.82

26185 8 00 00 00 00 ZZZ $79.56

26200 2 00 00 00 00 ZZZ $364.02

26200 8 00 00 00 00 ZZZ $72.80

26205 2 00 00 00 00 ZZZ $479.60

26205 8 00 00 00 00 ZZZ $95.92

26210 2 00 00 00 00 ZZZ $348.02

26210 8 00 00 00 00 ZZZ $69.60

26215 2 00 00 00 00 ZZZ $435.87

26215 8 00 00 00 00 ZZZ $87.17

26230 2 00 00 00 00 ZZZ $381.06

26230 8 00 00 00 00 ZZZ $76.21

26235 2 00 00 00 00 ZZZ $368.21

26235 8 00 00 00 00 ZZZ $73.64

26236 2 00 00 00 00 ZZZ $335.43

26236 8 00 00 00 00 ZZZ $67.09

26250 2 00 00 00 00 ZZZ $485.18

26250 8 00 00 00 00 ZZZ $97.04

26260 2 00 00 00 00 ZZZ $451.61

Page 67: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26260 8 00 00 00 00 ZZZ $90.32

26262 2 00 00 00 00 ZZZ $380.02

26262 8 00 00 00 00 ZZZ $76.00

26320 2 00 00 00 00 ZZZ $366.30

26320 8 00 00 00 00 ZZZ $73.26

26340 2 00 00 00 00 ZZZ $303.22

26340 8 00 00 00 00 ZZZ $60.64

26350 2 00 00 00 00 ZZZ $511.50

26350 8 00 00 00 00 ZZZ $102.30

26352 2 00 00 00 00 ZZZ $645.70

26352 8 00 00 00 00 ZZZ $129.14

26356 2 00 00 00 00 ZZZ $628.10

26356 8 00 00 00 00 ZZZ $125.62

26357 2 00 00 00 00 ZZZ $729.30

26357 8 00 00 00 00 ZZZ $145.86

26358 2 00 00 00 00 ZZZ $775.09

26358 8 00 00 00 00 ZZZ $155.02

26370 2 00 00 00 00 ZZZ $901.71

26370 8 00 00 00 00 ZZZ $180.34

26372 2 00 00 00 00 ZZZ $1,251.85

26372 8 00 00 00 00 ZZZ $250.37

26373 2 00 00 00 00 ZZZ $851.40

26373 8 00 00 00 00 ZZZ $170.28

26390 2 00 00 00 00 ZZZ $552.06

26390 8 00 00 00 00 ZZZ $110.41

26392 2 00 00 00 00 ZZZ $683.45

26392 8 00 00 00 00 ZZZ $136.69

26410 2 00 00 00 00 ZZZ $370.70

26410 8 00 00 00 00 ZZZ $74.14

26412 2 00 00 00 00 ZZZ $445.05

26412 8 00 00 00 00 ZZZ $89.01

26415 2 00 00 00 00 ZZZ $504.06

26415 8 00 00 00 00 ZZZ $100.81

26416 2 00 00 00 00 ZZZ $685.81

26416 8 00 00 00 00 ZZZ $137.16

26418 2 00 00 00 00 ZZZ $374.00

26418 8 00 00 00 00 ZZZ $74.80

26420 2 00 00 00 00 ZZZ $482.30

26420 8 00 00 00 00 ZZZ $96.46

26426 2 00 00 00 00 ZZZ $552.20

Page 68: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26426 8 00 00 00 00 ZZZ $110.44

26428 2 00 00 00 00 ZZZ $595.10

26428 8 00 00 00 00 ZZZ $119.02

26432 2 00 00 00 00 ZZZ $460.90

26432 8 00 00 00 00 ZZZ $92.18

26433 2 00 00 00 00 ZZZ $407.00

26433 8 00 00 00 00 ZZZ $81.40

26434 2 00 00 00 00 ZZZ $628.10

26434 8 00 00 00 00 ZZZ $125.62

26437 2 00 00 00 00 ZZZ $370.05

26437 8 00 00 00 00 ZZZ $74.01

26440 2 00 00 00 00 ZZZ $381.06

26440 8 00 00 00 00 ZZZ $76.21

26442 2 00 00 00 00 ZZZ $489.90

26442 8 00 00 00 00 ZZZ $97.98

26445 2 00 00 00 00 ZZZ $353.00

26445 8 00 00 00 00 ZZZ $70.60

26449 2 00 00 00 00 ZZZ $635.80

26449 8 00 00 00 00 ZZZ $127.16

26450 2 00 00 00 00 ZZZ $239.80

26450 8 00 00 00 00 ZZZ $47.96

26455 2 00 00 00 00 ZZZ $217.15

26455 8 00 00 00 00 ZZZ $43.43

26460 2 00 00 00 00 ZZZ $206.40

26460 8 00 00 00 00 ZZZ $41.28

26471 2 00 00 00 00 ZZZ $407.00

26471 8 00 00 00 00 ZZZ $81.40

26474 2 00 00 00 00 ZZZ $361.40

26474 8 00 00 00 00 ZZZ $72.28

26476 2 00 00 00 00 ZZZ $381.70

26476 8 00 00 00 00 ZZZ $76.34

26477 2 00 00 00 00 ZZZ $381.70

26477 8 00 00 00 00 ZZZ $76.34

26478 2 00 00 00 00 ZZZ $381.70

26478 8 00 00 00 00 ZZZ $76.34

26479 2 00 00 00 00 ZZZ $388.93

26479 8 00 00 00 00 ZZZ $77.79

26480 2 00 00 00 00 ZZZ $490.60

26480 8 00 00 00 00 ZZZ $98.12

26483 2 00 00 00 00 ZZZ $661.10

Page 69: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26483 8 00 00 00 00 ZZZ $132.22

26485 2 00 00 00 00 ZZZ $672.10

26485 8 00 00 00 00 ZZZ $134.42

26489 2 00 00 00 00 ZZZ $834.90

26489 8 00 00 00 00 ZZZ $166.98

26490 2 00 00 00 00 ZZZ $722.70

26490 8 00 00 00 00 ZZZ $144.54

26492 2 00 00 00 00 ZZZ $834.90

26492 8 00 00 00 00 ZZZ $166.98

26494 2 00 00 00 00 ZZZ $744.70

26494 8 00 00 00 00 ZZZ $148.94

26496 2 00 00 00 00 ZZZ $799.88

26496 8 00 00 00 00 ZZZ $159.98

26497 2 00 00 00 00 ZZZ $585.20

26497 8 00 00 00 00 ZZZ $117.04

26498 2 00 00 00 00 ZZZ $784.94

26498 8 00 00 00 00 ZZZ $156.99

26499 2 00 00 00 00 ZZZ $674.30

26499 8 00 00 00 00 ZZZ $134.86

26500 2 00 00 00 00 ZZZ $372.15

26500 8 00 00 00 00 ZZZ $74.43

26502 2 00 00 00 00 ZZZ $443.30

26502 8 00 00 00 00 ZZZ $88.66

26508 2 00 00 00 00 ZZZ $449.90

26508 8 00 00 00 00 ZZZ $89.98

26510 2 00 00 00 00 ZZZ $407.01

26510 8 00 00 00 00 ZZZ $81.40

26516 2 00 00 00 00 ZZZ $417.78

26516 8 00 00 00 00 ZZZ $83.56

26517 2 00 00 00 00 ZZZ $563.20

26517 8 00 00 00 00 ZZZ $112.64

26518 2 00 00 00 00 ZZZ $689.70

26518 8 00 00 00 00 ZZZ $137.94

26520 2 00 00 00 00 ZZZ $427.90

26520 8 00 00 00 00 ZZZ $85.58

26525 2 00 00 00 00 ZZZ $392.60

26525 8 00 00 00 00 ZZZ $78.52

26530 2 00 00 00 00 ZZZ $536.80

26530 8 00 00 00 00 ZZZ $107.36

26531 2 00 00 00 00 ZZZ $672.10

Page 70: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26531 8 00 00 00 00 ZZZ $134.42

26535 2 00 00 00 00 ZZZ $381.70

26535 8 00 00 00 00 ZZZ $76.34

26536 2 00 00 00 00 ZZZ $781.00

26536 8 00 00 00 00 ZZZ $156.20

26540 2 00 00 00 00 ZZZ $595.10

26540 8 00 00 00 00 ZZZ $119.02

26541 2 00 00 00 00 ZZZ $628.10

26541 8 00 00 00 00 ZZZ $125.62

26542 2 00 00 00 00 ZZZ $426.96

26542 8 00 00 00 00 ZZZ $85.39

26545 2 00 00 00 00 ZZZ $464.20

26545 8 00 00 00 00 ZZZ $92.84

26546 2 00 00 00 00 ZZZ $740.41

26546 8 00 00 00 00 ZZZ $148.08

26548 2 00 00 00 00 ZZZ $483.35

26548 8 00 00 00 00 ZZZ $96.67

26550 2 00 00 00 00 ZZZ $1,109.36

26550 8 00 00 00 00 ZZZ $221.87

26551 2 00 00 00 00 ZZZ $3,854.95

26551 8 00 00 00 00 ZZZ $770.99

26553 2 00 00 00 00 ZZZ $3,829.47

26553 8 00 00 00 00 ZZZ $765.89

26554 2 00 00 00 00 ZZZ $4,569.17

26554 8 00 00 00 00 ZZZ $913.83

26555 2 00 00 00 00 ZZZ $934.17

26555 8 00 00 00 00 ZZZ $186.83

26556 2 00 00 00 00 ZZZ $3,893.18

26556 8 00 00 00 00 ZZZ $778.64

26560 2 00 00 00 00 ZZZ $464.20

26560 8 00 00 00 00 ZZZ $92.84

26561 2 00 00 00 00 ZZZ $693.00

26561 8 00 00 00 00 ZZZ $138.60

26562 2 00 00 00 00 ZZZ $834.90

26562 8 00 00 00 00 ZZZ $166.98

26565 2 00 00 00 00 ZZZ $443.30

26565 8 00 00 00 00 ZZZ $88.66

26567 2 00 00 00 00 ZZZ $443.30

26567 8 00 00 00 00 ZZZ $88.66

26568 2 00 00 00 00 ZZZ $597.95

Page 71: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26568 8 00 00 00 00 ZZZ $119.59

26580 2 00 00 00 00 ZZZ $944.92

26580 8 00 00 00 00 ZZZ $188.98

26587 2 00 00 00 00 ZZZ $518.56

26587 8 00 00 00 00 ZZZ $103.71

26590 2 00 00 00 00 ZZZ $958.82

26590 8 00 00 00 00 ZZZ $191.76

26591 2 00 00 00 00 ZZZ $257.01

26591 8 00 00 00 00 ZZZ $51.40

26593 2 00 00 00 00 ZZZ $400.64

26593 8 00 00 00 00 ZZZ $80.13

26596 2 00 00 00 00 ZZZ $750.32

26596 8 00 00 00 00 ZZZ $150.06

26600 2 00 00 00 00 ZZZ $155.26

26600 8 00 00 00 00 ZZZ $31.05

26605 2 00 00 00 00 ZZZ $225.50

26605 8 00 00 00 00 ZZZ $45.10

26607 2 00 00 00 00 ZZZ $296.88

26607 8 00 00 00 00 ZZZ $59.38

26608 2 00 00 00 00 ZZZ $398.20

26608 8 00 00 00 00 ZZZ $79.64

26615 2 00 00 00 00 ZZZ $443.30

26615 8 00 00 00 00 ZZZ $88.66

26641 2 00 00 00 00 ZZZ $230.27

26641 8 00 00 00 00 ZZZ $46.05

26645 2 00 00 00 00 ZZZ $270.39

26645 8 00 00 00 00 ZZZ $54.08

26650 2 00 00 00 00 ZZZ $317.60

26650 8 00 00 00 00 ZZZ $63.52

26665 2 00 00 00 00 ZZZ $595.10

26665 8 00 00 00 00 ZZZ $119.02

26670 2 00 00 00 00 ZZZ $220.30

26670 8 00 00 00 00 ZZZ $44.06

26675 2 00 00 00 00 ZZZ $298.71

26675 8 00 00 00 00 ZZZ $59.74

26676 2 00 00 00 00 ZZZ $327.56

26676 8 00 00 00 00 ZZZ $65.51

26685 2 00 00 00 00 ZZZ $464.20

26685 8 00 00 00 00 ZZZ $92.84

26686 2 00 00 00 00 ZZZ $611.58

Page 72: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26686 8 00 00 00 00 ZZZ $122.32

26700 2 00 00 00 00 ZZZ $173.61

26700 8 00 00 00 00 ZZZ $34.72

26705 2 00 00 00 00 ZZZ $241.80

26705 8 00 00 00 00 ZZZ $48.36

26706 2 00 00 00 00 ZZZ $279.83

26706 8 00 00 00 00 ZZZ $55.97

26715 2 00 00 00 00 ZZZ $443.30

26715 8 00 00 00 00 ZZZ $88.66

26720 2 00 00 00 00 ZZZ $96.25

26720 8 00 00 00 00 ZZZ $19.25

26725 2 00 00 00 00 ZZZ $184.80

26725 8 00 00 00 00 ZZZ $36.96

26727 2 00 00 00 00 ZZZ $396.00

26727 8 00 00 00 00 ZZZ $79.20

26735 2 00 00 00 00 ZZZ $427.90

26735 8 00 00 00 00 ZZZ $85.58

26740 2 00 00 00 00 ZZZ $112.51

26740 8 00 00 00 00 ZZZ $22.50

26742 2 00 00 00 00 ZZZ $247.57

26742 8 00 00 00 00 ZZZ $49.51

26746 2 00 00 00 00 ZZZ $326.78

26746 8 00 00 00 00 ZZZ $65.36

26750 2 00 00 00 00 ZZZ $98.87

26750 8 00 00 00 00 ZZZ $19.77

26755 2 00 00 00 00 ZZZ $158.93

26755 8 00 00 00 00 ZZZ $31.79

26756 2 00 00 00 00 ZZZ $241.80

26756 8 00 00 00 00 ZZZ $48.36

26765 2 00 00 00 00 ZZZ $315.70

26765 8 00 00 00 00 ZZZ $63.14

26770 2 00 00 00 00 ZZZ $150.54

26770 8 00 00 00 00 ZZZ $30.11

26775 2 00 00 00 00 ZZZ $217.15

26775 8 00 00 00 00 ZZZ $43.43

26776 2 00 00 00 00 ZZZ $258.85

26776 8 00 00 00 00 ZZZ $51.77

26785 2 00 00 00 00 ZZZ $243.38

26785 8 00 00 00 00 ZZZ $48.68

26820 2 00 00 00 00 ZZZ $853.60

Page 73: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

26820 8 00 00 00 00 ZZZ $170.72

26841 2 00 00 00 00 ZZZ $544.50

26841 8 00 00 00 00 ZZZ $108.90

26842 2 00 00 00 00 ZZZ $661.10

26842 8 00 00 00 00 ZZZ $132.22

26843 2 00 00 00 00 ZZZ $476.79

26843 8 00 00 00 00 ZZZ $95.36

26844 2 00 00 00 00 ZZZ $544.50

26844 8 00 00 00 00 ZZZ $108.90

26850 2 00 00 00 00 ZZZ $432.30

26850 8 00 00 00 00 ZZZ $86.46

26852 2 00 00 00 00 ZZZ $494.36

26852 8 00 00 00 00 ZZZ $98.87

26860 2 00 00 00 00 ZZZ $377.30

26860 8 00 00 00 00 ZZZ $75.46

26861 2 00 00 00 00 ZZZ $182.00

26861 8 00 00 00 00 ZZZ $36.00

26862 2 00 00 00 00 ZZZ $450.82

26862 8 00 00 00 00 ZZZ $90.16

26863 2 00 00 00 00 ZZZ $243.10

26863 8 00 00 00 00 ZZZ $48.62

26910 2 00 00 00 00 ZZZ $672.10

26910 8 00 00 00 00 ZZZ $134.42

26951 2 00 00 00 00 ZZZ $306.32

26951 8 00 00 00 00 ZZZ $61.26

26952 2 00 00 00 00 ZZZ $386.57

26952 8 00 00 00 00 ZZZ $77.31

26989 2 00 00 00 00 ZZZ $0.00

26989 8 00 00 00 00 ZZZ $0.00

26990 2 00 00 00 00 ZZZ $429.84

26990 8 00 00 00 00 ZZZ $85.97

26991 2 00 00 00 00 ZZZ $352.22

26991 8 00 00 00 00 ZZZ $70.44

26992 2 00 00 00 00 ZZZ $682.92

26992 8 00 00 00 00 ZZZ $136.58

27000 2 00 00 00 00 ZZZ $273.01

27000 8 00 00 00 00 ZZZ $54.60

27001 2 00 00 00 00 ZZZ $328.09

27001 8 00 00 00 00 ZZZ $65.62

27003 2 00 00 00 00 ZZZ $415.94

Page 74: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27003 8 00 00 00 00 ZZZ $83.19

27005 2 00 00 00 00 ZZZ $445.05

27005 8 00 00 00 00 ZZZ $89.01

27006 2 00 00 00 00 ZZZ $469.71

27006 8 00 00 00 00 ZZZ $93.94

27025 2 00 00 00 00 ZZZ $595.10

27025 8 00 00 00 00 ZZZ $119.02

27027 2 00 00 00 00 ZZZ $1,060.40

27027 8 00 00 00 00 ZZZ $212.08

27030 2 00 00 00 00 ZZZ $684.24

27030 8 00 00 00 00 ZZZ $136.85

27033 2 00 00 00 00 ZZZ $834.90

27033 8 00 00 00 00 ZZZ $166.98

27035 2 00 00 00 00 ZZZ $943.80

27035 8 00 00 00 00 ZZZ $188.76

27036 2 00 00 00 00 ZZZ $1,044.08

27036 8 00 00 00 00 ZZZ $208.82

27040 2 00 00 00 00 ZZZ $154.21

27040 8 00 00 00 00 ZZZ $30.84

27041 2 00 00 00 00 ZZZ $416.73

27041 8 00 00 00 00 ZZZ $83.35

27043 2 00 00 00 00 ZZZ $601.81

27043 8 00 00 00 00 ZZZ $120.36

27045 2 00 00 00 00 ZZZ $957.02

27045 8 00 00 00 00 ZZZ $191.40

27047 2 00 00 00 00 ZZZ $348.80

27047 8 00 00 00 00 ZZZ $69.76

27048 2 00 00 00 00 ZZZ $595.39

27048 8 00 00 00 00 ZZZ $119.08

27049 2 00 00 00 00 ZZZ $731.50

27049 8 00 00 00 00 ZZZ $146.30

27050 2 00 00 00 00 ZZZ $359.70

27050 8 00 00 00 00 ZZZ $71.94

27052 2 00 00 00 00 ZZZ $661.10

27052 8 00 00 00 00 ZZZ $132.22

27054 2 00 00 00 00 ZZZ $893.78

27054 8 00 00 00 00 ZZZ $178.76

27057 2 00 00 00 00 ZZZ $1,167.10

27057 8 00 00 00 00 ZZZ $233.42

27059 2 00 00 00 00 ZZZ $2,346.07

Page 75: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27059 8 00 00 00 00 ZZZ $469.21

27060 2 00 00 00 00 ZZZ $292.42

27060 8 00 00 00 00 ZZZ $58.48

27062 2 00 00 00 00 ZZZ $330.00

27062 8 00 00 00 00 ZZZ $66.00

27065 2 00 00 00 00 ZZZ $347.76

27065 8 00 00 00 00 ZZZ $69.55

27066 2 00 00 00 00 ZZZ $817.30

27066 8 00 00 00 00 ZZZ $163.46

27067 2 00 00 00 00 ZZZ $953.70

27067 8 00 00 00 00 ZZZ $190.74

27070 2 00 00 00 00 ZZZ $619.98

27070 8 00 00 00 00 ZZZ $124.00

27071 2 00 00 00 00 ZZZ $662.73

27071 8 00 00 00 00 ZZZ $132.55

27075 2 00 00 00 00 ZZZ $1,271.60

27075 8 00 00 00 00 ZZZ $254.32

27076 2 00 00 00 00 ZZZ $1,271.60

27076 8 00 00 00 00 ZZZ $254.32

27077 2 00 00 00 00 ZZZ $1,271.60

27077 8 00 00 00 00 ZZZ $254.32

27078 2 00 00 00 00 ZZZ $1,233.21

27078 8 00 00 00 00 ZZZ $246.64

27080 2 00 00 00 00 ZZZ $511.50

27080 8 00 00 00 00 ZZZ $102.30

27086 2 00 00 00 00 ZZZ $116.97

27086 8 00 00 00 00 ZZZ $23.39

27087 2 00 00 00 00 ZZZ $401.00

27087 8 00 00 00 00 ZZZ $80.20

27090 2 00 00 00 00 ZZZ $715.00

27090 8 00 00 00 00 ZZZ $143.00

27091 2 00 00 00 00 ZZZ $1,790.87

27091 8 00 00 00 00 ZZZ $358.17

27093 2 00 00 00 00 ZZZ $179.39

27093 8 00 00 00 00 ZZZ $35.88

27095 2 00 00 00 00 ZZZ $187.52

27095 8 00 00 00 00 ZZZ $37.50

27096 2 00 00 00 00 ZZZ $459.98

27096 8 00 00 00 00 ZZZ $92.00

27097 2 00 00 00 00 ZZZ $763.40

Page 76: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27097 8 00 00 00 00 ZZZ $152.68

27098 2 00 00 00 00 ZZZ $763.40

27098 8 00 00 00 00 ZZZ $152.68

27100 2 00 00 00 00 ZZZ $907.50

27100 8 00 00 00 00 ZZZ $181.50

27105 2 00 00 00 00 ZZZ $943.80

27105 8 00 00 00 00 ZZZ $188.76

27110 2 00 00 00 00 ZZZ $1,107.70

27110 8 00 00 00 00 ZZZ $221.54

27111 2 00 00 00 00 ZZZ $1,052.70

27111 8 00 00 00 00 ZZZ $210.54

27120 2 00 00 00 00 ZZZ $955.67

27120 8 00 00 00 00 ZZZ $191.13

27122 2 00 00 00 00 ZZZ $980.10

27122 8 00 00 00 00 ZZZ $196.02

27125 2 00 00 00 00 ZZZ $1,343.10

27125 8 00 00 00 00 ZZZ $268.62

27130 2 00 00 00 00 ZZZ $2,261.00

27130 8 00 00 00 00 ZZZ $452.00

27132 2 00 00 00 00 ZZZ $2,005.40

27132 8 00 00 00 00 ZZZ $401.08

27134 2 00 00 00 00 ZZZ $2,518.88

27134 8 00 00 00 00 ZZZ $503.78

27137 2 00 00 00 00 ZZZ $2,010.29

27137 8 00 00 00 00 ZZZ $402.06

27138 2 00 00 00 00 ZZZ $2,056.31

27138 8 00 00 00 00 ZZZ $411.26

27140 2 00 00 00 00 ZZZ $762.30

27140 8 00 00 00 00 ZZZ $152.46

27146 2 00 00 00 00 ZZZ $980.10

27146 8 00 00 00 00 ZZZ $196.02

27147 2 00 00 00 00 ZZZ $1,107.70

27147 8 00 00 00 00 ZZZ $221.54

27151 2 00 00 00 00 ZZZ $1,032.26

27151 8 00 00 00 00 ZZZ $206.45

27156 2 00 00 00 00 ZZZ $1,204.50

27156 8 00 00 00 00 ZZZ $240.90

27158 2 00 00 00 00 ZZZ $1,590.60

27158 8 00 00 00 00 ZZZ $318.12

27161 2 00 00 00 00 ZZZ $1,107.70

Page 77: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27161 8 00 00 00 00 ZZZ $221.54

27165 2 00 00 00 00 ZZZ $1,234.20

27165 8 00 00 00 00 ZZZ $246.84

27170 2 00 00 00 00 ZZZ $1,325.50

27170 8 00 00 00 00 ZZZ $265.10

27175 2 00 00 00 00 ZZZ $445.50

27175 8 00 00 00 00 ZZZ $89.10

27176 2 00 00 00 00 ZZZ $853.60

27176 8 00 00 00 00 ZZZ $170.72

27177 2 00 00 00 00 ZZZ $1,197.90

27177 8 00 00 00 00 ZZZ $239.58

27178 2 00 00 00 00 ZZZ $1,016.40

27178 8 00 00 00 00 ZZZ $203.28

27179 2 00 00 00 00 ZZZ $1,052.70

27179 8 00 00 00 00 ZZZ $210.54

27181 2 00 00 00 00 ZZZ $1,197.90

27181 8 00 00 00 00 ZZZ $239.58

27185 2 00 00 00 00 ZZZ $402.83

27185 8 00 00 00 00 ZZZ $80.57

27187 2 00 00 00 00 ZZZ $1,295.37

27187 8 00 00 00 00 ZZZ $259.07

27197 2 00 00 00 00 ZZZ $135.20

27197 8 00 00 00 00 ZZZ $27.04

27198 2 00 00 00 00 ZZZ $346.69

27198 8 00 00 00 00 ZZZ $69.34

27200 2 00 00 00 00 ZZZ $127.60

27200 8 00 00 00 00 ZZZ $25.52

27202 2 00 00 00 00 ZZZ $472.59

27202 8 00 00 00 00 ZZZ $94.52

27215 2 00 00 00 00 ZZZ $980.38

27215 8 00 00 00 00 ZZZ $196.08

27216 2 00 00 00 00 ZZZ $646.47

27216 8 00 00 00 00 ZZZ $129.29

27217 2 00 00 00 00 ZZZ $1,238.74

27217 8 00 00 00 00 ZZZ $247.75

27218 2 00 00 00 00 ZZZ $1,472.33

27218 8 00 00 00 00 ZZZ $294.47

27220 2 00 00 00 00 ZZZ $457.60

27220 8 00 00 00 00 ZZZ $91.52

27222 2 00 00 00 00 ZZZ $579.86

Page 78: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27222 8 00 00 00 00 ZZZ $115.97

27226 2 00 00 00 00 ZZZ $1,197.90

27226 8 00 00 00 00 ZZZ $239.58

27227 2 00 00 00 00 ZZZ $1,851.03

27227 8 00 00 00 00 ZZZ $370.21

27228 2 00 00 00 00 ZZZ $2,010.29

27228 8 00 00 00 00 ZZZ $402.06

27230 2 00 00 00 00 ZZZ $292.42

27230 8 00 00 00 00 ZZZ $58.48

27232 2 00 00 00 00 ZZZ $628.10

27232 8 00 00 00 00 ZZZ $125.62

27235 2 00 00 00 00 ZZZ $1,194.98

27235 8 00 00 00 00 ZZZ $239.00

27236 2 00 00 00 00 ZZZ $1,415.70

27236 8 00 00 00 00 ZZZ $283.14

27238 2 00 00 00 00 ZZZ $578.00

27238 8 00 00 00 00 ZZZ $116.00

27240 2 00 00 00 00 ZZZ $1,106.00

27240 8 00 00 00 00 ZZZ $221.00

27244 2 00 00 00 00 ZZZ $1,325.50

27244 8 00 00 00 00 ZZZ $265.10

27245 2 00 00 00 00 ZZZ $1,325.50

27245 8 00 00 00 00 ZZZ $265.10

27246 2 00 00 00 00 ZZZ $317.90

27246 8 00 00 00 00 ZZZ $63.58

27248 2 00 00 00 00 ZZZ $762.30

27248 8 00 00 00 00 ZZZ $152.46

27250 2 00 00 00 00 ZZZ $330.00

27250 8 00 00 00 00 ZZZ $66.00

27252 2 00 00 00 00 ZZZ $460.53

27252 8 00 00 00 00 ZZZ $92.11

27253 2 00 00 00 00 ZZZ $871.20

27253 8 00 00 00 00 ZZZ $174.24

27254 2 00 00 00 00 ZZZ $1,325.50

27254 8 00 00 00 00 ZZZ $265.10

27256 2 00 00 00 00 ZZZ $254.10

27256 8 00 00 00 00 ZZZ $50.82

27257 2 00 00 00 00 ZZZ $315.70

27257 8 00 00 00 00 ZZZ $63.14

27258 2 00 00 00 00 ZZZ $943.80

Page 79: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27258 8 00 00 00 00 ZZZ $188.76

27259 2 00 00 00 00 ZZZ $1,234.20

27259 8 00 00 00 00 ZZZ $246.84

27265 2 00 00 00 00 ZZZ $263.31

27265 8 00 00 00 00 ZZZ $52.66

27266 2 00 00 00 00 ZZZ $365.85

27266 8 00 00 00 00 ZZZ $73.17

27267 2 00 00 00 00 ZZZ $506.02

27267 8 00 00 00 00 ZZZ $101.20

27268 2 00 00 00 00 ZZZ $625.05

27268 8 00 00 00 00 ZZZ $125.01

27269 2 00 00 00 00 ZZZ $1,497.18

27269 8 00 00 00 00 ZZZ $299.44

27275 2 00 00 00 00 ZZZ $163.90

27275 8 00 00 00 00 ZZZ $32.78

27279 2 00 00 00 00 ZZZ $527.45

27279 8 00 00 00 00 ZZZ $105.49

27280 2 00 00 00 00 ZZZ $711.70

27280 8 00 00 00 00 ZZZ $142.34

27282 2 00 00 00 00 ZZZ $851.40

27282 8 00 00 00 00 ZZZ $170.28

27284 2 00 00 00 00 ZZZ $1,488.30

27284 8 00 00 00 00 ZZZ $297.66

27286 2 00 00 00 00 ZZZ $1,579.60

27286 8 00 00 00 00 ZZZ $315.92

27290 2 00 00 00 00 ZZZ $2,141.70

27290 8 00 00 00 00 ZZZ $428.34

27295 2 00 00 00 00 ZZZ $1,524.60

27295 8 00 00 00 00 ZZZ $304.92

27299 2 00 00 00 00 ZZZ $0.00

27299 8 00 00 00 00 ZZZ $0.00

27301 2 00 00 00 00 ZZZ $397.58

27301 8 00 00 00 00 ZZZ $79.52

27303 2 00 00 00 00 ZZZ $488.85

27303 8 00 00 00 00 ZZZ $97.77

27305 2 00 00 00 00 ZZZ $330.97

27305 8 00 00 00 00 ZZZ $66.19

27306 2 00 00 00 00 ZZZ $247.05

27306 8 00 00 00 00 ZZZ $49.41

27307 2 00 00 00 00 ZZZ $300.29

Page 80: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27307 8 00 00 00 00 ZZZ $60.06

27310 2 00 00 00 00 ZZZ $715.00

27310 8 00 00 00 00 ZZZ $143.00

27323 2 00 00 00 00 ZZZ $140.31

27323 8 00 00 00 00 ZZZ $28.06

27324 2 00 00 00 00 ZZZ $314.28

27324 8 00 00 00 00 ZZZ $62.86

27325 2 00 00 00 00 ZZZ $616.98

27325 8 00 00 00 00 ZZZ $123.40

27326 2 00 00 00 00 ZZZ $597.54

27326 8 00 00 00 00 ZZZ $119.51

27327 2 00 00 00 00 ZZZ $255.96

27327 8 00 00 00 00 ZZZ $51.19

27328 2 00 00 00 00 ZZZ $578.00

27328 8 00 00 00 00 ZZZ $116.00

27329 2 00 00 00 00 ZZZ $745.80

27329 8 00 00 00 00 ZZZ $149.16

27330 2 00 00 00 00 ZZZ $584.00

27330 8 00 00 00 00 ZZZ $117.00

27331 2 00 00 00 00 ZZZ $743.00

27331 8 00 00 00 00 ZZZ $149.00

27332 2 00 00 00 00 ZZZ $833.17

27332 8 00 00 00 00 ZZZ $166.63

27333 2 00 00 00 00 ZZZ $929.57

27333 8 00 00 00 00 ZZZ $185.91

27334 2 00 00 00 00 ZZZ $891.00

27334 8 00 00 00 00 ZZZ $178.00

27335 2 00 00 00 00 ZZZ $1,221.00

27335 8 00 00 00 00 ZZZ $244.00

27337 2 00 00 00 00 ZZZ $536.84

27337 8 00 00 00 00 ZZZ $107.37

27339 2 00 00 00 00 ZZZ $966.98

27339 8 00 00 00 00 ZZZ $193.40

27340 2 00 00 00 00 ZZZ $337.70

27340 8 00 00 00 00 ZZZ $67.54

27345 2 00 00 00 00 ZZZ $647.00

27345 8 00 00 00 00 ZZZ $129.00

27347 2 00 00 00 00 ZZZ $369.63

27347 8 00 00 00 00 ZZZ $73.93

27350 2 00 00 00 00 ZZZ $781.00

Page 81: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27350 8 00 00 00 00 ZZZ $156.20

27355 2 00 00 00 00 ZZZ $808.46

27355 8 00 00 00 00 ZZZ $161.69

27356 2 00 00 00 00 ZZZ $744.70

27356 8 00 00 00 00 ZZZ $148.94

27357 2 00 00 00 00 ZZZ $871.20

27357 8 00 00 00 00 ZZZ $174.24

27358 2 00 00 00 00 ZZZ $254.10

27358 8 00 00 00 00 ZZZ $50.82

27360 2 00 00 00 00 ZZZ $631.52

27360 8 00 00 00 00 ZZZ $126.30

27364 2 00 00 00 00 ZZZ $2,019.79

27364 8 00 00 00 00 ZZZ $403.96

27365 2 00 00 00 00 ZZZ $1,271.60

27365 8 00 00 00 00 ZZZ $254.32

27370 2 00 00 00 00 ZZZ $170.73

27370 8 00 00 00 00 ZZZ $34.15

27372 2 00 00 00 00 ZZZ $366.30

27372 8 00 00 00 00 ZZZ $73.26

27380 2 00 00 00 00 ZZZ $490.60

27380 8 00 00 00 00 ZZZ $98.12

27381 2 00 00 00 00 ZZZ $711.70

27381 8 00 00 00 00 ZZZ $142.34

27385 2 00 00 00 00 ZZZ $464.20

27385 8 00 00 00 00 ZZZ $92.84

27386 2 00 00 00 00 ZZZ $798.60

27386 8 00 00 00 00 ZZZ $159.72

27390 2 00 00 00 00 ZZZ $301.34

27390 8 00 00 00 00 ZZZ $60.27

27391 2 00 00 00 00 ZZZ $443.30

27391 8 00 00 00 00 ZZZ $88.66

27392 2 00 00 00 00 ZZZ $595.10

27392 8 00 00 00 00 ZZZ $119.02

27393 2 00 00 00 00 ZZZ $362.18

27393 8 00 00 00 00 ZZZ $72.44

27394 2 00 00 00 00 ZZZ $544.50

27394 8 00 00 00 00 ZZZ $108.90

27395 2 00 00 00 00 ZZZ $907.50

27395 8 00 00 00 00 ZZZ $181.50

27396 2 00 00 00 00 ZZZ $689.70

Page 82: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27396 8 00 00 00 00 ZZZ $137.94

27397 2 00 00 00 00 ZZZ $834.90

27397 8 00 00 00 00 ZZZ $166.98

27400 2 00 00 00 00 ZZZ $711.70

27400 8 00 00 00 00 ZZZ $142.34

27403 2 00 00 00 00 ZZZ $680.90

27403 8 00 00 00 00 ZZZ $136.18

27405 2 00 00 00 00 ZZZ $891.92

27405 8 00 00 00 00 ZZZ $178.38

27407 2 00 00 00 00 ZZZ $974.00

27407 8 00 00 00 00 ZZZ $195.00

27409 2 00 00 00 00 ZZZ $1,403.00

27409 8 00 00 00 00 ZZZ $281.00

27412 2 00 00 00 00 ZZZ $1,974.99

27412 8 00 00 00 00 ZZZ $395.00

27415 2 00 00 00 00 ZZZ $1,649.09

27415 8 00 00 00 00 ZZZ $329.82

27416 2 00 00 00 00 ZZZ $1,171.85

27416 8 00 00 00 00 ZZZ $234.37

27418 2 00 00 00 00 ZZZ $987.45

27418 8 00 00 00 00 ZZZ $197.49

27420 2 00 00 00 00 ZZZ $907.50

27420 8 00 00 00 00 ZZZ $181.50

27422 2 00 00 00 00 ZZZ $985.17

27422 8 00 00 00 00 ZZZ $197.03

27424 2 00 00 00 00 ZZZ $853.60

27424 8 00 00 00 00 ZZZ $170.72

27425 2 00 00 00 00 ZZZ $698.19

27425 8 00 00 00 00 ZZZ $139.64

27427 2 00 00 00 00 ZZZ $909.59

27427 8 00 00 00 00 ZZZ $181.92

27428 2 00 00 00 00 ZZZ $1,657.01

27428 8 00 00 00 00 ZZZ $331.40

27429 2 00 00 00 00 ZZZ $1,146.72

27429 8 00 00 00 00 ZZZ $229.34

27430 2 00 00 00 00 ZZZ $762.30

27430 8 00 00 00 00 ZZZ $152.46

27435 2 00 00 00 00 ZZZ $744.70

27435 8 00 00 00 00 ZZZ $148.94

27437 2 00 00 00 00 ZZZ $488.33

Page 83: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27437 8 00 00 00 00 ZZZ $97.67

27438 2 00 00 00 00 ZZZ $711.70

27438 8 00 00 00 00 ZZZ $142.34

27440 2 00 00 00 00 ZZZ $759.00

27440 8 00 00 00 00 ZZZ $151.80

27441 2 00 00 00 00 ZZZ $1,188.00

27441 8 00 00 00 00 ZZZ $238.00

27442 2 00 00 00 00 ZZZ $1,052.70

27442 8 00 00 00 00 ZZZ $210.54

27443 2 00 00 00 00 ZZZ $1,098.46

27443 8 00 00 00 00 ZZZ $219.69

27445 2 00 00 00 00 ZZZ $1,714.83

27445 8 00 00 00 00 ZZZ $342.97

27446 2 00 00 00 00 ZZZ $1,815.00

27446 8 00 00 00 00 ZZZ $363.00

27447 2 00 00 00 00 ZZZ $2,475.00

27447 8 00 00 00 00 ZZZ $495.00

27448 2 00 00 00 00 ZZZ $762.30

27448 8 00 00 00 00 ZZZ $152.46

27450 2 00 00 00 00 ZZZ $1,052.70

27450 8 00 00 00 00 ZZZ $210.54

27454 2 00 00 00 00 ZZZ $980.10

27454 8 00 00 00 00 ZZZ $196.02

27455 2 00 00 00 00 ZZZ $817.30

27455 8 00 00 00 00 ZZZ $163.46

27457 2 00 00 00 00 ZZZ $1,052.70

27457 8 00 00 00 00 ZZZ $210.54

27465 2 00 00 00 00 ZZZ $1,107.70

27465 8 00 00 00 00 ZZZ $221.54

27466 2 00 00 00 00 ZZZ $1,488.30

27466 8 00 00 00 00 ZZZ $297.66

27468 2 00 00 00 00 ZZZ $1,799.00

27468 8 00 00 00 00 ZZZ $360.00

27470 2 00 00 00 00 ZZZ $1,052.70

27470 8 00 00 00 00 ZZZ $210.54

27472 2 00 00 00 00 ZZZ $1,197.90

27472 8 00 00 00 00 ZZZ $239.58

27475 2 00 00 00 00 ZZZ $682.00

27475 8 00 00 00 00 ZZZ $136.40

27477 2 00 00 00 00 ZZZ $711.70

Page 84: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27477 8 00 00 00 00 ZZZ $142.34

27479 2 00 00 00 00 ZZZ $943.80

27479 8 00 00 00 00 ZZZ $188.76

27485 2 00 00 00 00 ZZZ $595.10

27485 8 00 00 00 00 ZZZ $119.02

27486 2 00 00 00 00 ZZZ $1,797.94

27486 8 00 00 00 00 ZZZ $359.59

27487 2 00 00 00 00 ZZZ $2,381.92

27487 8 00 00 00 00 ZZZ $476.38

27488 2 00 00 00 00 ZZZ $1,369.69

27488 8 00 00 00 00 ZZZ $273.94

27495 2 00 00 00 00 ZZZ $1,433.40

27495 8 00 00 00 00 ZZZ $286.68

27496 2 00 00 00 00 ZZZ $343.20

27496 8 00 00 00 00 ZZZ $68.64

27497 2 00 00 00 00 ZZZ $445.50

27497 8 00 00 00 00 ZZZ $89.10

27498 2 00 00 00 00 ZZZ $576.90

27498 8 00 00 00 00 ZZZ $115.38

27499 2 00 00 00 00 ZZZ $664.68

27499 8 00 00 00 00 ZZZ $132.94

27500 2 00 00 00 00 ZZZ $425.12

27500 8 00 00 00 00 ZZZ $85.02

27501 2 00 00 00 00 ZZZ $435.09

27501 8 00 00 00 00 ZZZ $87.02

27502 2 00 00 00 00 ZZZ $541.83

27502 8 00 00 00 00 ZZZ $108.37

27503 2 00 00 00 00 ZZZ $543.14

27503 8 00 00 00 00 ZZZ $108.63

27506 2 00 00 00 00 ZZZ $1,343.10

27506 8 00 00 00 00 ZZZ $268.62

27507 2 00 00 00 00 ZZZ $1,343.10

27507 8 00 00 00 00 ZZZ $268.62

27508 2 00 00 00 00 ZZZ $342.51

27508 8 00 00 00 00 ZZZ $68.50

27509 2 00 00 00 00 ZZZ $480.63

27509 8 00 00 00 00 ZZZ $96.13

27510 2 00 00 00 00 ZZZ $464.20

27510 8 00 00 00 00 ZZZ $92.84

27511 2 00 00 00 00 ZZZ $980.10

Page 85: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27511 8 00 00 00 00 ZZZ $196.02

27513 2 00 00 00 00 ZZZ $1,343.10

27513 8 00 00 00 00 ZZZ $268.62

27514 2 00 00 00 00 ZZZ $1,107.70

27514 8 00 00 00 00 ZZZ $221.54

27516 2 00 00 00 00 ZZZ $345.40

27516 8 00 00 00 00 ZZZ $69.08

27517 2 00 00 00 00 ZZZ $488.59

27517 8 00 00 00 00 ZZZ $97.72

27519 2 00 00 00 00 ZZZ $1,052.70

27519 8 00 00 00 00 ZZZ $210.54

27520 2 00 00 00 00 ZZZ $218.73

27520 8 00 00 00 00 ZZZ $43.75

27524 2 00 00 00 00 ZZZ $871.20

27524 8 00 00 00 00 ZZZ $174.24

27530 2 00 00 00 00 ZZZ $256.75

27530 8 00 00 00 00 ZZZ $51.35

27532 2 00 00 00 00 ZZZ $381.85

27532 8 00 00 00 00 ZZZ $76.37

27535 2 00 00 00 00 ZZZ $1,016.40

27535 8 00 00 00 00 ZZZ $203.28

27536 2 00 00 00 00 ZZZ $1,016.40

27536 8 00 00 00 00 ZZZ $203.28

27538 2 00 00 00 00 ZZZ $317.90

27538 8 00 00 00 00 ZZZ $63.58

27540 2 00 00 00 00 ZZZ $675.40

27540 8 00 00 00 00 ZZZ $135.08

27550 2 00 00 00 00 ZZZ $317.60

27550 8 00 00 00 00 ZZZ $63.52

27552 2 00 00 00 00 ZZZ $374.00

27552 8 00 00 00 00 ZZZ $74.80

27556 2 00 00 00 00 ZZZ $980.10

27556 8 00 00 00 00 ZZZ $196.02

27557 2 00 00 00 00 ZZZ $891.00

27557 8 00 00 00 00 ZZZ $178.20

27558 2 00 00 00 00 ZZZ $1,394.47

27558 8 00 00 00 00 ZZZ $278.89

27560 2 00 00 00 00 ZZZ $228.95

27560 8 00 00 00 00 ZZZ $45.79

27562 2 00 00 00 00 ZZZ $306.32

Page 86: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27562 8 00 00 00 00 ZZZ $61.26

27566 2 00 00 00 00 ZZZ $711.70

27566 8 00 00 00 00 ZZZ $142.34

27570 2 00 00 00 00 ZZZ $156.20

27570 8 00 00 00 00 ZZZ $31.24

27580 2 00 00 00 00 ZZZ $1,107.70

27580 8 00 00 00 00 ZZZ $221.54

27590 2 00 00 00 00 ZZZ $980.10

27590 8 00 00 00 00 ZZZ $196.02

27592 2 00 00 00 00 ZZZ $595.10

27592 8 00 00 00 00 ZZZ $119.02

27594 2 00 00 00 00 ZZZ $357.46

27594 8 00 00 00 00 ZZZ $71.49

27596 2 00 00 00 00 ZZZ $613.80

27596 8 00 00 00 00 ZZZ $122.76

27598 2 00 00 00 00 ZZZ $762.30

27598 8 00 00 00 00 ZZZ $152.46

27599 2 00 00 00 00 ZZZ $0.00

27599 8 00 00 00 00 ZZZ $0.00

27600 2 00 00 00 00 ZZZ $309.99

27600 8 00 00 00 00 ZZZ $62.00

27601 2 00 00 00 00 ZZZ $310.78

27601 8 00 00 00 00 ZZZ $62.16

27602 2 00 00 00 00 ZZZ $381.70

27602 8 00 00 00 00 ZZZ $76.34

27603 2 00 00 00 00 ZZZ $349.33

27603 8 00 00 00 00 ZZZ $69.87

27604 2 00 00 00 00 ZZZ $256.49

27604 8 00 00 00 00 ZZZ $51.30

27605 2 00 00 00 00 ZZZ $192.24

27605 8 00 00 00 00 ZZZ $38.45

27606 2 00 00 00 00 ZZZ $256.75

27606 8 00 00 00 00 ZZZ $51.35

27607 2 00 00 00 00 ZZZ $479.67

27607 8 00 00 00 00 ZZZ $95.93

27610 2 00 00 00 00 ZZZ $479.60

27610 8 00 00 00 00 ZZZ $95.92

27612 2 00 00 00 00 ZZZ $544.50

27612 8 00 00 00 00 ZZZ $108.90

27613 2 00 00 00 00 ZZZ $140.57

Page 87: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27613 8 00 00 00 00 ZZZ $28.11

27614 2 00 00 00 00 ZZZ $314.97

27614 8 00 00 00 00 ZZZ $62.99

27615 2 00 00 00 00 ZZZ $745.80

27615 8 00 00 00 00 ZZZ $149.16

27616 2 00 00 00 00 ZZZ $1,648.46

27616 8 00 00 00 00 ZZZ $329.69

27618 2 00 00 00 00 ZZZ $306.85

27618 8 00 00 00 00 ZZZ $61.37

27619 2 00 00 00 00 ZZZ $527.35

27619 8 00 00 00 00 ZZZ $105.47

27620 2 00 00 00 00 ZZZ $479.60

27620 8 00 00 00 00 ZZZ $95.92

27625 2 00 00 00 00 ZZZ $817.30

27625 8 00 00 00 00 ZZZ $163.46

27626 2 00 00 00 00 ZZZ $834.90

27626 8 00 00 00 00 ZZZ $166.98

27630 2 00 00 00 00 ZZZ $315.70

27630 8 00 00 00 00 ZZZ $63.14

27632 2 00 00 00 00 ZZZ $530.20

27632 8 00 00 00 00 ZZZ $106.04

27634 2 00 00 00 00 ZZZ $864.07

27634 8 00 00 00 00 ZZZ $172.81

27635 2 00 00 00 00 ZZZ $726.00

27635 8 00 00 00 00 ZZZ $145.20

27637 2 00 00 00 00 ZZZ $834.90

27637 8 00 00 00 00 ZZZ $166.98

27638 2 00 00 00 00 ZZZ $711.70

27638 8 00 00 00 00 ZZZ $142.34

27640 2 00 00 00 00 ZZZ $715.00

27640 8 00 00 00 00 ZZZ $143.00

27641 2 00 00 00 00 ZZZ $549.44

27641 8 00 00 00 00 ZZZ $109.89

27645 2 00 00 00 00 ZZZ $1,271.60

27645 8 00 00 00 00 ZZZ $254.32

27646 2 00 00 00 00 ZZZ $1,271.60

27646 8 00 00 00 00 ZZZ $254.32

27647 2 00 00 00 00 ZZZ $763.40

27647 8 00 00 00 00 ZZZ $152.68

27648 2 00 00 00 00 ZZZ $139.26

Page 88: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27648 8 00 00 00 00 ZZZ $27.85

27650 2 00 00 00 00 ZZZ $536.80

27650 8 00 00 00 00 ZZZ $107.36

27652 2 00 00 00 00 ZZZ $715.00

27652 8 00 00 00 00 ZZZ $143.00

27654 2 00 00 00 00 ZZZ $781.00

27654 8 00 00 00 00 ZZZ $156.20

27656 2 00 00 00 00 ZZZ $328.35

27656 8 00 00 00 00 ZZZ $65.67

27658 2 00 00 00 00 ZZZ $366.30

27658 8 00 00 00 00 ZZZ $73.26

27659 2 00 00 00 00 ZZZ $460.90

27659 8 00 00 00 00 ZZZ $92.18

27664 2 00 00 00 00 ZZZ $374.00

27664 8 00 00 00 00 ZZZ $74.80

27665 2 00 00 00 00 ZZZ $388.67

27665 8 00 00 00 00 ZZZ $77.73

27675 2 00 00 00 00 ZZZ $443.30

27675 8 00 00 00 00 ZZZ $88.66

27676 2 00 00 00 00 ZZZ $715.00

27676 8 00 00 00 00 ZZZ $143.00

27680 2 00 00 00 00 ZZZ $311.83

27680 8 00 00 00 00 ZZZ $62.37

27681 2 00 00 00 00 ZZZ $385.00

27681 8 00 00 00 00 ZZZ $77.00

27685 2 00 00 00 00 ZZZ $479.60

27685 8 00 00 00 00 ZZZ $95.92

27686 2 00 00 00 00 ZZZ $490.60

27686 8 00 00 00 00 ZZZ $98.12

27687 2 00 00 00 00 ZZZ $366.30

27687 8 00 00 00 00 ZZZ $73.26

27690 2 00 00 00 00 ZZZ $544.50

27690 8 00 00 00 00 ZZZ $108.90

27691 2 00 00 00 00 ZZZ $715.00

27691 8 00 00 00 00 ZZZ $143.00

27692 2 00 00 00 00 ZZZ $130.90

27692 8 00 00 00 00 ZZZ $26.18

27695 2 00 00 00 00 ZZZ $710.00

27695 8 00 00 00 00 ZZZ $142.00

27696 2 00 00 00 00 ZZZ $718.30

Page 89: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27696 8 00 00 00 00 ZZZ $143.66

27698 2 00 00 00 00 ZZZ $853.60

27698 8 00 00 00 00 ZZZ $170.72

27700 2 00 00 00 00 ZZZ $884.46

27700 8 00 00 00 00 ZZZ $176.89

27702 2 00 00 00 00 ZZZ $1,353.96

27702 8 00 00 00 00 ZZZ $270.79

27703 2 00 00 00 00 ZZZ $1,259.97

27703 8 00 00 00 00 ZZZ $251.99

27704 2 00 00 00 00 ZZZ $449.90

27704 8 00 00 00 00 ZZZ $89.98

27705 2 00 00 00 00 ZZZ $726.00

27705 8 00 00 00 00 ZZZ $145.20

27707 2 00 00 00 00 ZZZ $388.30

27707 8 00 00 00 00 ZZZ $77.66

27709 2 00 00 00 00 ZZZ $871.20

27709 8 00 00 00 00 ZZZ $174.24

27712 2 00 00 00 00 ZZZ $943.80

27712 8 00 00 00 00 ZZZ $188.76

27715 2 00 00 00 00 ZZZ $1,306.80

27715 8 00 00 00 00 ZZZ $261.36

27720 2 00 00 00 00 ZZZ $834.90

27720 8 00 00 00 00 ZZZ $166.98

27722 2 00 00 00 00 ZZZ $943.80

27722 8 00 00 00 00 ZZZ $188.76

27724 2 00 00 00 00 ZZZ $1,125.30

27724 8 00 00 00 00 ZZZ $225.06

27725 2 00 00 00 00 ZZZ $891.00

27725 8 00 00 00 00 ZZZ $178.20

27726 2 00 00 00 00 ZZZ $1,105.46

27726 8 00 00 00 00 ZZZ $221.06

27727 2 00 00 00 00 ZZZ $700.50

27727 8 00 00 00 00 ZZZ $140.10

27730 2 00 00 00 00 ZZZ $479.60

27730 8 00 00 00 00 ZZZ $95.92

27732 2 00 00 00 00 ZZZ $393.13

27732 8 00 00 00 00 ZZZ $78.63

27734 2 00 00 00 00 ZZZ $595.10

27734 8 00 00 00 00 ZZZ $119.02

27740 2 00 00 00 00 ZZZ $907.50

Page 90: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27740 8 00 00 00 00 ZZZ $181.50

27742 2 00 00 00 00 ZZZ $1,016.40

27742 8 00 00 00 00 ZZZ $203.28

27745 2 00 00 00 00 ZZZ $814.03

27745 8 00 00 00 00 ZZZ $162.81

27750 2 00 00 00 00 ZZZ $235.77

27750 8 00 00 00 00 ZZZ $47.15

27752 2 00 00 00 00 ZZZ $464.20

27752 8 00 00 00 00 ZZZ $92.84

27756 2 00 00 00 00 ZZZ $825.00

27756 8 00 00 00 00 ZZZ $165.00

27758 2 00 00 00 00 ZZZ $1,125.30

27758 8 00 00 00 00 ZZZ $225.06

27759 2 00 00 00 00 ZZZ $1,125.30

27759 8 00 00 00 00 ZZZ $225.06

27760 2 00 00 00 00 ZZZ $214.79

27760 8 00 00 00 00 ZZZ $42.96

27762 2 00 00 00 00 ZZZ $352.00

27762 8 00 00 00 00 ZZZ $70.40

27766 2 00 00 00 00 ZZZ $588.50

27766 8 00 00 00 00 ZZZ $117.70

27767 2 00 00 00 00 ZZZ $304.46

27767 8 00 00 00 00 ZZZ $60.89

27768 2 00 00 00 00 ZZZ $478.51

27768 8 00 00 00 00 ZZZ $95.70

27769 2 00 00 00 00 ZZZ $831.34

27769 8 00 00 00 00 ZZZ $166.27

27780 2 00 00 00 00 ZZZ $166.01

27780 8 00 00 00 00 ZZZ $33.20

27781 2 00 00 00 00 ZZZ $355.30

27781 8 00 00 00 00 ZZZ $71.06

27784 2 00 00 00 00 ZZZ $464.20

27784 8 00 00 00 00 ZZZ $92.84

27786 2 00 00 00 00 ZZZ $209.02

27786 8 00 00 00 00 ZZZ $41.80

27788 2 00 00 00 00 ZZZ $279.83

27788 8 00 00 00 00 ZZZ $55.97

27792 2 00 00 00 00 ZZZ $536.80

27792 8 00 00 00 00 ZZZ $107.36

27808 2 00 00 00 00 ZZZ $223.97

Page 91: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27808 8 00 00 00 00 ZZZ $44.79

27810 2 00 00 00 00 ZZZ $402.60

27810 8 00 00 00 00 ZZZ $80.52

27814 2 00 00 00 00 ZZZ $744.70

27814 8 00 00 00 00 ZZZ $148.94

27816 2 00 00 00 00 ZZZ $381.70

27816 8 00 00 00 00 ZZZ $76.34

27818 2 00 00 00 00 ZZZ $726.00

27818 8 00 00 00 00 ZZZ $145.00

27822 2 00 00 00 00 ZZZ $943.80

27822 8 00 00 00 00 ZZZ $188.76

27823 2 00 00 00 00 ZZZ $1,016.40

27823 8 00 00 00 00 ZZZ $203.28

27824 2 00 00 00 00 ZZZ $324.50

27824 8 00 00 00 00 ZZZ $64.90

27825 2 00 00 00 00 ZZZ $726.00

27825 8 00 00 00 00 ZZZ $145.00

27826 2 00 00 00 00 ZZZ $907.50

27826 8 00 00 00 00 ZZZ $181.50

27827 2 00 00 00 00 ZZZ $1,055.34

27827 8 00 00 00 00 ZZZ $211.07

27828 2 00 00 00 00 ZZZ $1,150.53

27828 8 00 00 00 00 ZZZ $230.11

27829 2 00 00 00 00 ZZZ $574.61

27829 8 00 00 00 00 ZZZ $114.92

27830 2 00 00 00 00 ZZZ $253.34

27830 8 00 00 00 00 ZZZ $50.67

27831 2 00 00 00 00 ZZZ $317.90

27831 8 00 00 00 00 ZZZ $63.58

27832 2 00 00 00 00 ZZZ $367.69

27832 8 00 00 00 00 ZZZ $73.54

27840 2 00 00 00 00 ZZZ $224.76

27840 8 00 00 00 00 ZZZ $44.95

27842 2 00 00 00 00 ZZZ $272.80

27842 8 00 00 00 00 ZZZ $54.56

27846 2 00 00 00 00 ZZZ $522.68

27846 8 00 00 00 00 ZZZ $104.54

27848 2 00 00 00 00 ZZZ $795.70

27848 8 00 00 00 00 ZZZ $159.14

27860 2 00 00 00 00 ZZZ $127.60

Page 92: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

27860 8 00 00 00 00 ZZZ $25.52

27870 2 00 00 00 00 ZZZ $871.20

27870 8 00 00 00 00 ZZZ $174.24

27871 2 00 00 00 00 ZZZ $508.20

27871 8 00 00 00 00 ZZZ $101.64

27880 2 00 00 00 00 ZZZ $980.10

27880 8 00 00 00 00 ZZZ $196.02

27882 2 00 00 00 00 ZZZ $569.80

27882 8 00 00 00 00 ZZZ $113.96

27884 2 00 00 00 00 ZZZ $469.47

27884 8 00 00 00 00 ZZZ $93.89

27886 2 00 00 00 00 ZZZ $834.90

27886 8 00 00 00 00 ZZZ $166.98

27888 2 00 00 00 00 ZZZ $678.70

27888 8 00 00 00 00 ZZZ $135.74

27889 2 00 00 00 00 ZZZ $661.10

27889 8 00 00 00 00 ZZZ $132.22

27892 2 00 00 00 00 ZZZ $357.98

27892 8 00 00 00 00 ZZZ $71.60

27893 2 00 00 00 00 ZZZ $345.40

27893 8 00 00 00 00 ZZZ $69.08

27894 2 00 00 00 00 ZZZ $474.43

27894 8 00 00 00 00 ZZZ $94.89

27899 2 00 00 00 00 ZZZ $0.00

27899 8 00 00 00 00 ZZZ $0.00

28001 2 00 00 00 00 ZZZ $140.05

28001 8 00 00 00 00 ZZZ $28.01

28002 2 00 00 00 00 ZZZ $234.72

28002 8 00 00 00 00 ZZZ $46.94

28003 2 00 00 00 00 ZZZ $511.50

28003 8 00 00 00 00 ZZZ $102.30

28005 2 00 00 00 00 ZZZ $419.88

28005 8 00 00 00 00 ZZZ $83.98

28008 2 00 00 00 00 ZZZ $242.06

28008 8 00 00 00 00 ZZZ $48.41

28010 2 00 00 00 00 ZZZ $204.04

28010 8 00 00 00 00 ZZZ $40.81

28011 2 00 00 00 00 ZZZ $231.84

28011 8 00 00 00 00 ZZZ $46.37

28020 2 00 00 00 00 ZZZ $377.30

Page 93: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28020 8 00 00 00 00 ZZZ $75.46

28022 2 00 00 00 00 ZZZ $268.40

28022 8 00 00 00 00 ZZZ $53.68

28024 2 00 00 00 00 ZZZ $239.18

28024 8 00 00 00 00 ZZZ $47.84

28035 2 00 00 00 00 ZZZ $443.30

28035 8 00 00 00 00 ZZZ $88.66

28039 2 00 00 00 00 ZZZ $609.40

28039 8 00 00 00 00 ZZZ $121.88

28041 2 00 00 00 00 ZZZ $573.36

28041 8 00 00 00 00 ZZZ $114.67

28043 2 00 00 00 00 ZZZ $199.06

28043 8 00 00 00 00 ZZZ $39.81

28045 2 00 00 00 00 ZZZ $271.96

28045 8 00 00 00 00 ZZZ $54.39

28046 2 00 00 00 00 ZZZ $745.80

28046 8 00 00 00 00 ZZZ $149.16

28047 2 00 00 00 00 ZZZ $1,207.42

28047 8 00 00 00 00 ZZZ $241.48

28050 2 00 00 00 00 ZZZ $298.10

28050 8 00 00 00 00 ZZZ $59.62

28052 2 00 00 00 00 ZZZ $239.71

28052 8 00 00 00 00 ZZZ $47.94

28054 2 00 00 00 00 ZZZ $203.51

28054 8 00 00 00 00 ZZZ $40.70

28055 2 00 00 00 00 ZZZ $499.85

28055 8 00 00 00 00 ZZZ $99.97

28060 2 00 00 00 00 ZZZ $309.10

28060 8 00 00 00 00 ZZZ $61.82

28062 2 00 00 00 00 ZZZ $482.90

28062 8 00 00 00 00 ZZZ $96.58

28070 2 00 00 00 00 ZZZ $326.70

28070 8 00 00 00 00 ZZZ $65.34

28072 2 00 00 00 00 ZZZ $265.41

28072 8 00 00 00 00 ZZZ $53.08

28080 2 00 00 00 00 ZZZ $415.89

28080 8 00 00 00 00 ZZZ $83.18

28086 2 00 00 00 00 ZZZ $326.70

28086 8 00 00 00 00 ZZZ $65.34

28088 2 00 00 00 00 ZZZ $247.05

Page 94: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28088 8 00 00 00 00 ZZZ $49.41

28090 2 00 00 00 00 ZZZ $315.70

28090 8 00 00 00 00 ZZZ $63.14

28092 2 00 00 00 00 ZZZ $236.50

28092 8 00 00 00 00 ZZZ $47.30

28100 2 00 00 00 00 ZZZ $396.00

28100 8 00 00 00 00 ZZZ $79.20

28102 2 00 00 00 00 ZZZ $741.32

28102 8 00 00 00 00 ZZZ $148.26

28103 2 00 00 00 00 ZZZ $464.20

28103 8 00 00 00 00 ZZZ $92.84

28104 2 00 00 00 00 ZZZ $326.70

28104 8 00 00 00 00 ZZZ $65.34

28106 2 00 00 00 00 ZZZ $396.00

28106 8 00 00 00 00 ZZZ $79.20

28107 2 00 00 00 00 ZZZ $308.16

28107 8 00 00 00 00 ZZZ $61.63

28108 2 00 00 00 00 ZZZ $248.89

28108 8 00 00 00 00 ZZZ $49.78

28110 2 00 00 00 00 ZZZ $323.40

28110 8 00 00 00 00 ZZZ $64.68

28111 2 00 00 00 00 ZZZ $568.82

28111 8 00 00 00 00 ZZZ $113.76

28112 2 00 00 00 00 ZZZ $446.60

28112 8 00 00 00 00 ZZZ $89.32

28113 2 00 00 00 00 ZZZ $287.10

28113 8 00 00 00 00 ZZZ $57.42

28114 2 00 00 00 00 ZZZ $798.60

28114 8 00 00 00 00 ZZZ $159.72

28116 2 00 00 00 00 ZZZ $386.05

28116 8 00 00 00 00 ZZZ $77.21

28118 2 00 00 00 00 ZZZ $374.00

28118 8 00 00 00 00 ZZZ $74.80

28119 2 00 00 00 00 ZZZ $374.00

28119 8 00 00 00 00 ZZZ $74.80

28120 2 00 00 00 00 ZZZ $366.30

28120 8 00 00 00 00 ZZZ $73.26

28122 2 00 00 00 00 ZZZ $380.54

28122 8 00 00 00 00 ZZZ $76.11

28124 2 00 00 00 00 ZZZ $287.10

Page 95: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28124 8 00 00 00 00 ZZZ $57.42

28126 2 00 00 00 00 ZZZ $246.40

28126 8 00 00 00 00 ZZZ $49.28

28130 2 00 00 00 00 ZZZ $544.50

28130 8 00 00 00 00 ZZZ $108.90

28140 2 00 00 00 00 ZZZ $563.20

28140 8 00 00 00 00 ZZZ $112.64

28150 2 00 00 00 00 ZZZ $272.80

28150 8 00 00 00 00 ZZZ $54.56

28153 2 00 00 00 00 ZZZ $246.40

28153 8 00 00 00 00 ZZZ $49.28

28160 2 00 00 00 00 ZZZ $245.48

28160 8 00 00 00 00 ZZZ $49.10

28171 2 00 00 00 00 ZZZ $763.40

28171 8 00 00 00 00 ZZZ $152.68

28173 2 00 00 00 00 ZZZ $763.40

28173 8 00 00 00 00 ZZZ $152.68

28175 2 00 00 00 00 ZZZ $694.00

28175 8 00 00 00 00 ZZZ $138.00

28190 2 00 00 00 00 ZZZ $228.46

28190 8 00 00 00 00 ZZZ $45.69

28192 2 00 00 00 00 ZZZ $298.10

28192 8 00 00 00 00 ZZZ $59.62

28193 2 00 00 00 00 ZZZ $283.24

28193 8 00 00 00 00 ZZZ $56.65

28200 2 00 00 00 00 ZZZ $464.20

28200 8 00 00 00 00 ZZZ $92.84

28202 2 00 00 00 00 ZZZ $544.50

28202 8 00 00 00 00 ZZZ $108.90

28208 2 00 00 00 00 ZZZ $290.40

28208 8 00 00 00 00 ZZZ $58.08

28210 2 00 00 00 00 ZZZ $374.00

28210 8 00 00 00 00 ZZZ $74.80

28220 2 00 00 00 00 ZZZ $272.80

28220 8 00 00 00 00 ZZZ $54.56

28222 2 00 00 00 00 ZZZ $374.00

28222 8 00 00 00 00 ZZZ $74.80

28225 2 00 00 00 00 ZZZ $221.10

28225 8 00 00 00 00 ZZZ $44.22

28226 2 00 00 00 00 ZZZ $272.80

Page 96: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28226 8 00 00 00 00 ZZZ $54.56

28230 2 00 00 00 00 ZZZ $232.62

28230 8 00 00 00 00 ZZZ $46.52

28232 2 00 00 00 00 ZZZ $198.79

28232 8 00 00 00 00 ZZZ $39.76

28234 2 00 00 00 00 ZZZ $198.79

28234 8 00 00 00 00 ZZZ $39.76

28238 2 00 00 00 00 ZZZ $563.20

28238 8 00 00 00 00 ZZZ $112.64

28240 2 00 00 00 00 ZZZ $230.00

28240 8 00 00 00 00 ZZZ $46.00

28250 2 00 00 00 00 ZZZ $318.65

28250 8 00 00 00 00 ZZZ $63.73

28260 2 00 00 00 00 ZZZ $381.85

28260 8 00 00 00 00 ZZZ $76.37

28261 2 00 00 00 00 ZZZ $533.17

28261 8 00 00 00 00 ZZZ $106.63

28262 2 00 00 00 00 ZZZ $871.20

28262 8 00 00 00 00 ZZZ $174.24

28264 2 00 00 00 00 ZZZ $544.50

28264 8 00 00 00 00 ZZZ $108.90

28270 2 00 00 00 00 ZZZ $309.10

28270 8 00 00 00 00 ZZZ $61.82

28272 2 00 00 00 00 ZZZ $208.76

28272 8 00 00 00 00 ZZZ $41.75

28280 2 00 00 00 00 ZZZ $264.62

28280 8 00 00 00 00 ZZZ $52.92

28285 2 00 00 00 00 ZZZ $275.90

28285 8 00 00 00 00 ZZZ $55.18

28286 2 00 00 00 00 ZZZ $282.70

28286 8 00 00 00 00 ZZZ $56.54

28288 2 00 00 00 00 ZZZ $275.11

28288 8 00 00 00 00 ZZZ $55.02

28289 2 00 00 00 00 ZZZ $422.43

28289 8 00 00 00 00 ZZZ $84.49

28292 2 00 00 00 00 ZZZ $642.40

28292 8 00 00 00 00 ZZZ $128.48

28295 2 00 00 00 00 ZZZ $1,085.27

28295 8 00 00 00 00 ZZZ $217.05

28296 2 00 00 00 00 ZZZ $882.13

Page 97: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28296 8 00 00 00 00 ZZZ $176.43

28297 2 00 00 00 00 ZZZ $649.00

28297 8 00 00 00 00 ZZZ $129.80

28298 2 00 00 00 00 ZZZ $450.04

28298 8 00 00 00 00 ZZZ $90.01

28299 2 00 00 00 00 ZZZ $781.00

28299 8 00 00 00 00 ZZZ $156.20

28300 2 00 00 00 00 ZZZ $518.75

28300 8 00 00 00 00 ZZZ $103.75

28302 2 00 00 00 00 ZZZ $554.16

28302 8 00 00 00 00 ZZZ $110.83

28304 2 00 00 00 00 ZZZ $462.37

28304 8 00 00 00 00 ZZZ $92.47

28305 2 00 00 00 00 ZZZ $613.69

28305 8 00 00 00 00 ZZZ $122.74

28306 2 00 00 00 00 ZZZ $385.00

28306 8 00 00 00 00 ZZZ $77.00

28307 2 00 00 00 00 ZZZ $522.39

28307 8 00 00 00 00 ZZZ $104.48

28308 2 00 00 00 00 ZZZ $352.00

28308 8 00 00 00 00 ZZZ $70.40

28309 2 00 00 00 00 ZZZ $821.11

28309 8 00 00 00 00 ZZZ $164.22

28310 2 00 00 00 00 ZZZ $301.07

28310 8 00 00 00 00 ZZZ $60.21

28312 2 00 00 00 00 ZZZ $298.10

28312 8 00 00 00 00 ZZZ $59.62

28313 2 00 00 00 00 ZZZ $273.28

28313 8 00 00 00 00 ZZZ $54.66

28315 2 00 00 00 00 ZZZ $275.37

28315 8 00 00 00 00 ZZZ $55.07

28320 2 00 00 00 00 ZZZ $496.72

28320 8 00 00 00 00 ZZZ $99.34

28322 2 00 00 00 00 ZZZ $397.85

28322 8 00 00 00 00 ZZZ $79.57

28340 2 00 00 00 00 ZZZ $386.57

28340 8 00 00 00 00 ZZZ $77.31

28341 2 00 00 00 00 ZZZ $448.99

28341 8 00 00 00 00 ZZZ $89.80

28344 2 00 00 00 00 ZZZ $398.20

Page 98: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28344 8 00 00 00 00 ZZZ $79.64

28345 2 00 00 00 00 ZZZ $460.90

28345 8 00 00 00 00 ZZZ $92.18

28360 2 00 00 00 00 ZZZ $713.61

28360 8 00 00 00 00 ZZZ $142.72

28400 2 00 00 00 00 ZZZ $189.88

28400 8 00 00 00 00 ZZZ $37.98

28405 2 00 00 00 00 ZZZ $281.93

28405 8 00 00 00 00 ZZZ $56.39

28406 2 00 00 00 00 ZZZ $396.00

28406 8 00 00 00 00 ZZZ $79.20

28415 2 00 00 00 00 ZZZ $1,058.22

28415 8 00 00 00 00 ZZZ $211.64

28420 2 00 00 00 00 ZZZ $1,106.74

28420 8 00 00 00 00 ZZZ $221.35

28430 2 00 00 00 00 ZZZ $181.22

28430 8 00 00 00 00 ZZZ $36.24

28435 2 00 00 00 00 ZZZ $315.70

28435 8 00 00 00 00 ZZZ $63.14

28436 2 00 00 00 00 ZZZ $276.16

28436 8 00 00 00 00 ZZZ $55.23

28445 2 00 00 00 00 ZZZ $595.10

28445 8 00 00 00 00 ZZZ $119.02

28446 2 00 00 00 00 ZZZ $1,437.42

28446 8 00 00 00 00 ZZZ $287.48

28450 2 00 00 00 00 ZZZ $162.86

28450 8 00 00 00 00 ZZZ $32.57

28455 2 00 00 00 00 ZZZ $191.45

28455 8 00 00 00 00 ZZZ $38.29

28456 2 00 00 00 00 ZZZ $173.61

28456 8 00 00 00 00 ZZZ $34.72

28465 2 00 00 00 00 ZZZ $550.22

28465 8 00 00 00 00 ZZZ $110.04

28470 2 00 00 00 00 ZZZ $158.93

28470 8 00 00 00 00 ZZZ $31.79

28475 2 00 00 00 00 ZZZ $203.50

28475 8 00 00 00 00 ZZZ $40.70

28476 2 00 00 00 00 ZZZ $217.15

28476 8 00 00 00 00 ZZZ $43.43

28485 2 00 00 00 00 ZZZ $500.66

Page 99: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28485 8 00 00 00 00 ZZZ $100.13

28490 2 00 00 00 00 ZZZ $72.12

28490 8 00 00 00 00 ZZZ $14.42

28495 2 00 00 00 00 ZZZ $91.30

28495 8 00 00 00 00 ZZZ $18.26

28496 2 00 00 00 00 ZZZ $183.32

28496 8 00 00 00 00 ZZZ $36.66

28505 2 00 00 00 00 ZZZ $385.26

28505 8 00 00 00 00 ZZZ $77.05

28510 2 00 00 00 00 ZZZ $68.45

28510 8 00 00 00 00 ZZZ $13.69

28515 2 00 00 00 00 ZZZ $86.90

28515 8 00 00 00 00 ZZZ $17.38

28525 2 00 00 00 00 ZZZ $338.84

28525 8 00 00 00 00 ZZZ $67.77

28530 2 00 00 00 00 ZZZ $95.46

28530 8 00 00 00 00 ZZZ $19.09

28540 2 00 00 00 00 ZZZ $121.16

28540 8 00 00 00 00 ZZZ $24.23

28545 2 00 00 00 00 ZZZ $135.85

28545 8 00 00 00 00 ZZZ $27.17

28546 2 00 00 00 00 ZZZ $193.55

28546 8 00 00 00 00 ZZZ $38.71

28555 2 00 00 00 00 ZZZ $389.20

28555 8 00 00 00 00 ZZZ $77.84

28570 2 00 00 00 00 ZZZ $135.59

28570 8 00 00 00 00 ZZZ $27.12

28575 2 00 00 00 00 ZZZ $195.80

28575 8 00 00 00 00 ZZZ $39.16

28576 2 00 00 00 00 ZZZ $227.64

28576 8 00 00 00 00 ZZZ $45.53

28585 2 00 00 00 00 ZZZ $480.20

28585 8 00 00 00 00 ZZZ $96.04

28600 2 00 00 00 00 ZZZ $135.59

28600 8 00 00 00 00 ZZZ $27.12

28605 2 00 00 00 00 ZZZ $188.83

28605 8 00 00 00 00 ZZZ $37.77

28606 2 00 00 00 00 ZZZ $367.16

28606 8 00 00 00 00 ZZZ $73.43

28615 2 00 00 00 00 ZZZ $610.54

Page 100: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28615 8 00 00 00 00 ZZZ $122.11

28630 2 00 00 00 00 ZZZ $86.28

28630 8 00 00 00 00 ZZZ $17.26

28635 2 00 00 00 00 ZZZ $112.51

28635 8 00 00 00 00 ZZZ $22.50

28636 2 00 00 00 00 ZZZ $189.61

28636 8 00 00 00 00 ZZZ $37.92

28645 2 00 00 00 00 ZZZ $266.45

28645 8 00 00 00 00 ZZZ $53.29

28660 2 00 00 00 00 ZZZ $94.41

28660 8 00 00 00 00 ZZZ $18.88

28665 2 00 00 00 00 ZZZ $109.62

28665 8 00 00 00 00 ZZZ $21.92

28666 2 00 00 00 00 ZZZ $221.35

28666 8 00 00 00 00 ZZZ $44.27

28675 2 00 00 00 00 ZZZ $273.28

28675 8 00 00 00 00 ZZZ $54.66

28705 2 00 00 00 00 ZZZ $1,107.70

28705 8 00 00 00 00 ZZZ $221.54

28715 2 00 00 00 00 ZZZ $1,180.30

28715 8 00 00 00 00 ZZZ $236.06

28725 2 00 00 00 00 ZZZ $711.70

28725 8 00 00 00 00 ZZZ $142.34

28730 2 00 00 00 00 ZZZ $595.10

28730 8 00 00 00 00 ZZZ $119.02

28735 2 00 00 00 00 ZZZ $573.04

28735 8 00 00 00 00 ZZZ $114.61

28737 2 00 00 00 00 ZZZ $520.33

28737 8 00 00 00 00 ZZZ $104.07

28740 2 00 00 00 00 ZZZ $428.54

28740 8 00 00 00 00 ZZZ $85.71

28750 2 00 00 00 00 ZZZ $411.48

28750 8 00 00 00 00 ZZZ $82.30

28755 2 00 00 00 00 ZZZ $298.10

28755 8 00 00 00 00 ZZZ $59.62

28760 2 00 00 00 00 ZZZ $413.60

28760 8 00 00 00 00 ZZZ $82.72

28800 2 00 00 00 00 ZZZ $595.10

28800 8 00 00 00 00 ZZZ $119.02

28805 2 00 00 00 00 ZZZ $526.90

Page 101: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

28805 8 00 00 00 00 ZZZ $105.38

28810 2 00 00 00 00 ZZZ $366.30

28810 8 00 00 00 00 ZZZ $73.26

28820 2 00 00 00 00 ZZZ $274.59

28820 8 00 00 00 00 ZZZ $54.92

28825 2 00 00 00 00 ZZZ $239.97

28825 8 00 00 00 00 ZZZ $47.99

28890 2 00 00 00 00 ZZZ $411.64

28890 8 00 00 00 00 ZZZ $82.33

28899 2 00 00 00 00 ZZZ $0.00

28899 8 00 00 00 00 ZZZ $0.00

29000 2 00 00 00 00 ZZZ $265.10

29000 8 00 00 00 00 ZZZ $53.02

29010 2 00 00 00 00 ZZZ $223.71

29010 8 00 00 00 00 ZZZ $44.74

29015 2 00 00 00 00 ZZZ $282.70

29015 8 00 00 00 00 ZZZ $56.54

29035 2 00 00 00 00 ZZZ $236.03

29035 8 00 00 00 00 ZZZ $47.21

29040 2 00 00 00 00 ZZZ $204.56

29040 8 00 00 00 00 ZZZ $40.91

29044 2 00 00 00 00 ZZZ $287.44

29044 8 00 00 00 00 ZZZ $57.49

29046 2 00 00 00 00 ZZZ $297.93

29046 8 00 00 00 00 ZZZ $59.59

29049 2 00 00 00 00 ZZZ $109.10

29049 8 00 00 00 00 ZZZ $21.82

29055 2 00 00 00 00 ZZZ $193.55

29055 8 00 00 00 00 ZZZ $38.71

29058 2 00 00 00 00 ZZZ $131.39

29058 8 00 00 00 00 ZZZ $26.28

29065 2 00 00 00 00 ZZZ $93.37

29065 8 00 00 00 00 ZZZ $18.67

29075 2 00 00 00 00 ZZZ $81.82

29075 8 00 00 00 00 ZZZ $16.36

29085 2 00 00 00 00 ZZZ $82.09

29085 8 00 00 00 00 ZZZ $16.42

29086 2 00 00 00 00 ZZZ $61.88

29086 8 00 00 00 00 ZZZ $12.38

29105 2 00 00 00 00 ZZZ $69.76

Page 102: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

29105 8 00 00 00 00 ZZZ $13.95

29125 2 00 00 00 00 ZZZ $53.50

29125 8 00 00 00 00 ZZZ $10.70

29126 2 00 00 00 00 ZZZ $65.30

29126 8 00 00 00 00 ZZZ $13.06

29130 2 00 00 00 00 ZZZ $27.01

29130 8 00 00 00 00 ZZZ $5.40

29131 2 00 00 00 00 ZZZ $38.81

29131 8 00 00 00 00 ZZZ $7.76

29200 2 00 00 00 00 ZZZ $39.87

29200 8 00 00 00 00 ZZZ $7.97

29240 2 00 00 00 00 ZZZ $41.44

29240 8 00 00 00 00 ZZZ $8.29

29260 2 00 00 00 00 ZZZ $32.78

29260 8 00 00 00 00 ZZZ $6.56

29280 2 00 00 00 00 ZZZ $31.73

29280 8 00 00 00 00 ZZZ $6.35

29305 2 00 00 00 00 ZZZ $240.75

29305 8 00 00 00 00 ZZZ $48.15

29325 2 00 00 00 00 ZZZ $215.32

29325 8 00 00 00 00 ZZZ $43.06

29345 2 00 00 00 00 ZZZ $127.60

29345 8 00 00 00 00 ZZZ $25.52

29355 2 00 00 00 00 ZZZ $134.01

29355 8 00 00 00 00 ZZZ $26.80

29358 2 00 00 00 00 ZZZ $257.40

29358 8 00 00 00 00 ZZZ $51.48

29365 2 00 00 00 00 ZZZ $106.74

29365 8 00 00 00 00 ZZZ $21.35

29405 2 00 00 00 00 ZZZ $105.60

29405 8 00 00 00 00 ZZZ $21.12

29425 2 00 00 00 00 ZZZ $105.60

29425 8 00 00 00 00 ZZZ $21.12

29435 2 00 00 00 00 ZZZ $131.39

29435 8 00 00 00 00 ZZZ $26.28

29440 2 00 00 00 00 ZZZ $49.57

29440 8 00 00 00 00 ZZZ $9.91

29445 2 00 00 00 00 ZZZ $155.73

29445 8 00 00 00 00 ZZZ $31.15

29450 2 00 00 00 00 ZZZ $71.86

Page 103: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

29450 8 00 00 00 00 ZZZ $14.37

29505 2 00 00 00 00 ZZZ $69.76

29505 8 00 00 00 00 ZZZ $13.95

29515 2 00 00 00 00 ZZZ $59.54

29515 8 00 00 00 00 ZZZ $11.91

29520 2 00 00 00 00 ZZZ $35.41

29520 8 00 00 00 00 ZZZ $7.08

29530 2 00 00 00 00 ZZZ $35.93

29530 8 00 00 00 00 ZZZ $7.19

29540 2 00 00 00 00 ZZZ $25.18

29540 8 00 00 00 00 ZZZ $5.04

29550 2 00 00 00 00 ZZZ $23.08

29550 8 00 00 00 00 ZZZ $4.62

29580 2 00 00 00 00 ZZZ $40.39

29580 8 00 00 00 00 ZZZ $8.08

29581 2 00 00 00 00 ZZZ $113.82

29581 8 00 00 00 00 ZZZ $22.76

29582 2 00 00 00 00 ZZZ $63.21

29582 8 00 00 00 00 ZZZ $13.00

29583 2 00 00 00 00 ZZZ $37.14

29583 8 00 00 00 00 ZZZ $7.00

29584 2 00 00 00 00 ZZZ $63.21

29584 8 00 00 00 00 ZZZ $13.00

29700 2 00 00 00 00 ZZZ $30.69

29700 8 00 00 00 00 ZZZ $6.14

29705 2 00 00 00 00 ZZZ $38.55

29705 8 00 00 00 00 ZZZ $7.71

29710 2 00 00 00 00 ZZZ $63.99

29710 8 00 00 00 00 ZZZ $12.80

29720 2 00 00 00 00 ZZZ $80.25

29720 8 00 00 00 00 ZZZ $16.05

29730 2 00 00 00 00 ZZZ $36.72

29730 8 00 00 00 00 ZZZ $7.34

29740 2 00 00 00 00 ZZZ $76.84

29740 8 00 00 00 00 ZZZ $15.37

29750 2 00 00 00 00 ZZZ $72.65

29750 8 00 00 00 00 ZZZ $14.53

29799 2 00 00 00 00 ZZZ $0.00

29799 8 00 00 00 00 ZZZ $0.00

29800 2 00 00 00 00 ZZZ $336.22

Page 104: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

29800 8 00 00 00 00 ZZZ $67.24

29804 2 00 00 00 00 ZZZ $466.30

29804 8 00 00 00 00 ZZZ $93.26

29805 2 00 00 00 00 ZZZ $410.48

29805 8 00 00 00 00 ZZZ $82.10

29806 2 00 00 00 00 ZZZ $1,143.14

29806 8 00 00 00 00 ZZZ $228.63

29807 2 00 00 00 00 ZZZ $1,112.61

29807 8 00 00 00 00 ZZZ $222.52

29819 2 00 00 00 00 ZZZ $599.50

29819 8 00 00 00 00 ZZZ $119.90

29820 2 00 00 00 00 ZZZ $464.20

29820 8 00 00 00 00 ZZZ $92.84

29821 2 00 00 00 00 ZZZ $693.00

29821 8 00 00 00 00 ZZZ $138.60

29822 2 00 00 00 00 ZZZ $661.10

29822 8 00 00 00 00 ZZZ $132.22

29823 2 00 00 00 00 ZZZ $762.30

29823 8 00 00 00 00 ZZZ $152.46

29824 2 00 00 00 00 ZZZ $696.78

29824 8 00 00 00 00 ZZZ $139.36

29825 2 00 00 00 00 ZZZ $661.10

29825 8 00 00 00 00 ZZZ $132.22

29826 2 00 00 00 00 ZZZ $760.10

29826 8 00 00 00 00 ZZZ $152.02

29827 2 00 00 00 00 ZZZ $1,186.87

29827 8 00 00 00 00 ZZZ $237.37

29828 2 00 00 00 00 ZZZ $1,107.34

29828 8 00 00 00 00 ZZZ $221.47

29830 2 00 00 00 00 ZZZ $521.40

29830 8 00 00 00 00 ZZZ $104.28

29834 2 00 00 00 00 ZZZ $521.40

29834 8 00 00 00 00 ZZZ $104.28

29835 2 00 00 00 00 ZZZ $547.80

29835 8 00 00 00 00 ZZZ $109.56

29836 2 00 00 00 00 ZZZ $601.70

29836 8 00 00 00 00 ZZZ $120.34

29837 2 00 00 00 00 ZZZ $574.20

29837 8 00 00 00 00 ZZZ $114.84

29838 2 00 00 00 00 ZZZ $662.20

Page 105: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

29838 8 00 00 00 00 ZZZ $132.44

29840 2 00 00 00 00 ZZZ $521.40

29840 8 00 00 00 00 ZZZ $104.28

29843 2 00 00 00 00 ZZZ $547.80

29843 8 00 00 00 00 ZZZ $109.56

29844 2 00 00 00 00 ZZZ $574.20

29844 8 00 00 00 00 ZZZ $114.84

29845 2 00 00 00 00 ZZZ $601.70

29845 8 00 00 00 00 ZZZ $120.34

29846 2 00 00 00 00 ZZZ $660.00

29846 8 00 00 00 00 ZZZ $132.00

29847 2 00 00 00 00 ZZZ $605.92

29847 8 00 00 00 00 ZZZ $121.18

29848 2 00 00 00 00 ZZZ $671.39

29848 8 00 00 00 00 ZZZ $134.28

29850 2 00 00 00 00 ZZZ $675.40

29850 8 00 00 00 00 ZZZ $135.08

29851 2 00 00 00 00 ZZZ $677.42

29851 8 00 00 00 00 ZZZ $135.48

29855 2 00 00 00 00 ZZZ $1,016.40

29855 8 00 00 00 00 ZZZ $203.28

29856 2 00 00 00 00 ZZZ $1,016.40

29856 8 00 00 00 00 ZZZ $203.28

29860 2 00 00 00 00 ZZZ $563.11

29860 8 00 00 00 00 ZZZ $112.62

29861 2 00 00 00 00 ZZZ $835.79

29861 8 00 00 00 00 ZZZ $167.16

29862 2 00 00 00 00 ZZZ $919.55

29862 8 00 00 00 00 ZZZ $183.91

29863 2 00 00 00 00 ZZZ $839.51

29863 8 00 00 00 00 ZZZ $167.90

29866 2 00 00 00 00 ZZZ $1,287.29

29866 8 00 00 00 00 ZZZ $257.46

29867 2 00 00 00 00 ZZZ $1,537.66

29867 8 00 00 00 00 ZZZ $307.53

29868 2 00 00 00 00 ZZZ $2,084.56

29868 8 00 00 00 00 ZZZ $416.91

29870 2 00 00 00 00 ZZZ $584.00

29870 8 00 00 00 00 ZZZ $117.00

29871 2 00 00 00 00 ZZZ $726.00

Page 106: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

29871 8 00 00 00 00 ZZZ $145.00

29873 2 00 00 00 00 ZZZ $548.25

29873 8 00 00 00 00 ZZZ $109.65

29874 2 00 00 00 00 ZZZ $743.00

29874 8 00 00 00 00 ZZZ $149.00

29875 2 00 00 00 00 ZZZ $816.50

29875 8 00 00 00 00 ZZZ $163.30

29876 2 00 00 00 00 ZZZ $1,012.91

29876 8 00 00 00 00 ZZZ $202.58

29877 2 00 00 00 00 ZZZ $936.56

29877 8 00 00 00 00 ZZZ $187.31

29879 2 00 00 00 00 ZZZ $1,015.24

29879 8 00 00 00 00 ZZZ $203.05

29880 2 00 00 00 00 ZZZ $1,069.44

29880 8 00 00 00 00 ZZZ $213.89

29881 2 00 00 00 00 ZZZ $983.77

29881 8 00 00 00 00 ZZZ $196.75

29882 2 00 00 00 00 ZZZ $1,084.59

29882 8 00 00 00 00 ZZZ $216.92

29883 2 00 00 00 00 ZZZ $1,178.42

29883 8 00 00 00 00 ZZZ $235.68

29884 2 00 00 00 00 ZZZ $955.21

29884 8 00 00 00 00 ZZZ $191.00

29885 2 00 00 00 00 ZZZ $1,101.49

29885 8 00 00 00 00 ZZZ $220.30

29886 2 00 00 00 00 ZZZ $923.16

29886 8 00 00 00 00 ZZZ $184.63

29887 2 00 00 00 00 ZZZ $1,146.37

29887 8 00 00 00 00 ZZZ $229.27

29888 2 00 00 00 00 ZZZ $1,716.35

29888 8 00 00 00 00 ZZZ $343.27

29889 2 00 00 00 00 ZZZ $1,512.23

29889 8 00 00 00 00 ZZZ $302.45

29891 2 00 00 00 00 ZZZ $785.06

29891 8 00 00 00 00 ZZZ $157.01

29892 2 00 00 00 00 ZZZ $809.81

29892 8 00 00 00 00 ZZZ $161.96

29893 2 00 00 00 00 ZZZ $448.84

29893 8 00 00 00 00 ZZZ $89.77

29894 2 00 00 00 00 ZZZ $521.40

Page 107: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

29894 8 00 00 00 00 ZZZ $104.28

29895 2 00 00 00 00 ZZZ $509.30

29895 8 00 00 00 00 ZZZ $101.86

29897 2 00 00 00 00 ZZZ $601.70

29897 8 00 00 00 00 ZZZ $120.34

29898 2 00 00 00 00 ZZZ $662.20

29898 8 00 00 00 00 ZZZ $132.44

29899 2 00 00 00 00 ZZZ $1,090.74

29899 8 00 00 00 00 ZZZ $218.15

29900 2 00 00 00 00 ZZZ $494.63

29900 8 00 00 00 00 ZZZ $98.93

29901 2 00 00 00 00 ZZZ $545.37

29901 8 00 00 00 00 ZZZ $109.07

29902 2 00 00 00 00 ZZZ $585.39

29902 8 00 00 00 00 ZZZ $117.08

29904 2 00 00 00 00 ZZZ $741.71

29904 8 00 00 00 00 ZZZ $148.34

29905 2 00 00 00 00 ZZZ $798.62

29905 8 00 00 00 00 ZZZ $159.72

29906 2 00 00 00 00 ZZZ $841.30

29906 8 00 00 00 00 ZZZ $168.26

29907 2 00 00 00 00 ZZZ $1,032.42

29907 8 00 00 00 00 ZZZ $206.48

29914 2 00 00 00 00 ZZZ $1,310.93

29914 8 00 00 00 00 ZZZ $262.19

29915 2 00 00 00 00 ZZZ $1,336.00

29915 8 00 00 00 00 ZZZ $267.20

29916 2 00 00 00 00 ZZZ $1,336.00

29916 8 00 00 00 00 ZZZ $267.20

29999 2 00 00 00 00 ZZZ $0.00

29999 8 00 00 00 00 ZZZ $0.00

30000 2 00 00 00 00 ZZZ $76.32

30000 8 00 00 00 00 ZZZ $15.26

30020 2 00 00 00 00 ZZZ $123.20

30020 8 00 00 00 00 ZZZ $24.64

30100 2 00 00 00 00 ZZZ $71.50

30100 8 00 00 00 00 ZZZ $14.30

30110 2 00 00 00 00 ZZZ $208.06

30110 8 00 00 00 00 ZZZ $41.61

30115 2 00 00 00 00 ZZZ $319.00

Page 108: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

30115 8 00 00 00 00 ZZZ $63.80

30117 2 00 00 00 00 ZZZ $304.70

30117 8 00 00 00 00 ZZZ $60.94

30118 2 00 00 00 00 ZZZ $488.07

30118 8 00 00 00 00 ZZZ $97.61

30120 2 00 00 00 00 ZZZ $530.11

30120 8 00 00 00 00 ZZZ $106.02

30124 2 00 00 00 00 ZZZ $144.77

30124 8 00 00 00 00 ZZZ $28.95

30125 2 00 00 00 00 ZZZ $356.94

30125 8 00 00 00 00 ZZZ $71.39

30130 2 00 00 00 00 ZZZ $297.00

30130 8 00 00 00 00 ZZZ $59.00

30140 2 00 00 00 00 ZZZ $290.40

30140 8 00 00 00 00 ZZZ $58.08

30150 2 00 00 00 00 ZZZ $508.20

30150 8 00 00 00 00 ZZZ $101.64

30160 2 00 00 00 00 ZZZ $763.40

30160 8 00 00 00 00 ZZZ $152.68

30200 2 00 00 00 00 ZZZ $40.65

30200 8 00 00 00 00 ZZZ $8.13

30210 2 00 00 00 00 ZZZ $56.91

30210 8 00 00 00 00 ZZZ $11.38

30220 2 00 00 00 00 ZZZ $130.24

30220 8 00 00 00 00 ZZZ $26.05

30300 2 00 00 00 00 ZZZ $64.26

30300 8 00 00 00 00 ZZZ $12.85

30310 2 00 00 00 00 ZZZ $179.97

30310 8 00 00 00 00 ZZZ $35.99

30320 2 00 00 00 00 ZZZ $381.70

30320 8 00 00 00 00 ZZZ $76.34

30400 2 00 00 00 00 ZZZ $613.80

30400 8 00 00 00 00 ZZZ $122.76

30410 2 00 00 00 00 ZZZ $1,234.20

30410 8 00 00 00 00 ZZZ $246.84

30420 2 00 00 00 00 ZZZ $1,650.00

30420 8 00 00 00 00 ZZZ $330.00

30430 2 00 00 00 00 ZZZ $372.93

30430 8 00 00 00 00 ZZZ $74.59

30435 2 00 00 00 00 ZZZ $927.29

Page 109: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

30435 8 00 00 00 00 ZZZ $185.46

30450 2 00 00 00 00 ZZZ $861.26

30450 8 00 00 00 00 ZZZ $172.25

30460 2 00 00 00 00 ZZZ $782.18

30460 8 00 00 00 00 ZZZ $156.44

30462 2 00 00 00 00 ZZZ $1,567.89

30462 8 00 00 00 00 ZZZ $313.58

30465 2 00 00 00 00 ZZZ $890.25

30465 8 00 00 00 00 ZZZ $178.05

30520 2 00 00 00 00 ZZZ $706.35

30520 8 00 00 00 00 ZZZ $141.27

30540 2 00 00 00 00 ZZZ $569.80

30540 8 00 00 00 00 ZZZ $113.96

30545 2 00 00 00 00 ZZZ $1,039.71

30545 8 00 00 00 00 ZZZ $207.94

30560 2 00 00 00 00 ZZZ $68.71

30560 8 00 00 00 00 ZZZ $13.74

30580 2 00 00 00 00 ZZZ $522.50

30580 8 00 00 00 00 ZZZ $104.50

30600 2 00 00 00 00 ZZZ $493.75

30600 8 00 00 00 00 ZZZ $98.75

30620 2 00 00 00 00 ZZZ $746.57

30620 8 00 00 00 00 ZZZ $149.31

30630 2 00 00 00 00 ZZZ $710.00

30630 8 00 00 00 00 ZZZ $142.00

30801 2 00 00 00 00 ZZZ $65.57

30801 8 00 00 00 00 ZZZ $13.11

30802 2 00 00 00 00 ZZZ $119.90

30802 8 00 00 00 00 ZZZ $23.98

30901 2 00 00 00 00 ZZZ $67.14

30901 8 00 00 00 00 ZZZ $13.43

30903 2 00 00 00 00 ZZZ $97.90

30903 8 00 00 00 00 ZZZ $19.58

30905 2 00 00 00 00 ZZZ $195.80

30905 8 00 00 00 00 ZZZ $39.16

30906 2 00 00 00 00 ZZZ $140.57

30906 8 00 00 00 00 ZZZ $28.11

30915 2 00 00 00 00 ZZZ $530.20

30915 8 00 00 00 00 ZZZ $106.04

30920 2 00 00 00 00 ZZZ $913.83

Page 110: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

30920 8 00 00 00 00 ZZZ $182.77

30930 2 00 00 00 00 ZZZ $111.13

30930 8 00 00 00 00 ZZZ $22.23

30999 2 00 00 00 00 ZZZ $0.00

30999 8 00 00 00 00 ZZZ $0.00

31000 2 00 00 00 00 ZZZ $64.52

31000 8 00 00 00 00 ZZZ $12.90

31002 2 00 00 00 00 ZZZ $108.90

31002 8 00 00 00 00 ZZZ $21.78

31020 2 00 00 00 00 ZZZ $360.00

31020 8 00 00 00 00 ZZZ $72.00

31030 2 00 00 00 00 ZZZ $647.00

31030 8 00 00 00 00 ZZZ $129.00

31032 2 00 00 00 00 ZZZ $625.74

31032 8 00 00 00 00 ZZZ $125.15

31040 2 00 00 00 00 ZZZ $818.25

31040 8 00 00 00 00 ZZZ $163.65

31050 2 00 00 00 00 ZZZ $388.30

31050 8 00 00 00 00 ZZZ $77.66

31051 2 00 00 00 00 ZZZ $389.98

31051 8 00 00 00 00 ZZZ $78.00

31070 2 00 00 00 00 ZZZ $427.90

31070 8 00 00 00 00 ZZZ $85.58

31075 2 00 00 00 00 ZZZ $974.00

31075 8 00 00 00 00 ZZZ $195.00

31080 2 00 00 00 00 ZZZ $1,205.00

31080 8 00 00 00 00 ZZZ $241.00

31081 2 00 00 00 00 ZZZ $908.60

31081 8 00 00 00 00 ZZZ $181.72

31084 2 00 00 00 00 ZZZ $851.40

31084 8 00 00 00 00 ZZZ $170.28

31085 2 00 00 00 00 ZZZ $851.40

31085 8 00 00 00 00 ZZZ $170.28

31086 2 00 00 00 00 ZZZ $1,103.30

31086 8 00 00 00 00 ZZZ $220.66

31087 2 00 00 00 00 ZZZ $1,103.30

31087 8 00 00 00 00 ZZZ $220.66

31090 2 00 00 00 00 ZZZ $1,122.00

31090 8 00 00 00 00 ZZZ $224.00

31200 2 00 00 00 00 ZZZ $385.00

Page 111: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31200 8 00 00 00 00 ZZZ $77.00

31201 2 00 00 00 00 ZZZ $628.10

31201 8 00 00 00 00 ZZZ $125.62

31205 2 00 00 00 00 ZZZ $678.70

31205 8 00 00 00 00 ZZZ $135.74

31225 2 00 00 00 00 ZZZ $1,325.50

31225 8 00 00 00 00 ZZZ $265.10

31230 2 00 00 00 00 ZZZ $1,488.30

31230 8 00 00 00 00 ZZZ $297.66

31231 2 00 00 00 00 ZZZ $116.60

31231 8 00 00 00 00 ZZZ $23.32

31233 2 00 00 00 00 ZZZ $192.50

31233 8 00 00 00 00 ZZZ $38.50

31235 2 00 00 00 00 ZZZ $307.00

31235 8 00 00 00 00 ZZZ $61.00

31237 2 00 00 00 00 ZZZ $168.11

31237 8 00 00 00 00 ZZZ $33.62

31238 2 00 00 00 00 ZZZ $185.42

31238 8 00 00 00 00 ZZZ $37.08

31239 2 00 00 00 00 ZZZ $461.84

31239 8 00 00 00 00 ZZZ $92.37

31240 2 00 00 00 00 ZZZ $151.80

31240 8 00 00 00 00 ZZZ $30.36

31254 2 00 00 00 00 ZZZ $428.57

31254 8 00 00 00 00 ZZZ $85.71

31255 2 00 00 00 00 ZZZ $646.72

31255 8 00 00 00 00 ZZZ $129.34

31256 2 00 00 00 00 ZZZ $301.19

31256 8 00 00 00 00 ZZZ $60.24

31267 2 00 00 00 00 ZZZ $480.22

31267 8 00 00 00 00 ZZZ $96.04

31276 2 00 00 00 00 ZZZ $620.79

31276 8 00 00 00 00 ZZZ $124.16

31287 2 00 00 00 00 ZZZ $201.94

31287 8 00 00 00 00 ZZZ $40.39

31288 2 00 00 00 00 ZZZ $235.77

31288 8 00 00 00 00 ZZZ $47.15

31290 2 00 00 00 00 ZZZ $1,415.82

31290 8 00 00 00 00 ZZZ $283.16

31291 2 00 00 00 00 ZZZ $1,454.19

Page 112: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31291 8 00 00 00 00 ZZZ $290.84

31292 2 00 00 00 00 ZZZ $735.90

31292 8 00 00 00 00 ZZZ $147.18

31293 2 00 00 00 00 ZZZ $801.99

31293 8 00 00 00 00 ZZZ $160.40

31294 2 00 00 00 00 ZZZ $945.71

31294 8 00 00 00 00 ZZZ $189.14

31295 2 00 00 00 00 ZZZ $225.40

31295 8 00 00 00 00 ZZZ $45.08

31296 2 00 00 00 00 ZZZ $269.88

31296 8 00 00 00 00 ZZZ $53.98

31297 2 00 00 00 00 ZZZ $220.60

31297 8 00 00 00 00 ZZZ $44.12

31299 2 00 00 00 00 ZZZ $0.00

31299 8 00 00 00 00 ZZZ $0.00

31300 2 00 00 00 00 ZZZ $834.90

31300 8 00 00 00 00 ZZZ $166.98

31320 2 00 00 00 00 ZZZ $445.50

31320 8 00 00 00 00 ZZZ $89.10

31360 2 00 00 00 00 ZZZ $1,325.50

31360 8 00 00 00 00 ZZZ $265.10

31365 2 00 00 00 00 ZZZ $1,978.90

31365 8 00 00 00 00 ZZZ $395.78

31367 2 00 00 00 00 ZZZ $1,633.50

31367 8 00 00 00 00 ZZZ $326.70

31368 2 00 00 00 00 ZZZ $1,978.90

31368 8 00 00 00 00 ZZZ $395.78

31370 2 00 00 00 00 ZZZ $1,488.30

31370 8 00 00 00 00 ZZZ $297.66

31375 2 00 00 00 00 ZZZ $1,488.30

31375 8 00 00 00 00 ZZZ $297.66

31380 2 00 00 00 00 ZZZ $1,488.30

31380 8 00 00 00 00 ZZZ $297.66

31382 2 00 00 00 00 ZZZ $1,488.30

31382 8 00 00 00 00 ZZZ $297.66

31390 2 00 00 00 00 ZZZ $2,098.80

31390 8 00 00 00 00 ZZZ $419.76

31395 2 00 00 00 00 ZZZ $2,544.30

31395 8 00 00 00 00 ZZZ $508.86

31400 2 00 00 00 00 ZZZ $1,026.66

Page 113: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31400 8 00 00 00 00 ZZZ $205.33

31420 2 00 00 00 00 ZZZ $817.30

31420 8 00 00 00 00 ZZZ $163.46

31500 2 00 00 00 00 ZZZ $89.17

31500 8 00 00 00 00 ZZZ $17.83

31502 2 00 00 00 00 ZZZ $104.90

31502 8 00 00 00 00 ZZZ $20.98

31505 2 00 00 00 00 ZZZ $43.01

31505 8 00 00 00 00 ZZZ $8.60

31510 2 00 00 00 00 ZZZ $93.10

31510 8 00 00 00 00 ZZZ $18.62

31511 2 00 00 00 00 ZZZ $108.58

31511 8 00 00 00 00 ZZZ $21.72

31512 2 00 00 00 00 ZZZ $117.23

31512 8 00 00 00 00 ZZZ $23.45

31513 2 00 00 00 00 ZZZ $193.69

31513 8 00 00 00 00 ZZZ $38.74

31515 2 00 00 00 00 ZZZ $101.20

31515 8 00 00 00 00 ZZZ $20.24

31520 2 00 00 00 00 ZZZ $218.00

31520 8 00 00 00 00 ZZZ $44.00

31525 2 00 00 00 00 ZZZ $239.80

31525 8 00 00 00 00 ZZZ $47.96

31526 2 00 00 00 00 ZZZ $234.98

31526 8 00 00 00 00 ZZZ $47.00

31527 2 00 00 00 00 ZZZ $295.00

31527 8 00 00 00 00 ZZZ $59.00

31528 2 00 00 00 00 ZZZ $268.09

31528 8 00 00 00 00 ZZZ $53.62

31529 2 00 00 00 00 ZZZ $287.90

31529 8 00 00 00 00 ZZZ $57.58

31530 2 00 00 00 00 ZZZ $301.19

31530 8 00 00 00 00 ZZZ $60.24

31531 2 00 00 00 00 ZZZ $403.00

31531 8 00 00 00 00 ZZZ $81.00

31535 2 00 00 00 00 ZZZ $307.00

31535 8 00 00 00 00 ZZZ $61.00

31536 2 00 00 00 00 ZZZ $407.38

31536 8 00 00 00 00 ZZZ $81.48

31540 2 00 00 00 00 ZZZ $472.65

Page 114: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31540 8 00 00 00 00 ZZZ $94.53

31541 2 00 00 00 00 ZZZ $504.12

31541 8 00 00 00 00 ZZZ $100.82

31545 2 00 00 00 00 ZZZ $472.77

31545 8 00 00 00 00 ZZZ $94.55

31546 2 00 00 00 00 ZZZ $721.74

31546 8 00 00 00 00 ZZZ $144.35

31551 2 00 00 00 00 ZZZ $1,656.16

31551 8 00 00 00 00 ZZZ $331.23

31552 2 00 00 00 00 ZZZ $1,669.72

31552 8 00 00 00 00 ZZZ $333.94

31553 2 00 00 00 00 ZZZ $1,819.02

31553 8 00 00 00 00 ZZZ $363.80

31554 2 00 00 00 00 ZZZ $1,910.89

31554 8 00 00 00 00 ZZZ $382.18

31560 2 00 00 00 00 ZZZ $590.38

31560 8 00 00 00 00 ZZZ $118.08

31561 2 00 00 00 00 ZZZ $674.30

31561 8 00 00 00 00 ZZZ $134.86

31570 2 00 00 00 00 ZZZ $338.80

31570 8 00 00 00 00 ZZZ $67.76

31571 2 00 00 00 00 ZZZ $481.39

31571 8 00 00 00 00 ZZZ $96.28

31572 2 00 00 00 00 ZZZ $557.53

31572 8 00 00 00 00 ZZZ $111.51

31573 2 00 00 00 00 ZZZ $299.78

31573 8 00 00 00 00 ZZZ $59.96

31574 2 00 00 00 00 ZZZ $1,134.69

31574 8 00 00 00 00 ZZZ $226.94

31575 2 00 00 00 00 ZZZ $76.58

31575 8 00 00 00 00 ZZZ $15.32

31576 2 00 00 00 00 ZZZ $197.22

31576 8 00 00 00 00 ZZZ $39.44

31577 2 00 00 00 00 ZZZ $243.84

31577 8 00 00 00 00 ZZZ $48.77

31578 2 00 00 00 00 ZZZ $279.28

31578 8 00 00 00 00 ZZZ $55.86

31579 2 00 00 00 00 ZZZ $130.34

31579 8 00 00 00 00 ZZZ $26.07

31580 2 00 00 00 00 ZZZ $871.20

Page 115: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31580 8 00 00 00 00 ZZZ $174.24

31584 2 00 00 00 00 ZZZ $1,525.70

31584 8 00 00 00 00 ZZZ $305.14

31587 2 00 00 00 00 ZZZ $743.25

31587 8 00 00 00 00 ZZZ $148.65

31590 2 00 00 00 00 ZZZ $525.23

31590 8 00 00 00 00 ZZZ $105.05

31591 2 00 00 00 00 ZZZ $1,204.55

31591 8 00 00 00 00 ZZZ $240.91

31592 2 00 00 00 00 ZZZ $1,961.59

31592 8 00 00 00 00 ZZZ $392.32

31595 2 00 00 00 00 ZZZ $625.74

31595 8 00 00 00 00 ZZZ $125.15

31599 2 00 00 00 00 ZZZ $0.00

31599 8 00 00 00 00 ZZZ $0.00

31600 2 00 00 00 00 ZZZ $324.04

31600 8 00 00 00 00 ZZZ $64.81

31601 2 00 00 00 00 ZZZ $370.70

31601 8 00 00 00 00 ZZZ $74.14

31603 2 00 00 00 00 ZZZ $204.30

31603 8 00 00 00 00 ZZZ $40.86

31605 2 00 00 00 00 ZZZ $347.00

31605 8 00 00 00 00 ZZZ $70.00

31610 2 00 00 00 00 ZZZ $588.50

31610 8 00 00 00 00 ZZZ $117.70

31611 2 00 00 00 00 ZZZ $516.74

31611 8 00 00 00 00 ZZZ $103.35

31612 2 00 00 00 00 ZZZ $70.40

31612 8 00 00 00 00 ZZZ $14.08

31613 2 00 00 00 00 ZZZ $277.48

31613 8 00 00 00 00 ZZZ $55.50

31614 2 00 00 00 00 ZZZ $559.90

31614 8 00 00 00 00 ZZZ $111.98

31615 2 00 00 00 00 ZZZ $218.90

31615 8 00 00 00 00 ZZZ $43.78

31622 2 00 00 00 00 ZZZ $282.70

31622 8 00 00 00 00 ZZZ $56.54

31623 2 00 00 00 00 ZZZ $275.17

31623 8 00 00 00 00 ZZZ $55.03

31624 2 00 00 00 00 ZZZ $277.63

Page 116: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31624 8 00 00 00 00 ZZZ $55.53

31625 2 00 00 00 00 ZZZ $290.40

31625 8 00 00 00 00 ZZZ $58.08

31626 2 00 00 00 00 ZZZ $442.75

31626 8 00 00 00 00 ZZZ $88.55

31627 2 00 00 00 00 ZZZ $1,065.82

31627 8 00 00 00 00 ZZZ $213.16

31628 2 00 00 00 00 ZZZ $337.70

31628 8 00 00 00 00 ZZZ $67.54

31629 2 00 00 00 00 ZZZ $280.21

31629 8 00 00 00 00 ZZZ $56.04

31630 2 00 00 00 00 ZZZ $290.40

31630 8 00 00 00 00 ZZZ $58.08

31631 2 00 00 00 00 ZZZ $290.40

31631 8 00 00 00 00 ZZZ $58.08

31632 2 00 00 00 00 ZZZ $80.86

31632 8 00 00 00 00 ZZZ $16.17

31633 2 00 00 00 00 ZZZ $99.01

31633 8 00 00 00 00 ZZZ $19.80

31634 2 00 00 00 00 ZZZ $1,560.55

31634 8 00 00 00 00 ZZZ $312.11

31635 2 00 00 00 00 ZZZ $316.11

31635 8 00 00 00 00 ZZZ $63.22

31636 2 00 00 00 00 ZZZ $296.99

31636 8 00 00 00 00 ZZZ $59.40

31637 2 00 00 00 00 ZZZ $105.84

31637 8 00 00 00 00 ZZZ $21.17

31638 2 00 00 00 00 ZZZ $329.63

31638 8 00 00 00 00 ZZZ $65.93

31640 2 00 00 00 00 ZZZ $317.90

31640 8 00 00 00 00 ZZZ $63.58

31641 2 00 00 00 00 ZZZ $462.68

31641 8 00 00 00 00 ZZZ $92.54

31643 2 00 00 00 00 ZZZ $242.98

31643 8 00 00 00 00 ZZZ $48.60

31645 2 00 00 00 00 ZZZ $264.36

31645 8 00 00 00 00 ZZZ $52.87

31646 2 00 00 00 00 ZZZ $228.00

31646 8 00 00 00 00 ZZZ $46.00

31647 2 00 00 00 00 ZZZ $277.17

Page 117: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31647 8 00 00 00 00 ZZZ $55.43

31648 2 00 00 00 00 ZZZ $282.80

31648 8 00 00 00 00 ZZZ $56.56

31649 2 00 00 00 00 ZZZ $90.86

31649 8 00 00 00 00 ZZZ $18.17

31652 2 00 00 00 00 ZZZ $874.18

31652 8 00 00 00 00 ZZZ $174.84

31653 2 00 00 00 00 ZZZ $929.70

31653 8 00 00 00 00 ZZZ $185.94

31654 2 00 00 00 00 ZZZ $108.36

31654 8 00 00 00 00 ZZZ $21.67

31659 8 00 00 00 00 ZZZ $51.00

31660 2 00 00 00 00 ZZZ $275.17

31660 8 00 00 00 00 ZZZ $55.03

31661 2 00 00 00 00 ZZZ $291.05

31661 8 00 00 00 00 ZZZ $58.21

31717 2 00 00 00 00 ZZZ $231.00

31717 8 00 00 00 00 ZZZ $46.00

31720 2 00 00 00 00 ZZZ $63.73

31720 8 00 00 00 00 ZZZ $12.75

31725 2 00 00 00 00 ZZZ $112.20

31725 8 00 00 00 00 ZZZ $22.44

31730 2 00 00 00 00 ZZZ $145.29

31730 8 00 00 00 00 ZZZ $29.06

31750 2 00 00 00 00 ZZZ $682.14

31750 8 00 00 00 00 ZZZ $136.43

31755 2 00 00 00 00 ZZZ $1,081.30

31755 8 00 00 00 00 ZZZ $216.26

31760 2 00 00 00 00 ZZZ $1,081.30

31760 8 00 00 00 00 ZZZ $216.26

31766 2 00 00 00 00 ZZZ $1,379.75

31766 8 00 00 00 00 ZZZ $275.95

31770 2 00 00 00 00 ZZZ $1,082.08

31770 8 00 00 00 00 ZZZ $216.42

31775 2 00 00 00 00 ZZZ $1,176.24

31775 8 00 00 00 00 ZZZ $235.25

31780 2 00 00 00 00 ZZZ $1,197.90

31780 8 00 00 00 00 ZZZ $239.58

31781 2 00 00 00 00 ZZZ $1,197.90

31781 8 00 00 00 00 ZZZ $239.58

Page 118: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

31785 2 00 00 00 00 ZZZ $1,083.02

31785 8 00 00 00 00 ZZZ $216.60

31786 2 00 00 00 00 ZZZ $1,571.43

31786 8 00 00 00 00 ZZZ $314.29

31800 2 00 00 00 00 ZZZ $374.51

31800 8 00 00 00 00 ZZZ $74.90

31805 2 00 00 00 00 ZZZ $700.24

31805 8 00 00 00 00 ZZZ $140.05

31820 2 00 00 00 00 ZZZ $273.01

31820 8 00 00 00 00 ZZZ $54.60

31825 2 00 00 00 00 ZZZ $392.86

31825 8 00 00 00 00 ZZZ $78.57

31830 2 00 00 00 00 ZZZ $274.06

31830 8 00 00 00 00 ZZZ $54.81

31899 2 00 00 00 00 ZZZ $0.00

31899 8 00 00 00 00 ZZZ $0.00

32035 2 00 00 00 00 ZZZ $511.50

32035 8 00 00 00 00 ZZZ $102.30

32036 2 00 00 00 00 ZZZ $613.80

32036 8 00 00 00 00 ZZZ $122.76

32096 2 00 00 00 00 ZZZ $731.68

32096 8 00 00 00 00 ZZZ $146.39

32097 2 00 00 00 00 ZZZ $731.68

32097 8 00 00 00 00 ZZZ $146.39

32098 2 00 00 00 00 ZZZ $687.80

32098 8 00 00 00 00 ZZZ $137.56

32100 2 00 00 00 00 ZZZ $1,144.00

32100 8 00 00 00 00 ZZZ $228.80

32110 2 00 00 00 00 ZZZ $953.70

32110 8 00 00 00 00 ZZZ $190.74

32120 2 00 00 00 00 ZZZ $680.90

32120 8 00 00 00 00 ZZZ $136.18

32124 2 00 00 00 00 ZZZ $953.70

32124 8 00 00 00 00 ZZZ $190.74

32140 2 00 00 00 00 ZZZ $1,180.30

32140 8 00 00 00 00 ZZZ $236.06

32141 2 00 00 00 00 ZZZ $1,180.30

32141 8 00 00 00 00 ZZZ $236.06

32150 2 00 00 00 00 ZZZ $730.66

32150 8 00 00 00 00 ZZZ $146.13

Page 119: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

32151 2 00 00 00 00 ZZZ $733.80

32151 8 00 00 00 00 ZZZ $146.76

32160 2 00 00 00 00 ZZZ $613.80

32160 8 00 00 00 00 ZZZ $122.76

32200 2 00 00 00 00 ZZZ $674.79

32200 8 00 00 00 00 ZZZ $134.96

32215 2 00 00 00 00 ZZZ $662.20

32215 8 00 00 00 00 ZZZ $132.44

32220 2 00 00 00 00 ZZZ $1,579.60

32220 8 00 00 00 00 ZZZ $315.92

32225 2 00 00 00 00 ZZZ $891.00

32225 8 00 00 00 00 ZZZ $178.20

32310 2 00 00 00 00 ZZZ $980.10

32310 8 00 00 00 00 ZZZ $196.02

32320 2 00 00 00 00 ZZZ $1,452.00

32320 8 00 00 00 00 ZZZ $290.40

32400 2 00 00 00 00 ZZZ $152.90

32400 8 00 00 00 00 ZZZ $30.58

32405 2 00 00 00 00 ZZZ $192.50

32405 8 00 00 00 00 ZZZ $38.50

32440 2 00 00 00 00 ZZZ $1,946.55

32440 8 00 00 00 00 ZZZ $389.31

32442 2 00 00 00 00 ZZZ $2,217.44

32442 8 00 00 00 00 ZZZ $443.49

32445 2 00 00 00 00 ZZZ $2,310.00

32445 8 00 00 00 00 ZZZ $462.00

32480 2 00 00 00 00 ZZZ $1,597.20

32480 8 00 00 00 00 ZZZ $319.44

32482 2 00 00 00 00 ZZZ $1,815.00

32482 8 00 00 00 00 ZZZ $363.00

32484 2 00 00 00 00 ZZZ $1,597.20

32484 8 00 00 00 00 ZZZ $319.44

32486 2 00 00 00 00 ZZZ $2,032.80

32486 8 00 00 00 00 ZZZ $406.56

32488 2 00 00 00 00 ZZZ $2,105.40

32488 8 00 00 00 00 ZZZ $421.08

32491 2 00 00 00 00 ZZZ $1,597.20

32491 8 00 00 00 00 ZZZ $319.44

32501 2 00 00 00 00 ZZZ $360.29

32501 8 00 00 00 00 ZZZ $72.06

Page 120: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

32503 2 00 00 00 00 ZZZ $1,608.81

32503 8 00 00 00 00 ZZZ $321.76

32504 2 00 00 00 00 ZZZ $1,841.95

32504 8 00 00 00 00 ZZZ $368.39

32505 2 00 00 00 00 ZZZ $844.89

32505 8 00 00 00 00 ZZZ $168.98

32506 2 00 00 00 00 ZZZ $142.72

32506 8 00 00 00 00 ZZZ $28.54

32507 2 00 00 00 00 ZZZ $142.72

32507 8 00 00 00 00 ZZZ $28.54

32540 2 00 00 00 00 ZZZ $962.50

32540 8 00 00 00 00 ZZZ $192.50

32550 2 00 00 00 00 ZZZ $292.61

32550 8 00 00 00 00 ZZZ $58.58

32551 2 00 00 00 00 ZZZ $231.43

32551 8 00 00 00 00 ZZZ $46.29

32552 2 00 00 00 00 ZZZ $237.59

32552 8 00 00 00 00 ZZZ $47.52

32553 2 00 00 00 00 ZZZ $764.00

32553 8 00 00 00 00 ZZZ $152.80

32554 2 00 00 00 00 ZZZ $827.59

32554 8 00 00 00 00 ZZZ $165.52

32555 2 00 00 00 00 ZZZ $551.02

32555 8 00 00 00 00 ZZZ $110.20

32556 2 00 00 00 00 ZZZ $582.23

32556 8 00 00 00 00 ZZZ $116.45

32557 2 00 00 00 00 ZZZ $1,043.89

32557 8 00 00 00 00 ZZZ $208.78

32560 2 00 00 00 00 ZZZ $136.21

32560 8 00 00 00 00 ZZZ $27.24

32561 2 00 00 00 00 ZZZ $123.78

32561 8 00 00 00 00 ZZZ $24.76

32562 2 00 00 00 00 ZZZ $110.02

32562 8 00 00 00 00 ZZZ $22.00

32601 2 00 00 00 00 ZZZ $468.60

32601 8 00 00 00 00 ZZZ $93.72

32604 2 00 00 00 00 ZZZ $702.16

32604 8 00 00 00 00 ZZZ $140.43

32606 2 00 00 00 00 ZZZ $674.65

32606 8 00 00 00 00 ZZZ $134.93

Page 121: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

32607 2 00 00 00 00 ZZZ $280.71

32607 8 00 00 00 00 ZZZ $56.14

32608 2 00 00 00 00 ZZZ $344.77

32608 8 00 00 00 00 ZZZ $68.95

32609 2 00 00 00 00 ZZZ $237.67

32609 8 00 00 00 00 ZZZ $47.53

32650 2 00 00 00 00 ZZZ $871.20

32650 8 00 00 00 00 ZZZ $174.24

32651 2 00 00 00 00 ZZZ $958.10

32651 8 00 00 00 00 ZZZ $191.62

32652 2 00 00 00 00 ZZZ $1,002.10

32652 8 00 00 00 00 ZZZ $200.42

32653 2 00 00 00 00 ZZZ $1,071.40

32653 8 00 00 00 00 ZZZ $214.28

32654 2 00 00 00 00 ZZZ $1,002.10

32654 8 00 00 00 00 ZZZ $200.42

32655 2 00 00 00 00 ZZZ $1,071.40

32655 8 00 00 00 00 ZZZ $214.28

32656 2 00 00 00 00 ZZZ $1,052.70

32656 8 00 00 00 00 ZZZ $210.54

32658 2 00 00 00 00 ZZZ $962.50

32658 8 00 00 00 00 ZZZ $192.50

32659 2 00 00 00 00 ZZZ $943.80

32659 8 00 00 00 00 ZZZ $188.76

32661 2 00 00 00 00 ZZZ $1,089.00

32661 8 00 00 00 00 ZZZ $217.80

32662 2 00 00 00 00 ZZZ $1,361.80

32662 8 00 00 00 00 ZZZ $272.36

32663 2 00 00 00 00 ZZZ $1,002.10

32663 8 00 00 00 00 ZZZ $200.42

32664 2 00 00 00 00 ZZZ $1,180.30

32664 8 00 00 00 00 ZZZ $236.06

32665 2 00 00 00 00 ZZZ $1,270.50

32665 8 00 00 00 00 ZZZ $254.10

32666 2 00 00 00 00 ZZZ $788.96

32666 8 00 00 00 00 ZZZ $157.92

32667 2 00 00 00 00 ZZZ $142.72

32667 8 00 00 00 00 ZZZ $28.54

32668 2 00 00 00 00 ZZZ $143.33

32668 8 00 00 00 00 ZZZ $28.67

Page 122: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

32669 2 00 00 00 00 ZZZ $1,217.25

32669 8 00 00 00 00 ZZZ $243.45

32670 2 00 00 00 00 ZZZ $1,454.00

32670 8 00 00 00 00 ZZZ $290.80

32671 2 00 00 00 00 ZZZ $1,612.10

32671 8 00 00 00 00 ZZZ $322.42

32672 2 00 00 00 00 ZZZ $1,378.87

32672 8 00 00 00 00 ZZZ $275.77

32673 2 00 00 00 00 ZZZ $1,093.02

32673 8 00 00 00 00 ZZZ $218.60

32674 2 00 00 00 00 ZZZ $196.86

32674 8 00 00 00 00 ZZZ $39.37

32701 2 00 00 00 00 ZZZ $271.85

32701 8 00 00 00 00 ZZZ $54.37

32800 2 00 00 00 00 ZZZ $1,017.50

32800 8 00 00 00 00 ZZZ $203.50

32810 2 00 00 00 00 ZZZ $1,017.72

32810 8 00 00 00 00 ZZZ $203.54

32815 2 00 00 00 00 ZZZ $1,142.67

32815 8 00 00 00 00 ZZZ $228.53

32820 2 00 00 00 00 ZZZ $1,271.60

32820 8 00 00 00 00 ZZZ $254.32

32900 2 00 00 00 00 ZZZ $913.19

32900 8 00 00 00 00 ZZZ $182.64

32905 2 00 00 00 00 ZZZ $990.03

32905 8 00 00 00 00 ZZZ $198.01

32906 2 00 00 00 00 ZZZ $1,251.50

32906 8 00 00 00 00 ZZZ $250.30

32940 2 00 00 00 00 ZZZ $926.56

32940 8 00 00 00 00 ZZZ $185.31

32960 2 00 00 00 00 ZZZ $101.20

32960 8 00 00 00 00 ZZZ $20.24

32997 2 00 00 00 00 ZZZ $365.51

32997 8 00 00 00 00 ZZZ $73.10

32998 2 00 00 00 00 ZZZ $2,482.92

32998 8 00 00 00 00 ZZZ $496.58

32999 2 00 00 00 00 ZZZ $0.00

32999 8 00 00 00 00 ZZZ $0.00

33010 2 00 00 00 00 ZZZ $175.78

33010 8 00 00 00 00 ZZZ $35.16

Page 123: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33011 2 00 00 00 00 ZZZ $159.50

33011 8 00 00 00 00 ZZZ $31.90

33015 2 00 00 00 00 ZZZ $381.70

33015 8 00 00 00 00 ZZZ $76.34

33020 2 00 00 00 00 ZZZ $762.30

33020 8 00 00 00 00 ZZZ $152.46

33025 2 00 00 00 00 ZZZ $762.30

33025 8 00 00 00 00 ZZZ $152.46

33030 2 00 00 00 00 ZZZ $1,325.50

33030 8 00 00 00 00 ZZZ $265.10

33031 2 00 00 00 00 ZZZ $1,281.50

33031 8 00 00 00 00 ZZZ $256.30

33050 2 00 00 00 00 ZZZ $762.30

33050 8 00 00 00 00 ZZZ $152.46

33120 2 00 00 00 00 ZZZ $1,633.50

33120 8 00 00 00 00 ZZZ $326.70

33130 2 00 00 00 00 ZZZ $1,033.30

33130 8 00 00 00 00 ZZZ $206.66

33140 2 00 00 00 00 ZZZ $1,473.16

33140 8 00 00 00 00 ZZZ $294.63

33141 2 00 00 00 00 ZZZ $305.69

33141 8 00 00 00 00 ZZZ $61.14

33202 2 00 00 00 00 ZZZ $903.76

33202 8 00 00 00 00 ZZZ $180.75

33203 2 00 00 00 00 ZZZ $927.34

33203 8 00 00 00 00 ZZZ $185.47

33206 2 00 00 00 00 ZZZ $672.10

33206 8 00 00 00 00 ZZZ $134.42

33207 2 00 00 00 00 ZZZ $858.00

33207 8 00 00 00 00 ZZZ $172.00

33208 2 00 00 00 00 ZZZ $1,012.32

33208 8 00 00 00 00 ZZZ $202.46

33210 2 00 00 00 00 ZZZ $360.17

33210 8 00 00 00 00 ZZZ $72.03

33211 2 00 00 00 00 ZZZ $370.08

33211 8 00 00 00 00 ZZZ $74.02

33212 2 00 00 00 00 ZZZ $464.20

33212 8 00 00 00 00 ZZZ $92.84

33213 2 00 00 00 00 ZZZ $526.90

33213 8 00 00 00 00 ZZZ $105.38

Page 124: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33214 2 00 00 00 00 ZZZ $635.80

33214 8 00 00 00 00 ZZZ $127.16

33215 2 00 00 00 00 ZZZ $341.18

33215 8 00 00 00 00 ZZZ $68.24

33216 2 00 00 00 00 ZZZ $449.90

33216 8 00 00 00 00 ZZZ $89.98

33217 2 00 00 00 00 ZZZ $468.60

33217 8 00 00 00 00 ZZZ $93.72

33218 2 00 00 00 00 ZZZ $435.60

33218 8 00 00 00 00 ZZZ $87.12

33220 2 00 00 00 00 ZZZ $443.30

33220 8 00 00 00 00 ZZZ $88.66

33221 2 00 00 00 00 ZZZ $1,040.00

33221 8 00 00 00 00 ZZZ $208.00

33222 2 00 00 00 00 ZZZ $337.70

33222 8 00 00 00 00 ZZZ $67.54

33223 2 00 00 00 00 ZZZ $526.90

33223 8 00 00 00 00 ZZZ $105.38

33224 2 00 00 00 00 ZZZ $549.90

33224 8 00 00 00 00 ZZZ $109.98

33225 2 00 00 00 00 ZZZ $487.20

33225 8 00 00 00 00 ZZZ $97.44

33226 2 00 00 00 00 ZZZ $529.69

33226 8 00 00 00 00 ZZZ $105.94

33227 2 00 00 00 00 ZZZ $1,040.00

33227 8 00 00 00 00 ZZZ $208.00

33228 2 00 00 00 00 ZZZ $1,040.00

33228 8 00 00 00 00 ZZZ $208.00

33229 2 00 00 00 00 ZZZ $1,040.00

33229 8 00 00 00 00 ZZZ $208.00

33230 2 00 00 00 00 ZZZ $1,040.00

33230 8 00 00 00 00 ZZZ $208.00

33231 2 00 00 00 00 ZZZ $1,040.00

33231 8 00 00 00 00 ZZZ $208.00

33233 2 00 00 00 00 ZZZ $243.10

33233 8 00 00 00 00 ZZZ $48.62

33234 2 00 00 00 00 ZZZ $363.00

33234 8 00 00 00 00 ZZZ $72.60

33235 2 00 00 00 00 ZZZ $475.20

33235 8 00 00 00 00 ZZZ $95.04

Page 125: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33236 2 00 00 00 00 ZZZ $998.80

33236 8 00 00 00 00 ZZZ $199.76

33237 2 00 00 00 00 ZZZ $1,071.40

33237 8 00 00 00 00 ZZZ $214.28

33238 2 00 00 00 00 ZZZ $735.90

33238 8 00 00 00 00 ZZZ $147.18

33240 2 00 00 00 00 ZZZ $464.20

33240 8 00 00 00 00 ZZZ $92.84

33241 2 00 00 00 00 ZZZ $243.10

33241 8 00 00 00 00 ZZZ $48.62

33243 2 00 00 00 00 ZZZ $998.80

33243 8 00 00 00 00 ZZZ $199.76

33244 2 00 00 00 00 ZZZ $849.20

33244 8 00 00 00 00 ZZZ $169.84

33249 2 00 00 00 00 ZZZ $1,107.70

33249 8 00 00 00 00 ZZZ $221.54

33250 2 00 00 00 00 ZZZ $1,582.08

33250 8 00 00 00 00 ZZZ $316.42

33251 2 00 00 00 00 ZZZ $1,941.80

33251 8 00 00 00 00 ZZZ $388.36

33254 2 00 00 00 00 ZZZ $2,342.27

33254 8 00 00 00 00 ZZZ $468.45

33255 2 00 00 00 00 ZZZ $1,928.12

33255 8 00 00 00 00 ZZZ $385.62

33256 2 00 00 00 00 ZZZ $2,311.52

33256 8 00 00 00 00 ZZZ $462.30

33257 2 00 00 00 00 ZZZ $758.31

33257 8 00 00 00 00 ZZZ $151.66

33258 2 00 00 00 00 ZZZ $857.42

33258 8 00 00 00 00 ZZZ $171.48

33259 2 00 00 00 00 ZZZ $1,124.90

33259 8 00 00 00 00 ZZZ $224.98

33261 2 00 00 00 00 ZZZ $1,868.78

33261 8 00 00 00 00 ZZZ $373.76

33262 2 00 00 00 00 ZZZ $1,040.00

33262 8 00 00 00 00 ZZZ $208.00

33263 2 00 00 00 00 ZZZ $1,040.00

33263 8 00 00 00 00 ZZZ $208.00

33264 2 00 00 00 00 ZZZ $1,040.00

33264 8 00 00 00 00 ZZZ $208.00

Page 126: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33265 2 00 00 00 00 ZZZ $1,595.21

33265 8 00 00 00 00 ZZZ $319.04

33266 2 00 00 00 00 ZZZ $2,197.96

33266 8 00 00 00 00 ZZZ $439.59

33270 2 00 00 00 00 ZZZ $573.09

33270 8 00 00 00 00 ZZZ $114.62

33271 2 00 00 00 00 ZZZ $453.34

33271 8 00 00 00 00 ZZZ $90.67

33272 2 00 00 00 00 ZZZ $374.67

33272 8 00 00 00 00 ZZZ $74.94

33273 2 00 00 00 00 ZZZ $366.65

33273 8 00 00 00 00 ZZZ $73.33

33282 2 00 00 00 00 ZZZ $447.37

33282 8 00 00 00 00 ZZZ $89.47

33284 2 00 00 00 00 ZZZ $341.99

33284 8 00 00 00 00 ZZZ $68.40

33300 2 00 00 00 00 ZZZ $1,161.60

33300 8 00 00 00 00 ZZZ $232.32

33305 2 00 00 00 00 ZZZ $1,325.50

33305 8 00 00 00 00 ZZZ $265.10

33310 2 00 00 00 00 ZZZ $962.50

33310 8 00 00 00 00 ZZZ $192.50

33315 2 00 00 00 00 ZZZ $1,524.60

33315 8 00 00 00 00 ZZZ $304.92

33320 2 00 00 00 00 ZZZ $1,343.10

33320 8 00 00 00 00 ZZZ $268.62

33321 2 00 00 00 00 ZZZ $1,544.57

33321 8 00 00 00 00 ZZZ $308.91

33322 2 00 00 00 00 ZZZ $1,724.80

33322 8 00 00 00 00 ZZZ $344.96

33330 2 00 00 00 00 ZZZ $1,828.59

33330 8 00 00 00 00 ZZZ $365.72

33335 2 00 00 00 00 ZZZ $2,468.40

33335 8 00 00 00 00 ZZZ $493.68

33361 2 00 00 00 00 ZZZ $1,643.69

33361 8 00 00 00 00 ZZZ $328.74

33362 2 00 00 00 00 ZZZ $1,798.54

33362 8 00 00 00 00 ZZZ $359.71

33363 2 00 00 00 00 ZZZ $1,862.36

33363 8 00 00 00 00 ZZZ $372.47

Page 127: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33364 2 00 00 00 00 ZZZ $1,975.86

33364 8 00 00 00 00 ZZZ $395.17

33365 2 00 00 00 00 ZZZ $2,171.74

33365 8 00 00 00 00 ZZZ $434.35

33366 2 00 00 00 00 ZZZ $2,425.62

33366 8 00 00 00 00 ZZZ $485.12

33367 2 00 00 00 00 ZZZ $767.03

33367 8 00 00 00 00 ZZZ $153.41

33368 2 00 00 00 00 ZZZ $929.54

33368 8 00 00 00 00 ZZZ $185.91

33369 2 00 00 00 00 ZZZ $1,227.31

33369 8 00 00 00 00 ZZZ $245.46

33390 2 00 00 00 00 ZZZ $2,236.96

33390 8 00 00 00 00 ZZZ $447.39

33391 2 00 00 00 00 ZZZ $2,650.48

33391 8 00 00 00 00 ZZZ $530.10

33404 2 00 00 00 00 ZZZ $2,619.05

33404 8 00 00 00 00 ZZZ $523.81

33405 2 00 00 00 00 ZZZ $2,704.90

33405 8 00 00 00 00 ZZZ $540.98

33406 2 00 00 00 00 ZZZ $2,704.90

33406 8 00 00 00 00 ZZZ $540.98

33410 2 00 00 00 00 ZZZ $2,472.73

33410 8 00 00 00 00 ZZZ $494.55

33411 2 00 00 00 00 ZZZ $1,784.20

33411 8 00 00 00 00 ZZZ $356.84

33412 2 00 00 00 00 ZZZ $1,915.02

33412 8 00 00 00 00 ZZZ $383.00

33413 2 00 00 00 00 ZZZ $3,404.76

33413 8 00 00 00 00 ZZZ $680.95

33414 2 00 00 00 00 ZZZ $2,178.00

33414 8 00 00 00 00 ZZZ $435.60

33415 2 00 00 00 00 ZZZ $1,527.40

33415 8 00 00 00 00 ZZZ $305.48

33416 2 00 00 00 00 ZZZ $1,599.79

33416 8 00 00 00 00 ZZZ $319.96

33417 2 00 00 00 00 ZZZ $1,642.80

33417 8 00 00 00 00 ZZZ $328.56

33418 2 00 00 00 00 ZZZ $1,707.32

33418 8 00 00 00 00 ZZZ $341.47

Page 128: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33419 2 00 00 00 00 ZZZ $473.16

33419 8 00 00 00 00 ZZZ $94.64

33420 2 00 00 00 00 ZZZ $1,107.70

33420 8 00 00 00 00 ZZZ $221.54

33422 2 00 00 00 00 ZZZ $1,633.50

33422 8 00 00 00 00 ZZZ $326.70

33425 2 00 00 00 00 ZZZ $1,495.67

33425 8 00 00 00 00 ZZZ $299.13

33426 2 00 00 00 00 ZZZ $1,672.70

33426 8 00 00 00 00 ZZZ $334.54

33427 2 00 00 00 00 ZZZ $1,803.83

33427 8 00 00 00 00 ZZZ $360.77

33430 2 00 00 00 00 ZZZ $3,063.20

33430 8 00 00 00 00 ZZZ $612.64

33460 2 00 00 00 00 ZZZ $1,478.40

33460 8 00 00 00 00 ZZZ $295.68

33463 2 00 00 00 00 ZZZ $1,524.60

33463 8 00 00 00 00 ZZZ $304.92

33464 2 00 00 00 00 ZZZ $1,633.50

33464 8 00 00 00 00 ZZZ $326.70

33465 2 00 00 00 00 ZZZ $1,923.90

33465 8 00 00 00 00 ZZZ $384.78

33468 2 00 00 00 00 ZZZ $2,051.50

33468 8 00 00 00 00 ZZZ $410.30

33470 2 00 00 00 00 ZZZ $1,197.90

33470 8 00 00 00 00 ZZZ $239.58

33471 2 00 00 00 00 ZZZ $1,197.90

33471 8 00 00 00 00 ZZZ $239.58

33474 2 00 00 00 00 ZZZ $1,524.60

33474 8 00 00 00 00 ZZZ $304.92

33475 2 00 00 00 00 ZZZ $2,323.20

33475 8 00 00 00 00 ZZZ $464.64

33476 2 00 00 00 00 ZZZ $1,633.50

33476 8 00 00 00 00 ZZZ $326.70

33477 2 00 00 00 00 ZZZ $1,330.31

33477 8 00 00 00 00 ZZZ $266.06

33478 2 00 00 00 00 ZZZ $1,851.30

33478 8 00 00 00 00 ZZZ $370.26

33496 2 00 00 00 00 ZZZ $2,580.82

33496 8 00 00 00 00 ZZZ $516.16

Page 129: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33500 2 00 00 00 00 ZZZ $2,420.85

33500 8 00 00 00 00 ZZZ $484.17

33501 2 00 00 00 00 ZZZ $1,352.00

33501 8 00 00 00 00 ZZZ $270.40

33502 2 00 00 00 00 ZZZ $1,155.25

33502 8 00 00 00 00 ZZZ $231.05

33503 2 00 00 00 00 ZZZ $1,325.50

33503 8 00 00 00 00 ZZZ $265.10

33504 2 00 00 00 00 ZZZ $1,870.00

33504 8 00 00 00 00 ZZZ $374.00

33505 2 00 00 00 00 ZZZ $2,567.58

33505 8 00 00 00 00 ZZZ $513.52

33506 2 00 00 00 00 ZZZ $1,815.00

33506 8 00 00 00 00 ZZZ $363.00

33507 2 00 00 00 00 ZZZ $1,560.75

33507 8 00 00 00 00 ZZZ $312.15

33508 2 00 00 00 00 ZZZ $18.57

33508 8 00 00 00 00 ZZZ $3.71

33510 2 00 00 00 00 ZZZ $2,640.00

33510 8 00 00 00 00 ZZZ $528.00

33511 2 00 00 00 00 ZZZ $2,838.00

33511 8 00 00 00 00 ZZZ $568.00

33512 2 00 00 00 00 ZZZ $3,102.00

33512 8 00 00 00 00 ZZZ $620.00

33513 2 00 00 00 00 ZZZ $3,201.00

33513 8 00 00 00 00 ZZZ $640.00

33514 2 00 00 00 00 ZZZ $3,388.17

33514 8 00 00 00 00 ZZZ $677.63

33516 2 00 00 00 00 ZZZ $3,606.83

33516 8 00 00 00 00 ZZZ $721.37

33517 2 00 00 00 00 ZZZ $229.90

33517 8 00 00 00 00 ZZZ $45.98

33518 2 00 00 00 00 ZZZ $438.26

33518 8 00 00 00 00 ZZZ $87.65

33519 2 00 00 00 00 ZZZ $580.80

33519 8 00 00 00 00 ZZZ $116.16

33521 2 00 00 00 00 ZZZ $685.30

33521 8 00 00 00 00 ZZZ $137.06

33522 2 00 00 00 00 ZZZ $770.00

33522 8 00 00 00 00 ZZZ $154.00

Page 130: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33523 2 00 00 00 00 ZZZ $770.00

33523 8 00 00 00 00 ZZZ $154.00

33530 2 00 00 00 00 ZZZ $659.69

33530 8 00 00 00 00 ZZZ $131.92

33533 2 00 00 00 00 ZZZ $2,825.00

33533 8 00 00 00 00 ZZZ $565.00

33534 2 00 00 00 00 ZZZ $2,915.00

33534 8 00 00 00 00 ZZZ $583.00

33535 2 00 00 00 00 ZZZ $3,172.00

33535 8 00 00 00 00 ZZZ $634.00

33536 2 00 00 00 00 ZZZ $3,392.00

33536 8 00 00 00 00 ZZZ $678.00

33542 2 00 00 00 00 ZZZ $1,923.90

33542 8 00 00 00 00 ZZZ $384.78

33545 2 00 00 00 00 ZZZ $2,214.30

33545 8 00 00 00 00 ZZZ $442.86

33548 2 00 00 00 00 ZZZ $2,042.67

33548 8 00 00 00 00 ZZZ $408.53

33572 2 00 00 00 00 ZZZ $346.85

33572 8 00 00 00 00 ZZZ $69.37

33600 2 00 00 00 00 ZZZ $2,801.17

33600 8 00 00 00 00 ZZZ $560.23

33602 2 00 00 00 00 ZZZ $2,604.89

33602 8 00 00 00 00 ZZZ $520.98

33606 2 00 00 00 00 ZZZ $2,999.79

33606 8 00 00 00 00 ZZZ $599.96

33608 2 00 00 00 00 ZZZ $3,115.42

33608 8 00 00 00 00 ZZZ $623.08

33610 2 00 00 00 00 ZZZ $3,042.22

33610 8 00 00 00 00 ZZZ $608.44

33611 2 00 00 00 00 ZZZ $3,163.44

33611 8 00 00 00 00 ZZZ $632.69

33612 2 00 00 00 00 ZZZ $3,224.25

33612 8 00 00 00 00 ZZZ $644.85

33615 2 00 00 00 00 ZZZ $3,160.55

33615 8 00 00 00 00 ZZZ $632.11

33617 2 00 00 00 00 ZZZ $3,231.34

33617 8 00 00 00 00 ZZZ $646.27

33619 2 00 00 00 00 ZZZ $3,620.65

33619 8 00 00 00 00 ZZZ $724.13

Page 131: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33620 2 00 00 00 00 ZZZ $2,224.03

33620 8 00 00 00 00 ZZZ $444.81

33621 2 00 00 00 00 ZZZ $1,196.23

33621 8 00 00 00 00 ZZZ $239.25

33622 2 00 00 00 00 ZZZ $4,694.08

33622 8 00 00 00 00 ZZZ $938.82

33641 2 00 00 00 00 ZZZ $1,652.20

33641 8 00 00 00 00 ZZZ $330.44

33645 2 00 00 00 00 ZZZ $1,524.60

33645 8 00 00 00 00 ZZZ $304.92

33647 2 00 00 00 00 ZZZ $2,831.40

33647 8 00 00 00 00 ZZZ $566.28

33660 2 00 00 00 00 ZZZ $1,524.60

33660 8 00 00 00 00 ZZZ $304.92

33665 2 00 00 00 00 ZZZ $1,942.60

33665 8 00 00 00 00 ZZZ $388.52

33670 2 00 00 00 00 ZZZ $2,214.30

33670 8 00 00 00 00 ZZZ $442.86

33675 2 00 00 00 00 ZZZ $2,506.09

33675 8 00 00 00 00 ZZZ $501.22

33676 2 00 00 00 00 ZZZ $2,587.95

33676 8 00 00 00 00 ZZZ $517.59

33677 2 00 00 00 00 ZZZ $0.00

33677 8 00 00 00 00 ZZZ $0.00

33681 2 00 00 00 00 ZZZ $1,583.53

33681 8 00 00 00 00 ZZZ $316.71

33684 2 00 00 00 00 ZZZ $1,923.90

33684 8 00 00 00 00 ZZZ $384.78

33688 2 00 00 00 00 ZZZ $2,015.20

33688 8 00 00 00 00 ZZZ $403.04

33690 2 00 00 00 00 ZZZ $1,123.00

33690 8 00 00 00 00 ZZZ $224.60

33692 2 00 00 00 00 ZZZ $2,214.30

33692 8 00 00 00 00 ZZZ $442.86

33694 2 00 00 00 00 ZZZ $2,305.60

33694 8 00 00 00 00 ZZZ $461.12

33697 2 00 00 00 00 ZZZ $2,758.80

33697 8 00 00 00 00 ZZZ $551.76

33702 2 00 00 00 00 ZZZ $1,564.20

33702 8 00 00 00 00 ZZZ $312.84

Page 132: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33710 2 00 00 00 00 ZZZ $1,627.85

33710 8 00 00 00 00 ZZZ $325.57

33720 2 00 00 00 00 ZZZ $1,923.90

33720 8 00 00 00 00 ZZZ $384.78

33722 2 00 00 00 00 ZZZ $2,341.90

33722 8 00 00 00 00 ZZZ $468.38

33724 2 00 00 00 00 ZZZ $1,834.15

33724 8 00 00 00 00 ZZZ $366.83

33726 2 00 00 00 00 ZZZ $2,425.85

33726 8 00 00 00 00 ZZZ $485.17

33730 2 00 00 00 00 ZZZ $1,923.90

33730 8 00 00 00 00 ZZZ $384.78

33732 2 00 00 00 00 ZZZ $2,323.20

33732 8 00 00 00 00 ZZZ $464.64

33735 2 00 00 00 00 ZZZ $1,234.20

33735 8 00 00 00 00 ZZZ $246.84

33736 2 00 00 00 00 ZZZ $1,706.10

33736 8 00 00 00 00 ZZZ $341.22

33737 2 00 00 00 00 ZZZ $1,178.33

33737 8 00 00 00 00 ZZZ $235.67

33750 2 00 00 00 00 ZZZ $1,119.06

33750 8 00 00 00 00 ZZZ $223.81

33755 2 00 00 00 00 ZZZ $1,107.70

33755 8 00 00 00 00 ZZZ $221.54

33762 2 00 00 00 00 ZZZ $1,132.70

33762 8 00 00 00 00 ZZZ $226.54

33764 2 00 00 00 00 ZZZ $1,129.55

33764 8 00 00 00 00 ZZZ $225.91

33766 2 00 00 00 00 ZZZ $1,263.04

33766 8 00 00 00 00 ZZZ $252.61

33767 2 00 00 00 00 ZZZ $1,295.30

33767 8 00 00 00 00 ZZZ $259.06

33768 2 00 00 00 00 ZZZ $388.54

33768 8 00 00 00 00 ZZZ $77.71

33770 2 00 00 00 00 ZZZ $2,741.20

33770 8 00 00 00 00 ZZZ $548.24

33771 2 00 00 00 00 ZZZ $2,850.10

33771 8 00 00 00 00 ZZZ $570.02

33774 2 00 00 00 00 ZZZ $2,214.30

33774 8 00 00 00 00 ZZZ $442.86

Page 133: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33775 2 00 00 00 00 ZZZ $2,305.60

33775 8 00 00 00 00 ZZZ $461.12

33776 2 00 00 00 00 ZZZ $2,450.80

33776 8 00 00 00 00 ZZZ $490.16

33777 2 00 00 00 00 ZZZ $2,824.33

33777 8 00 00 00 00 ZZZ $564.87

33778 2 00 00 00 00 ZZZ $3,390.03

33778 8 00 00 00 00 ZZZ $678.01

33779 2 00 00 00 00 ZZZ $3,307.04

33779 8 00 00 00 00 ZZZ $661.41

33780 2 00 00 00 00 ZZZ $3,425.00

33780 8 00 00 00 00 ZZZ $685.00

33781 2 00 00 00 00 ZZZ $3,238.97

33781 8 00 00 00 00 ZZZ $647.79

33782 2 00 00 00 00 ZZZ $4,311.79

33782 8 00 00 00 00 ZZZ $862.36

33783 2 00 00 00 00 ZZZ $4,660.83

33783 8 00 00 00 00 ZZZ $932.17

33786 2 00 00 00 00 ZZZ $2,305.60

33786 8 00 00 00 00 ZZZ $461.12

33788 2 00 00 00 00 ZZZ $1,363.49

33788 8 00 00 00 00 ZZZ $272.70

33800 2 00 00 00 00 ZZZ $1,334.30

33800 8 00 00 00 00 ZZZ $266.86

33802 2 00 00 00 00 ZZZ $1,044.06

33802 8 00 00 00 00 ZZZ $208.81

33803 2 00 00 00 00 ZZZ $1,107.70

33803 8 00 00 00 00 ZZZ $221.54

33813 2 00 00 00 00 ZZZ $1,153.16

33813 8 00 00 00 00 ZZZ $230.63

33814 2 00 00 00 00 ZZZ $1,468.40

33814 8 00 00 00 00 ZZZ $293.68

33820 2 00 00 00 00 ZZZ $964.85

33820 8 00 00 00 00 ZZZ $192.97

33822 2 00 00 00 00 ZZZ $929.45

33822 8 00 00 00 00 ZZZ $185.89

33824 2 00 00 00 00 ZZZ $1,123.00

33824 8 00 00 00 00 ZZZ $224.60

33840 2 00 00 00 00 ZZZ $1,379.40

33840 8 00 00 00 00 ZZZ $275.88

Page 134: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33845 2 00 00 00 00 ZZZ $1,524.60

33845 8 00 00 00 00 ZZZ $304.92

33851 2 00 00 00 00 ZZZ $1,269.08

33851 8 00 00 00 00 ZZZ $253.82

33852 2 00 00 00 00 ZZZ $1,377.65

33852 8 00 00 00 00 ZZZ $275.53

33853 2 00 00 00 00 ZZZ $2,596.00

33853 8 00 00 00 00 ZZZ $519.20

33860 2 00 00 00 00 ZZZ $2,686.20

33860 8 00 00 00 00 ZZZ $537.24

33863 2 00 00 00 00 ZZZ $3,104.20

33863 8 00 00 00 00 ZZZ $620.84

33864 2 00 00 00 00 ZZZ $4,118.30

33864 8 00 00 00 00 ZZZ $823.66

33870 2 00 00 00 00 ZZZ $3,448.50

33870 8 00 00 00 00 ZZZ $689.70

33875 2 00 00 00 00 ZZZ $2,087.80

33875 8 00 00 00 00 ZZZ $417.56

33877 2 00 00 00 00 ZZZ $2,245.47

33877 8 00 00 00 00 ZZZ $449.09

33880 2 00 00 00 00 ZZZ $1,643.41

33880 8 00 00 00 00 ZZZ $328.68

33881 2 00 00 00 00 ZZZ $1,410.17

33881 8 00 00 00 00 ZZZ $282.03

33883 2 00 00 00 00 ZZZ $1,033.70

33883 8 00 00 00 00 ZZZ $206.74

33884 2 00 00 00 00 ZZZ $387.84

33884 8 00 00 00 00 ZZZ $77.57

33886 2 00 00 00 00 ZZZ $891.39

33886 8 00 00 00 00 ZZZ $178.28

33889 2 00 00 00 00 ZZZ $766.35

33889 8 00 00 00 00 ZZZ $153.27

33891 2 00 00 00 00 ZZZ $976.48

33891 8 00 00 00 00 ZZZ $195.30

33910 2 00 00 00 00 ZZZ $1,633.50

33910 8 00 00 00 00 ZZZ $326.70

33915 2 00 00 00 00 ZZZ $1,107.70

33915 8 00 00 00 00 ZZZ $221.54

33916 2 00 00 00 00 ZZZ $1,249.41

33916 8 00 00 00 00 ZZZ $249.88

Page 135: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33917 2 00 00 00 00 ZZZ $1,960.20

33917 8 00 00 00 00 ZZZ $392.04

33920 2 00 00 00 00 ZZZ $2,577.30

33920 8 00 00 00 00 ZZZ $515.46

33922 2 00 00 00 00 ZZZ $2,123.55

33922 8 00 00 00 00 ZZZ $424.71

33924 2 00 00 00 00 ZZZ $382.24

33924 8 00 00 00 00 ZZZ $76.45

33925 2 00 00 00 00 ZZZ $1,582.04

33925 8 00 00 00 00 ZZZ $316.41

33926 2 00 00 00 00 ZZZ $2,150.69

33926 8 00 00 00 00 ZZZ $430.14

33946 2 00 00 00 00 ZZZ $297.00

33946 8 00 00 00 00 ZZZ $59.40

33947 2 00 00 00 00 ZZZ $325.66

33947 8 00 00 00 00 ZZZ $65.14

33948 2 00 00 00 00 ZZZ $230.79

33948 8 00 00 00 00 ZZZ $46.16

33949 2 00 00 00 00 ZZZ $224.88

33949 8 00 00 00 00 ZZZ $44.96

33951 2 00 00 00 00 ZZZ $531.94

33951 8 00 00 00 00 ZZZ $106.39

33952 2 00 00 00 00 ZZZ $519.94

33952 8 00 00 00 00 ZZZ $103.99

33953 2 00 00 00 00 ZZZ $592.87

33953 8 00 00 00 00 ZZZ $118.57

33954 2 00 00 00 00 ZZZ $579.63

33954 8 00 00 00 00 ZZZ $115.93

33955 2 00 00 00 00 ZZZ $1,175.32

33955 8 00 00 00 00 ZZZ $235.06

33956 2 00 00 00 00 ZZZ $1,116.98

33956 8 00 00 00 00 ZZZ $223.40

33957 2 00 00 00 00 ZZZ $357.14

33957 8 00 00 00 00 ZZZ $71.43

33958 2 00 00 00 00 ZZZ $349.27

33958 8 00 00 00 00 ZZZ $69.85

33959 2 00 00 00 00 ZZZ $420.13

33959 8 00 00 00 00 ZZZ $84.03

33962 2 00 00 00 00 ZZZ $401.51

33962 8 00 00 00 00 ZZZ $80.30

Page 136: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33963 2 00 00 00 00 ZZZ $716.73

33963 8 00 00 00 00 ZZZ $143.35

33964 2 00 00 00 00 ZZZ $729.15

33964 8 00 00 00 00 ZZZ $145.83

33965 2 00 00 00 00 ZZZ $353.42

33965 8 00 00 00 00 ZZZ $70.68

33966 2 00 00 00 00 ZZZ $399.28

33966 8 00 00 00 00 ZZZ $79.86

33967 2 00 00 00 00 ZZZ $294.14

33967 8 00 00 00 00 ZZZ $58.83

33968 2 00 00 00 00 ZZZ $47.85

33968 8 00 00 00 00 ZZZ $9.57

33969 2 00 00 00 00 ZZZ $433.70

33969 8 00 00 00 00 ZZZ $86.74

33970 2 00 00 00 00 ZZZ $610.78

33970 8 00 00 00 00 ZZZ $122.16

33971 2 00 00 00 00 ZZZ $493.57

33971 8 00 00 00 00 ZZZ $98.71

33973 2 00 00 00 00 ZZZ $450.56

33973 8 00 00 00 00 ZZZ $90.11

33974 2 00 00 00 00 ZZZ $678.73

33974 8 00 00 00 00 ZZZ $135.75

33975 2 00 00 00 00 ZZZ $1,504.18

33975 8 00 00 00 00 ZZZ $300.84

33976 2 00 00 00 00 ZZZ $2,049.22

33976 8 00 00 00 00 ZZZ $409.84

33977 2 00 00 00 00 ZZZ $1,316.60

33977 8 00 00 00 00 ZZZ $263.32

33978 2 00 00 00 00 ZZZ $1,504.18

33978 8 00 00 00 00 ZZZ $300.84

33979 2 00 00 00 00 ZZZ $3,267.04

33979 8 00 00 00 00 ZZZ $653.41

33980 2 00 00 00 00 ZZZ $0.00

33980 8 00 00 00 00 ZZZ $0.00

33981 2 00 00 00 00 ZZZ $0.00

33981 8 00 00 00 00 ZZZ $0.00

33982 2 00 00 00 00 ZZZ $0.00

33982 8 00 00 00 00 ZZZ $0.00

33983 2 00 00 00 00 ZZZ $0.00

33983 8 00 00 00 00 ZZZ $0.00

Page 137: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

33984 2 00 00 00 00 ZZZ $427.00

33984 8 00 00 00 00 ZZZ $85.40

33985 2 00 00 00 00 ZZZ $806.24

33985 8 00 00 00 00 ZZZ $161.25

33986 2 00 00 00 00 ZZZ $771.57

33986 8 00 00 00 00 ZZZ $154.31

33987 2 00 00 00 00 ZZZ $321.34

33987 8 00 00 00 00 ZZZ $64.27

33988 2 00 00 00 00 ZZZ $996.90

33988 8 00 00 00 00 ZZZ $199.38

33989 2 00 00 00 00 ZZZ $656.62

33989 8 00 00 00 00 ZZZ $131.32

33990 2 00 00 00 00 ZZZ $534.13

33990 8 00 00 00 00 ZZZ $106.83

33991 2 00 00 00 00 ZZZ $778.49

33991 8 00 00 00 00 ZZZ $155.70

33992 2 00 00 00 00 ZZZ $256.36

33992 8 00 00 00 00 ZZZ $51.27

33993 2 00 00 00 00 ZZZ $225.06

33993 8 00 00 00 00 ZZZ $45.01

33999 2 00 00 00 00 ZZZ $0.00

33999 8 00 00 00 00 ZZZ $0.00

34001 2 00 00 00 00 ZZZ $661.10

34001 8 00 00 00 00 ZZZ $132.22

34051 2 00 00 00 00 ZZZ $871.20

34051 8 00 00 00 00 ZZZ $174.24

34101 2 00 00 00 00 ZZZ $522.50

34101 8 00 00 00 00 ZZZ $104.50

34111 2 00 00 00 00 ZZZ $522.50

34111 8 00 00 00 00 ZZZ $104.50

34151 2 00 00 00 00 ZZZ $1,107.70

34151 8 00 00 00 00 ZZZ $221.54

34201 2 00 00 00 00 ZZZ $715.00

34201 8 00 00 00 00 ZZZ $143.00

34203 2 00 00 00 00 ZZZ $715.00

34203 8 00 00 00 00 ZZZ $143.00

34401 2 00 00 00 00 ZZZ $834.90

34401 8 00 00 00 00 ZZZ $166.98

34421 2 00 00 00 00 ZZZ $522.50

34421 8 00 00 00 00 ZZZ $104.50

Page 138: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

34451 2 00 00 00 00 ZZZ $719.40

34451 8 00 00 00 00 ZZZ $143.88

34471 2 00 00 00 00 ZZZ $522.50

34471 8 00 00 00 00 ZZZ $104.50

34490 2 00 00 00 00 ZZZ $522.50

34490 8 00 00 00 00 ZZZ $104.50

34501 2 00 00 00 00 ZZZ $739.71

34501 8 00 00 00 00 ZZZ $147.94

34502 2 00 00 00 00 ZZZ $1,978.44

34502 8 00 00 00 00 ZZZ $395.69

34510 2 00 00 00 00 ZZZ $895.43

34510 8 00 00 00 00 ZZZ $179.09

34520 2 00 00 00 00 ZZZ $937.90

34520 8 00 00 00 00 ZZZ $187.58

34530 2 00 00 00 00 ZZZ $1,242.27

34530 8 00 00 00 00 ZZZ $248.45

34800 2 00 00 00 00 ZZZ $1,318.46

34800 8 00 00 00 00 ZZZ $263.69

34802 2 00 00 00 00 ZZZ $1,455.01

34802 8 00 00 00 00 ZZZ $291.00

34803 2 00 00 00 00 ZZZ $1,687.79

34803 8 00 00 00 00 ZZZ $337.56

34804 2 00 00 00 00 ZZZ $1,455.01

34804 8 00 00 00 00 ZZZ $291.00

34805 2 00 00 00 00 ZZZ $1,373.74

34805 8 00 00 00 00 ZZZ $274.75

34808 2 00 00 00 00 ZZZ $283.01

34808 8 00 00 00 00 ZZZ $56.60

34812 2 00 00 00 00 ZZZ $410.06

34812 8 00 00 00 00 ZZZ $82.01

34813 2 00 00 00 00 ZZZ $291.25

34813 8 00 00 00 00 ZZZ $58.25

34820 2 00 00 00 00 ZZZ $591.99

34820 8 00 00 00 00 ZZZ $118.40

34825 2 00 00 00 00 ZZZ $787.53

34825 8 00 00 00 00 ZZZ $157.51

34826 2 00 00 00 00 ZZZ $250.40

34826 8 00 00 00 00 ZZZ $50.08

34830 2 00 00 00 00 ZZZ $2,051.95

34830 8 00 00 00 00 ZZZ $410.39

Page 139: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

34831 2 00 00 00 00 ZZZ $2,218.21

34831 8 00 00 00 00 ZZZ $443.64

34832 2 00 00 00 00 ZZZ $2,218.21

34832 8 00 00 00 00 ZZZ $443.64

34833 2 00 00 00 00 ZZZ $729.37

34833 8 00 00 00 00 ZZZ $145.87

34834 2 00 00 00 00 ZZZ $343.22

34834 8 00 00 00 00 ZZZ $68.64

34841 2 00 00 00 00 ZZZ $0.00

34841 8 00 00 00 00 ZZZ $0.00

34842 2 00 00 00 00 ZZZ $0.00

34842 8 00 00 00 00 ZZZ $0.00

34843 2 00 00 00 00 ZZZ $0.00

34843 8 00 00 00 00 ZZZ $0.00

34844 2 00 00 00 00 ZZZ $0.00

34844 8 00 00 00 00 ZZZ $0.00

34845 2 00 00 00 00 ZZZ $0.00

34845 8 00 00 00 00 ZZZ $0.00

34846 2 00 00 00 00 ZZZ $0.00

34846 8 00 00 00 00 ZZZ $0.00

34847 2 00 00 00 00 ZZZ $0.00

34847 8 00 00 00 00 ZZZ $0.00

34848 2 00 00 00 00 ZZZ $0.00

34848 8 00 00 00 00 ZZZ $0.00

34900 2 00 00 00 00 ZZZ $1,077.12

34900 8 00 00 00 00 ZZZ $215.42

35001 2 00 00 00 00 ZZZ $1,657.48

35001 8 00 00 00 00 ZZZ $331.50

35002 2 00 00 00 00 ZZZ $1,622.50

35002 8 00 00 00 00 ZZZ $324.50

35005 2 00 00 00 00 ZZZ $1,679.05

35005 8 00 00 00 00 ZZZ $335.81

35011 2 00 00 00 00 ZZZ $907.50

35011 8 00 00 00 00 ZZZ $181.50

35013 2 00 00 00 00 ZZZ $1,128.60

35013 8 00 00 00 00 ZZZ $225.72

35021 2 00 00 00 00 ZZZ $1,766.00

35021 8 00 00 00 00 ZZZ $353.00

35022 2 00 00 00 00 ZZZ $1,622.50

35022 8 00 00 00 00 ZZZ $324.50

Page 140: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35045 2 00 00 00 00 ZZZ $827.20

35045 8 00 00 00 00 ZZZ $165.44

35081 2 00 00 00 00 ZZZ $2,305.09

35081 8 00 00 00 00 ZZZ $461.02

35082 2 00 00 00 00 ZZZ $2,378.20

35082 8 00 00 00 00 ZZZ $475.64

35091 2 00 00 00 00 ZZZ $1,780.90

35091 8 00 00 00 00 ZZZ $356.18

35092 2 00 00 00 00 ZZZ $2,011.90

35092 8 00 00 00 00 ZZZ $402.38

35102 2 00 00 00 00 ZZZ $2,341.90

35102 8 00 00 00 00 ZZZ $468.38

35103 2 00 00 00 00 ZZZ $2,050.40

35103 8 00 00 00 00 ZZZ $410.08

35111 2 00 00 00 00 ZZZ $1,654.00

35111 8 00 00 00 00 ZZZ $330.00

35112 2 00 00 00 00 ZZZ $1,789.78

35112 8 00 00 00 00 ZZZ $357.96

35121 2 00 00 00 00 ZZZ $1,870.00

35121 8 00 00 00 00 ZZZ $374.00

35122 2 00 00 00 00 ZZZ $2,076.80

35122 8 00 00 00 00 ZZZ $415.36

35131 2 00 00 00 00 ZZZ $1,583.82

35131 8 00 00 00 00 ZZZ $316.76

35132 2 00 00 00 00 ZZZ $1,790.80

35132 8 00 00 00 00 ZZZ $358.16

35141 2 00 00 00 00 ZZZ $1,304.07

35141 8 00 00 00 00 ZZZ $260.81

35142 2 00 00 00 00 ZZZ $1,534.00

35142 8 00 00 00 00 ZZZ $306.00

35151 2 00 00 00 00 ZZZ $1,252.90

35151 8 00 00 00 00 ZZZ $250.58

35152 2 00 00 00 00 ZZZ $1,628.34

35152 8 00 00 00 00 ZZZ $325.67

35180 2 00 00 00 00 ZZZ $867.12

35180 8 00 00 00 00 ZZZ $173.42

35182 2 00 00 00 00 ZZZ $1,677.00

35182 8 00 00 00 00 ZZZ $335.00

35184 2 00 00 00 00 ZZZ $1,292.65

35184 8 00 00 00 00 ZZZ $258.53

Page 141: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35188 2 00 00 00 00 ZZZ $941.45

35188 8 00 00 00 00 ZZZ $188.29

35189 2 00 00 00 00 ZZZ $1,677.00

35189 8 00 00 00 00 ZZZ $335.00

35190 2 00 00 00 00 ZZZ $1,348.02

35190 8 00 00 00 00 ZZZ $269.60

35201 2 00 00 00 00 ZZZ $1,128.88

35201 8 00 00 00 00 ZZZ $225.78

35206 2 00 00 00 00 ZZZ $1,105.57

35206 8 00 00 00 00 ZZZ $221.11

35207 2 00 00 00 00 ZZZ $898.98

35207 8 00 00 00 00 ZZZ $179.80

35211 2 00 00 00 00 ZZZ $1,844.70

35211 8 00 00 00 00 ZZZ $368.94

35216 2 00 00 00 00 ZZZ $1,677.00

35216 8 00 00 00 00 ZZZ $335.00

35221 2 00 00 00 00 ZZZ $1,646.41

35221 8 00 00 00 00 ZZZ $329.28

35226 2 00 00 00 00 ZZZ $1,113.73

35226 8 00 00 00 00 ZZZ $222.75

35231 2 00 00 00 00 ZZZ $1,387.00

35231 8 00 00 00 00 ZZZ $278.00

35236 2 00 00 00 00 ZZZ $1,254.77

35236 8 00 00 00 00 ZZZ $250.95

35241 2 00 00 00 00 ZZZ $1,780.90

35241 8 00 00 00 00 ZZZ $356.18

35246 2 00 00 00 00 ZZZ $1,653.30

35246 8 00 00 00 00 ZZZ $330.66

35251 2 00 00 00 00 ZZZ $1,503.00

35251 8 00 00 00 00 ZZZ $301.00

35256 2 00 00 00 00 ZZZ $1,346.85

35256 8 00 00 00 00 ZZZ $269.37

35261 2 00 00 00 00 ZZZ $1,335.78

35261 8 00 00 00 00 ZZZ $267.16

35266 2 00 00 00 00 ZZZ $1,219.80

35266 8 00 00 00 00 ZZZ $243.96

35271 2 00 00 00 00 ZZZ $1,780.90

35271 8 00 00 00 00 ZZZ $356.18

35276 2 00 00 00 00 ZZZ $1,632.78

35276 8 00 00 00 00 ZZZ $326.56

Page 142: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35281 2 00 00 00 00 ZZZ $1,503.00

35281 8 00 00 00 00 ZZZ $301.00

35286 2 00 00 00 00 ZZZ $1,371.91

35286 8 00 00 00 00 ZZZ $274.38

35301 2 00 00 00 00 ZZZ $1,574.50

35301 8 00 00 00 00 ZZZ $314.90

35302 2 00 00 00 00 ZZZ $1,378.51

35302 8 00 00 00 00 ZZZ $275.70

35303 2 00 00 00 00 ZZZ $1,517.05

35303 8 00 00 00 00 ZZZ $303.41

35304 2 00 00 00 00 ZZZ $1,579.59

35304 8 00 00 00 00 ZZZ $315.92

35305 2 00 00 00 00 ZZZ $1,517.05

35305 8 00 00 00 00 ZZZ $303.41

35306 2 00 00 00 00 ZZZ $578.38

35306 8 00 00 00 00 ZZZ $115.68

35311 2 00 00 00 00 ZZZ $1,399.20

35311 8 00 00 00 00 ZZZ $279.84

35321 2 00 00 00 00 ZZZ $1,272.00

35321 8 00 00 00 00 ZZZ $254.00

35331 2 00 00 00 00 ZZZ $1,289.20

35331 8 00 00 00 00 ZZZ $257.84

35341 2 00 00 00 00 ZZZ $1,524.60

35341 8 00 00 00 00 ZZZ $304.92

35351 2 00 00 00 00 ZZZ $1,197.90

35351 8 00 00 00 00 ZZZ $239.58

35355 2 00 00 00 00 ZZZ $1,197.90

35355 8 00 00 00 00 ZZZ $239.58

35361 2 00 00 00 00 ZZZ $1,633.50

35361 8 00 00 00 00 ZZZ $326.70

35363 2 00 00 00 00 ZZZ $1,197.90

35363 8 00 00 00 00 ZZZ $239.58

35371 2 00 00 00 00 ZZZ $1,065.82

35371 8 00 00 00 00 ZZZ $213.16

35372 2 00 00 00 00 ZZZ $778.80

35372 8 00 00 00 00 ZZZ $155.76

35390 2 00 00 00 00 ZZZ $298.39

35390 8 00 00 00 00 ZZZ $59.68

35400 2 00 00 00 00 ZZZ $228.55

35400 8 00 00 00 00 ZZZ $45.71

Page 143: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35500 2 00 00 00 00 ZZZ $396.45

35500 8 00 00 00 00 ZZZ $79.29

35501 2 00 00 00 00 ZZZ $1,197.90

35501 8 00 00 00 00 ZZZ $239.58

35506 2 00 00 00 00 ZZZ $1,415.70

35506 8 00 00 00 00 ZZZ $283.14

35508 2 00 00 00 00 ZZZ $1,415.70

35508 8 00 00 00 00 ZZZ $283.14

35509 2 00 00 00 00 ZZZ $924.00

35509 8 00 00 00 00 ZZZ $184.80

35510 2 00 00 00 00 ZZZ $1,453.77

35510 8 00 00 00 00 ZZZ $290.75

35511 2 00 00 00 00 ZZZ $1,485.00

35511 8 00 00 00 00 ZZZ $297.00

35512 2 00 00 00 00 ZZZ $1,426.14

35512 8 00 00 00 00 ZZZ $285.23

35515 2 00 00 00 00 ZZZ $1,415.70

35515 8 00 00 00 00 ZZZ $283.14

35516 2 00 00 00 00 ZZZ $1,052.70

35516 8 00 00 00 00 ZZZ $210.54

35518 2 00 00 00 00 ZZZ $1,485.00

35518 8 00 00 00 00 ZZZ $297.00

35521 2 00 00 00 00 ZZZ $1,361.80

35521 8 00 00 00 00 ZZZ $272.36

35522 2 00 00 00 00 ZZZ $1,384.88

35522 8 00 00 00 00 ZZZ $276.98

35523 2 00 00 00 00 ZZZ $1,676.91

35523 8 00 00 00 00 ZZZ $335.38

35525 2 00 00 00 00 ZZZ $1,322.17

35525 8 00 00 00 00 ZZZ $264.43

35526 2 00 00 00 00 ZZZ $1,590.60

35526 8 00 00 00 00 ZZZ $318.12

35531 2 00 00 00 00 ZZZ $1,524.60

35531 8 00 00 00 00 ZZZ $304.92

35533 2 00 00 00 00 ZZZ $1,818.80

35533 8 00 00 00 00 ZZZ $363.76

35535 2 00 00 00 00 ZZZ $2,694.16

35535 8 00 00 00 00 ZZZ $538.83

35536 2 00 00 00 00 ZZZ $1,289.20

35536 8 00 00 00 00 ZZZ $257.84

Page 144: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35537 2 00 00 00 00 ZZZ $1,929.68

35537 8 00 00 00 00 ZZZ $385.94

35538 2 00 00 00 00 ZZZ $2,990.63

35538 8 00 00 00 00 ZZZ $598.13

35539 2 00 00 00 00 ZZZ $1,900.75

35539 8 00 00 00 00 ZZZ $380.15

35540 2 00 00 00 00 ZZZ $3,137.05

35540 8 00 00 00 00 ZZZ $627.41

35556 2 00 00 00 00 ZZZ $1,848.64

35556 8 00 00 00 00 ZZZ $369.73

35558 2 00 00 00 00 ZZZ $1,052.70

35558 8 00 00 00 00 ZZZ $210.54

35560 2 00 00 00 00 ZZZ $1,524.60

35560 8 00 00 00 00 ZZZ $304.92

35563 2 00 00 00 00 ZZZ $1,387.00

35563 8 00 00 00 00 ZZZ $278.00

35565 2 00 00 00 00 ZZZ $1,389.86

35565 8 00 00 00 00 ZZZ $277.97

35566 2 00 00 00 00 ZZZ $1,870.00

35566 8 00 00 00 00 ZZZ $374.00

35570 2 00 00 00 00 ZZZ $2,080.02

35570 8 00 00 00 00 ZZZ $416.00

35571 2 00 00 00 00 ZZZ $1,361.80

35571 8 00 00 00 00 ZZZ $272.36

35572 2 00 00 00 00 ZZZ $413.38

35572 8 00 00 00 00 ZZZ $82.68

35583 2 00 00 00 00 ZZZ $1,233.10

35583 8 00 00 00 00 ZZZ $246.62

35585 2 00 00 00 00 ZZZ $1,357.20

35585 8 00 00 00 00 ZZZ $271.44

35587 2 00 00 00 00 ZZZ $1,045.00

35587 8 00 00 00 00 ZZZ $209.00

35600 2 00 00 00 00 ZZZ $308.17

35600 8 00 00 00 00 ZZZ $61.63

35601 2 00 00 00 00 ZZZ $1,107.70

35601 8 00 00 00 00 ZZZ $221.54

35606 2 00 00 00 00 ZZZ $1,452.00

35606 8 00 00 00 00 ZZZ $290.40

35612 2 00 00 00 00 ZZZ $871.20

35612 8 00 00 00 00 ZZZ $174.24

Page 145: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35616 2 00 00 00 00 ZZZ $871.20

35616 8 00 00 00 00 ZZZ $174.24

35621 2 00 00 00 00 ZZZ $980.10

35621 8 00 00 00 00 ZZZ $196.02

35623 2 00 00 00 00 ZZZ $1,144.00

35623 8 00 00 00 00 ZZZ $228.80

35626 2 00 00 00 00 ZZZ $1,296.90

35626 8 00 00 00 00 ZZZ $259.38

35631 2 00 00 00 00 ZZZ $1,415.70

35631 8 00 00 00 00 ZZZ $283.14

35632 2 00 00 00 00 ZZZ $2,558.05

35632 8 00 00 00 00 ZZZ $511.61

35633 2 00 00 00 00 ZZZ $2,762.45

35633 8 00 00 00 00 ZZZ $552.49

35634 2 00 00 00 00 ZZZ $2,503.51

35634 8 00 00 00 00 ZZZ $500.70

35636 2 00 00 00 00 ZZZ $1,107.70

35636 8 00 00 00 00 ZZZ $221.54

35637 2 00 00 00 00 ZZZ $1,856.65

35637 8 00 00 00 00 ZZZ $371.33

35638 2 00 00 00 00 ZZZ $2,155.56

35638 8 00 00 00 00 ZZZ $431.11

35642 2 00 00 00 00 ZZZ $1,375.41

35642 8 00 00 00 00 ZZZ $275.08

35645 2 00 00 00 00 ZZZ $1,381.47

35645 8 00 00 00 00 ZZZ $276.29

35646 2 00 00 00 00 ZZZ $1,923.90

35646 8 00 00 00 00 ZZZ $384.78

35647 2 00 00 00 00 ZZZ $1,771.84

35647 8 00 00 00 00 ZZZ $354.37

35650 2 00 00 00 00 ZZZ $980.10

35650 8 00 00 00 00 ZZZ $196.02

35654 2 00 00 00 00 ZZZ $1,698.51

35654 8 00 00 00 00 ZZZ $339.70

35656 2 00 00 00 00 ZZZ $1,197.90

35656 8 00 00 00 00 ZZZ $239.58

35661 2 00 00 00 00 ZZZ $907.50

35661 8 00 00 00 00 ZZZ $181.50

35663 2 00 00 00 00 ZZZ $1,042.80

35663 8 00 00 00 00 ZZZ $208.56

Page 146: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35665 2 00 00 00 00 ZZZ $1,042.80

35665 8 00 00 00 00 ZZZ $208.56

35666 2 00 00 00 00 ZZZ $1,004.98

35666 8 00 00 00 00 ZZZ $201.00

35671 2 00 00 00 00 ZZZ $1,145.10

35671 8 00 00 00 00 ZZZ $229.02

35681 2 00 00 00 00 ZZZ $459.83

35681 8 00 00 00 00 ZZZ $91.97

35682 2 00 00 00 00 ZZZ $526.39

35682 8 00 00 00 00 ZZZ $105.28

35683 2 00 00 00 00 ZZZ $601.06

35683 8 00 00 00 00 ZZZ $120.21

35685 2 00 00 00 00 ZZZ $245.87

35685 8 00 00 00 00 ZZZ $49.17

35686 2 00 00 00 00 ZZZ $203.38

35686 8 00 00 00 00 ZZZ $40.68

35691 2 00 00 00 00 ZZZ $1,434.40

35691 8 00 00 00 00 ZZZ $286.88

35693 2 00 00 00 00 ZZZ $1,197.90

35693 8 00 00 00 00 ZZZ $239.58

35694 2 00 00 00 00 ZZZ $1,433.69

35694 8 00 00 00 00 ZZZ $286.74

35695 2 00 00 00 00 ZZZ $1,431.82

35695 8 00 00 00 00 ZZZ $286.36

35697 2 00 00 00 00 ZZZ $796.36

35697 8 00 00 00 00 ZZZ $159.27

35700 2 00 00 00 00 ZZZ $208.81

35700 8 00 00 00 00 ZZZ $41.76

35701 2 00 00 00 00 ZZZ $385.00

35701 8 00 00 00 00 ZZZ $77.00

35721 2 00 00 00 00 ZZZ $388.30

35721 8 00 00 00 00 ZZZ $77.66

35741 2 00 00 00 00 ZZZ $326.70

35741 8 00 00 00 00 ZZZ $65.34

35761 2 00 00 00 00 ZZZ $508.20

35761 8 00 00 00 00 ZZZ $101.64

35772 2 00 00 00 00 ZZZ $409.00

35800 2 00 00 00 00 ZZZ $694.00

35800 8 00 00 00 00 ZZZ $138.00

35820 2 00 00 00 00 ZZZ $1,007.54

Page 147: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

35820 8 00 00 00 00 ZZZ $201.51

35840 2 00 00 00 00 ZZZ $925.00

35840 8 00 00 00 00 ZZZ $185.00

35860 2 00 00 00 00 ZZZ $657.40

35860 8 00 00 00 00 ZZZ $131.48

35870 2 00 00 00 00 ZZZ $1,380.31

35870 8 00 00 00 00 ZZZ $276.06

35875 2 00 00 00 00 ZZZ $714.93

35875 8 00 00 00 00 ZZZ $142.99

35876 2 00 00 00 00 ZZZ $937.90

35876 8 00 00 00 00 ZZZ $187.58

35879 2 00 00 00 00 ZZZ $1,090.33

35879 8 00 00 00 00 ZZZ $218.07

35881 2 00 00 00 00 ZZZ $1,195.52

35881 8 00 00 00 00 ZZZ $239.10

35883 2 00 00 00 00 ZZZ $1,532.70

35883 8 00 00 00 00 ZZZ $306.41

35884 2 00 00 00 00 ZZZ $1,628.68

35884 8 00 00 00 00 ZZZ $325.74

35901 2 00 00 00 00 ZZZ $624.80

35901 8 00 00 00 00 ZZZ $124.96

35903 2 00 00 00 00 ZZZ $744.70

35903 8 00 00 00 00 ZZZ $148.94

35905 2 00 00 00 00 ZZZ $1,423.43

35905 8 00 00 00 00 ZZZ $284.69

35907 2 00 00 00 00 ZZZ $1,415.04

35907 8 00 00 00 00 ZZZ $283.01

36000 2 00 00 00 00 ZZZ $29.00

36000 8 00 00 00 00 ZZZ $6.00

36002 2 00 00 00 00 ZZZ $205.85

36002 8 00 00 00 00 ZZZ $41.17

36005 2 00 00 00 00 ZZZ $231.57

36005 8 00 00 00 00 ZZZ $46.31

36010 2 00 00 00 00 ZZZ $205.00

36010 8 00 00 00 00 ZZZ $41.00

36011 2 00 00 00 00 ZZZ $217.80

36011 8 00 00 00 00 ZZZ $43.56

36012 2 00 00 00 00 ZZZ $274.00

36012 8 00 00 00 00 ZZZ $55.00

36013 2 00 00 00 00 ZZZ $199.09

Page 148: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

36013 8 00 00 00 00 ZZZ $40.00

36014 2 00 00 00 00 ZZZ $234.00

36014 8 00 00 00 00 ZZZ $47.00

36015 2 00 00 00 00 ZZZ $274.00

36015 8 00 00 00 00 ZZZ $55.00

36100 2 00 00 00 00 ZZZ $251.00

36100 8 00 00 00 00 ZZZ $50.00

36120 2 00 00 00 00 ZZZ $198.00

36120 8 00 00 00 00 ZZZ $40.00

36140 2 00 00 00 00 ZZZ $150.13

36140 8 00 00 00 00 ZZZ $30.03

36160 2 00 00 00 00 ZZZ $218.00

36160 8 00 00 00 00 ZZZ $44.00

36200 2 00 00 00 00 ZZZ $228.80

36200 8 00 00 00 00 ZZZ $45.76

36215 2 00 00 00 00 ZZZ $250.80

36215 8 00 00 00 00 ZZZ $50.16

36216 2 00 00 00 00 ZZZ $377.19

36216 8 00 00 00 00 ZZZ $75.44

36217 2 00 00 00 00 ZZZ $454.58

36217 8 00 00 00 00 ZZZ $90.92

36218 2 00 00 00 00 ZZZ $92.08

36218 8 00 00 00 00 ZZZ $18.42

36221 2 00 00 00 00 ZZZ $266.43

36221 8 00 00 00 00 ZZZ $53.29

36222 2 00 00 00 00 ZZZ $358.13

36222 8 00 00 00 00 ZZZ $71.63

36223 2 00 00 00 00 ZZZ $387.53

36223 8 00 00 00 00 ZZZ $77.51

36224 2 00 00 00 00 ZZZ $421.59

36224 8 00 00 00 00 ZZZ $84.32

36225 2 00 00 00 00 ZZZ $386.30

36225 8 00 00 00 00 ZZZ $77.26

36226 2 00 00 00 00 ZZZ $422.20

36226 8 00 00 00 00 ZZZ $84.44

36227 2 00 00 00 00 ZZZ $133.90

36227 8 00 00 00 00 ZZZ $26.78

36228 2 00 00 00 00 ZZZ $272.96

36228 8 00 00 00 00 ZZZ $54.59

36245 2 00 00 00 00 ZZZ $268.40

Page 149: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

36245 8 00 00 00 00 ZZZ $53.68

36246 2 00 00 00 00 ZZZ $383.71

36246 8 00 00 00 00 ZZZ $76.74

36247 2 00 00 00 00 ZZZ $453.65

36247 8 00 00 00 00 ZZZ $90.73

36248 2 00 00 00 00 ZZZ $93.25

36248 8 00 00 00 00 ZZZ $18.65

36251 2 00 00 00 00 ZZZ $348.85

36251 8 00 00 00 00 ZZZ $69.77

36252 2 00 00 00 00 ZZZ $454.71

36252 8 00 00 00 00 ZZZ $90.94

36253 2 00 00 00 00 ZZZ $487.37

36253 8 00 00 00 00 ZZZ $97.47

36254 2 00 00 00 00 ZZZ $525.85

36254 8 00 00 00 00 ZZZ $105.17

36260 2 00 00 00 00 ZZZ $446.63

36260 8 00 00 00 00 ZZZ $89.33

36261 2 00 00 00 00 ZZZ $317.12

36261 8 00 00 00 00 ZZZ $63.42

36262 2 00 00 00 00 ZZZ $248.46

36262 8 00 00 00 00 ZZZ $49.69

36299 2 00 00 00 00 ZZZ $0.00

36299 8 00 00 00 00 ZZZ $0.00

36400 2 00 00 00 00 ZZZ $14.16

36400 8 00 00 00 00 ZZZ $2.83

36405 2 00 00 00 00 ZZZ $26.40

36405 8 00 00 00 00 ZZZ $5.28

36406 2 00 00 00 00 ZZZ $16.50

36406 8 00 00 00 00 ZZZ $3.30

36410 2 00 00 00 00 ZZZ $19.80

36410 8 00 00 00 00 ZZZ $4.00

36415 2 00 00 00 00 ZZZ $3.00

36415 A FP 00 00 00 ZZZ $3.00

36420 2 00 00 00 00 ZZZ $72.26

36420 8 00 00 00 00 ZZZ $14.45

36425 2 00 00 00 00 ZZZ $57.17

36425 8 00 00 00 00 ZZZ $11.43

36430 2 00 00 00 00 ZZZ $55.00

36430 8 00 00 00 00 ZZZ $11.20

36440 2 00 00 00 00 ZZZ $55.00

Page 150: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

36440 8 00 00 00 00 ZZZ $11.00

36450 2 00 00 00 00 ZZZ $218.55

36450 8 00 00 00 00 ZZZ $43.71

36455 2 00 00 00 00 ZZZ $248.86

36455 8 00 00 00 00 ZZZ $49.77

36460 2 00 00 00 00 ZZZ $508.20

36460 8 00 00 00 00 ZZZ $101.64

36470 2 00 00 00 00 ZZZ $70.55

36470 8 00 00 00 00 ZZZ $14.11

36471 2 00 00 00 00 ZZZ $91.53

36471 8 00 00 00 00 ZZZ $18.31

36475 2 00 00 00 00 ZZZ $1,827.21

36475 8 00 00 00 00 ZZZ $365.44

36476 2 00 00 00 00 ZZZ $421.66

36476 8 00 00 00 00 ZZZ $84.33

36478 2 00 00 00 00 ZZZ $1,827.21

36478 8 00 00 00 00 ZZZ $365.44

36479 2 00 00 00 00 ZZZ $421.66

36479 8 00 00 00 00 ZZZ $84.33

36481 2 00 00 00 00 ZZZ $548.00

36481 8 00 00 00 00 ZZZ $110.00

36500 2 00 00 00 00 ZZZ $127.60

36500 8 00 00 00 00 ZZZ $25.52

36510 2 00 00 00 00 ZZZ $89.00

36510 8 00 00 00 00 ZZZ $18.00

36511 2 00 00 00 00 ZZZ $103.13

36511 8 00 00 00 00 ZZZ $20.63

36512 2 00 00 00 00 ZZZ $103.13

36512 8 00 00 00 00 ZZZ $20.63

36513 2 00 00 00 00 ZZZ $103.13

36513 8 00 00 00 00 ZZZ $20.63

36514 2 00 00 00 00 ZZZ $103.13

36514 8 00 00 00 00 ZZZ $20.63

36515 2 00 00 00 00 ZZZ $103.13

36515 8 00 00 00 00 ZZZ $20.63

36516 2 00 00 00 00 ZZZ $103.13

36516 8 00 00 00 00 ZZZ $20.63

36522 2 00 00 00 00 ZZZ $188.30

36522 8 00 00 00 00 ZZZ $37.66

36555 2 00 00 00 00 ZZZ $366.74

Page 151: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

36555 8 00 00 00 00 ZZZ $73.35

36556 2 00 00 00 00 ZZZ $348.59

36556 8 00 00 00 00 ZZZ $69.72

36557 2 00 00 00 00 ZZZ $618.26

36557 8 00 00 00 00 ZZZ $123.65

36558 2 00 00 00 00 ZZZ $602.77

36558 8 00 00 00 00 ZZZ $120.55

36560 2 00 00 00 00 ZZZ $1,108.25

36560 8 00 00 00 00 ZZZ $221.65

36561 2 00 00 00 00 ZZZ $1,095.67

36561 8 00 00 00 00 ZZZ $219.13

36563 2 00 00 00 00 ZZZ $1,361.89

36563 8 00 00 00 00 ZZZ $272.38

36565 2 00 00 00 00 ZZZ $898.60

36565 8 00 00 00 00 ZZZ $179.72

36566 2 00 00 00 00 ZZZ $941.88

36566 8 00 00 00 00 ZZZ $188.38

36568 2 00 00 00 00 ZZZ $319.76

36568 8 00 00 00 00 ZZZ $63.95

36569 2 00 00 00 00 ZZZ $290.92

36569 8 00 00 00 00 ZZZ $58.18

36570 2 00 00 00 00 ZZZ $1,383.60

36570 8 00 00 00 00 ZZZ $276.72

36571 2 00 00 00 00 ZZZ $1,251.68

36571 8 00 00 00 00 ZZZ $250.34

36575 2 00 00 00 00 ZZZ $190.18

36575 8 00 00 00 00 ZZZ $38.04

36576 2 00 00 00 00 ZZZ $474.00

36576 8 00 00 00 00 ZZZ $94.80

36578 2 00 00 00 00 ZZZ $603.12

36578 8 00 00 00 00 ZZZ $120.62

36580 2 00 00 00 00 ZZZ $252.04

36580 8 00 00 00 00 ZZZ $50.41

36581 2 00 00 00 00 ZZZ $541.57

36581 8 00 00 00 00 ZZZ $108.31

36582 2 00 00 00 00 ZZZ $992.45

36582 8 00 00 00 00 ZZZ $198.49

36583 2 00 00 00 00 ZZZ $612.27

36583 8 00 00 00 00 ZZZ $122.45

36584 2 00 00 00 00 ZZZ $260.81

Page 152: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

36584 8 00 00 00 00 ZZZ $52.16

36585 2 00 00 00 00 ZZZ $1,225.96

36585 8 00 00 00 00 ZZZ $245.19

36589 2 00 00 00 00 ZZZ $194.71

36589 8 00 00 00 00 ZZZ $38.94

36590 2 00 00 00 00 ZZZ $417.48

36590 8 00 00 00 00 ZZZ $83.50

36591 2 00 00 00 00 ZZZ $19.80

36591 8 00 00 00 00 ZZZ $3.96

36592 2 00 00 00 00 ZZZ $24.48

36592 8 00 00 00 00 ZZZ $4.90

36593 2 00 00 00 00 ZZZ $34.92

36593 8 00 00 00 00 ZZZ $6.98

36595 2 00 00 00 00 ZZZ $717.72

36595 8 00 00 00 00 ZZZ $143.54

36596 2 00 00 00 00 ZZZ $157.30

36596 8 00 00 00 00 ZZZ $31.46

36597 2 00 00 00 00 ZZZ $183.99

36597 8 00 00 00 00 ZZZ $36.80

36598 2 00 00 00 00 ZZZ $163.14

36598 8 00 00 00 00 ZZZ $32.63

36600 2 00 00 00 00 ZZZ $39.00

36600 8 00 00 00 00 ZZZ $8.00

36620 2 00 00 00 00 ZZZ $99.66

36620 8 00 00 00 00 ZZZ $19.93

36625 2 00 00 00 00 ZZZ $175.42

36625 8 00 00 00 00 ZZZ $35.08

36640 2 00 00 00 00 ZZZ $229.04

36640 8 00 00 00 00 ZZZ $45.81

36660 2 00 00 00 00 ZZZ $114.23

36660 8 00 00 00 00 ZZZ $22.85

36680 2 00 00 00 00 ZZZ $102.10

36680 8 00 00 00 00 ZZZ $20.42

36800 2 00 00 00 00 ZZZ $130.90

36800 8 00 00 00 00 ZZZ $26.18

36810 2 00 00 00 00 ZZZ $366.00

36810 8 00 00 00 00 ZZZ $73.00

36815 2 00 00 00 00 ZZZ $277.00

36815 8 00 00 00 00 ZZZ $55.00

36818 2 00 00 00 00 ZZZ $905.90

Page 153: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

36818 8 00 00 00 00 ZZZ $181.18

36819 2 00 00 00 00 ZZZ $915.83

36819 8 00 00 00 00 ZZZ $183.17

36820 2 00 00 00 00 ZZZ $911.30

36820 8 00 00 00 00 ZZZ $182.26

36821 2 00 00 00 00 ZZZ $667.70

36821 8 00 00 00 00 ZZZ $133.54

36823 2 00 00 00 00 ZZZ $1,370.03

36823 8 00 00 00 00 ZZZ $274.01

36825 2 00 00 00 00 ZZZ $762.30

36825 8 00 00 00 00 ZZZ $152.46

36830 2 00 00 00 00 ZZZ $781.00

36830 8 00 00 00 00 ZZZ $156.20

36831 2 00 00 00 00 ZZZ $481.45

36831 8 00 00 00 00 ZZZ $96.29

36832 2 00 00 00 00 ZZZ $697.24

36832 8 00 00 00 00 ZZZ $139.45

36833 2 00 00 00 00 ZZZ $732.66

36833 8 00 00 00 00 ZZZ $146.53

36835 2 00 00 00 00 ZZZ $717.43

36835 8 00 00 00 00 ZZZ $143.49

36838 2 00 00 00 00 ZZZ $1,359.30

36838 8 00 00 00 00 ZZZ $271.86

36860 2 00 00 00 00 ZZZ $118.28

36860 8 00 00 00 00 ZZZ $23.66

36861 2 00 00 00 00 ZZZ $148.50

36861 8 00 00 00 00 ZZZ $29.70

36901 2 00 00 00 00 ZZZ $634.15

36901 8 00 00 00 00 ZZZ $126.83

36902 2 00 00 00 00 ZZZ $1,342.70

36902 8 00 00 00 00 ZZZ $268.54

36903 2 00 00 00 00 ZZZ $6,110.48

36903 8 00 00 00 00 ZZZ $1,222.10

36904 2 00 00 00 00 ZZZ $1,959.57

36904 8 00 00 00 00 ZZZ $391.91

36905 2 00 00 00 00 ZZZ $2,506.97

36905 8 00 00 00 00 ZZZ $501.39

36906 2 00 00 00 00 ZZZ $7,419.06

36906 8 00 00 00 00 ZZZ $1,483.81

36907 2 00 00 00 00 ZZZ $803.22

Page 154: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

36907 8 00 00 00 00 ZZZ $160.64

36908 2 00 00 00 00 ZZZ $2,939.83

36908 8 00 00 00 00 ZZZ $587.97

36909 2 00 00 00 00 ZZZ $2,146.99

36909 8 00 00 00 00 ZZZ $429.40

37140 2 00 00 00 00 ZZZ $1,488.30

37140 8 00 00 00 00 ZZZ $297.66

37145 2 00 00 00 00 ZZZ $1,488.30

37145 8 00 00 00 00 ZZZ $297.66

37160 2 00 00 00 00 ZZZ $1,488.30

37160 8 00 00 00 00 ZZZ $297.66

37180 2 00 00 00 00 ZZZ $1,488.30

37180 8 00 00 00 00 ZZZ $297.66

37181 2 00 00 00 00 ZZZ $1,488.30

37181 8 00 00 00 00 ZZZ $297.66

37182 2 00 00 00 00 ZZZ $1,025.55

37182 8 00 00 00 00 ZZZ $205.11

37183 2 00 00 00 00 ZZZ $476.48

37183 8 00 00 00 00 ZZZ $95.30

37184 2 00 00 00 00 ZZZ $2,483.54

37184 8 00 00 00 00 ZZZ $496.71

37185 2 00 00 00 00 ZZZ $811.94

37185 8 00 00 00 00 ZZZ $162.39

37186 2 00 00 00 00 ZZZ $1,672.09

37186 8 00 00 00 00 ZZZ $334.42

37187 2 00 00 00 00 ZZZ $2,414.42

37187 8 00 00 00 00 ZZZ $482.88

37188 2 00 00 00 00 ZZZ $2,080.85

37188 8 00 00 00 00 ZZZ $416.17

37191 2 00 00 00 00 ZZZ $2,456.30

37191 8 00 00 00 00 ZZZ $491.26

37192 2 00 00 00 00 ZZZ $1,723.75

37192 8 00 00 00 00 ZZZ $344.75

37193 2 00 00 00 00 ZZZ $1,650.97

37193 8 00 00 00 00 ZZZ $330.19

37195 2 00 00 00 00 ZZZ $339.02

37195 8 00 00 00 00 ZZZ $67.80

37197 2 00 00 00 00 ZZZ $1,616.07

37197 8 00 00 00 00 ZZZ $323.21

37200 2 00 00 00 00 ZZZ $290.40

Page 155: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

37200 8 00 00 00 00 ZZZ $58.08

37211 2 00 00 00 00 ZZZ $501.73

37211 8 00 00 00 00 ZZZ $100.35

37212 2 00 00 00 00 ZZZ $442.94

37212 8 00 00 00 00 ZZZ $88.59

37213 2 00 00 00 00 ZZZ $310.71

37213 8 00 00 00 00 ZZZ $62.14

37214 2 00 00 00 00 ZZZ $178.92

37214 8 00 00 00 00 ZZZ $35.78

37215 2 00 00 00 00 ZZZ $1,346.97

37215 8 00 00 00 00 ZZZ $269.39

37216 2 00 00 00 00 ZZZ $1,297.54

37216 8 00 00 00 00 ZZZ $259.51

37217 2 00 00 00 00 ZZZ $1,481.49

37217 8 00 00 00 00 ZZZ $296.30

37218 2 00 00 00 00 ZZZ $747.06

37218 8 00 00 00 00 ZZZ $149.42

37220 2 00 00 00 00 ZZZ $528.92

37220 8 00 00 00 00 ZZZ $105.78

37221 2 00 00 00 00 ZZZ $644.31

37221 8 00 00 00 00 ZZZ $128.86

37222 2 00 00 00 00 ZZZ $240.62

37222 8 00 00 00 00 ZZZ $48.12

37223 2 00 00 00 00 ZZZ $273.35

37223 8 00 00 00 00 ZZZ $54.67

37224 2 00 00 00 00 ZZZ $582.72

37224 8 00 00 00 00 ZZZ $116.54

37225 2 00 00 00 00 ZZZ $783.02

37225 8 00 00 00 00 ZZZ $156.60

37226 2 00 00 00 00 ZZZ $651.59

37226 8 00 00 00 00 ZZZ $130.32

37227 2 00 00 00 00 ZZZ $945.90

37227 8 00 00 00 00 ZZZ $189.18

37228 2 00 00 00 00 ZZZ $712.36

37228 8 00 00 00 00 ZZZ $142.47

37229 2 00 00 00 00 ZZZ $917.11

37229 8 00 00 00 00 ZZZ $183.42

37230 2 00 00 00 00 ZZZ $887.97

37230 8 00 00 00 00 ZZZ $177.59

37231 2 00 00 00 00 ZZZ $965.12

Page 156: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

37231 8 00 00 00 00 ZZZ $193.02

37232 2 00 00 00 00 ZZZ $257.67

37232 8 00 00 00 00 ZZZ $51.53

37233 2 00 00 00 00 ZZZ $422.98

37233 8 00 00 00 00 ZZZ $84.60

37234 2 00 00 00 00 ZZZ $353.85

37234 8 00 00 00 00 ZZZ $70.77

37235 2 00 00 00 00 ZZZ $502.02

37235 8 00 00 00 00 ZZZ $100.40

37236 2 00 00 00 00 ZZZ $2,697.27

37236 8 00 00 00 00 ZZZ $539.45

37237 2 00 00 00 00 ZZZ $1,177.91

37237 8 00 00 00 00 ZZZ $235.58

37238 2 00 00 00 00 ZZZ $3,818.25

37238 8 00 00 00 00 ZZZ $763.65

37239 2 00 00 00 00 ZZZ $1,895.03

37239 8 00 00 00 00 ZZZ $379.01

37241 2 00 00 00 00 ZZZ $4,263.27

37241 8 00 00 00 00 ZZZ $852.65

37242 2 00 00 00 00 ZZZ $7,087.93

37242 8 00 00 00 00 ZZZ $1,417.59

37243 2 00 00 00 00 ZZZ $8,934.97

37243 8 00 00 00 00 ZZZ $1,786.99

37244 2 00 00 00 00 ZZZ $6,358.06

37244 8 00 00 00 00 ZZZ $1,271.61

37246 2 00 00 00 00 ZZZ $2,362.41

37246 8 00 00 00 00 ZZZ $472.48

37247 2 00 00 00 00 ZZZ $958.13

37247 8 00 00 00 00 ZZZ $191.63

37248 2 00 00 00 00 ZZZ $1,640.39

37248 8 00 00 00 00 ZZZ $328.08

37249 2 00 00 00 00 ZZZ $704.31

37249 8 00 00 00 00 ZZZ $140.86

37252 2 00 00 00 00 ZZZ $1,325.76

37252 8 00 00 00 00 ZZZ $265.15

37253 2 00 00 00 00 ZZZ $208.55

37253 8 00 00 00 00 ZZZ $41.71

37500 2 00 00 00 00 ZZZ $829.19

37500 8 00 00 00 00 ZZZ $165.84

37501 2 00 00 00 00 ZZZ $0.00

Page 157: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

37501 8 00 00 00 00 ZZZ $0.00

37565 2 00 00 00 00 ZZZ $381.70

37565 8 00 00 00 00 ZZZ $76.34

37600 2 00 00 00 00 ZZZ $315.70

37600 8 00 00 00 00 ZZZ $63.14

37605 2 00 00 00 00 ZZZ $508.20

37605 8 00 00 00 00 ZZZ $101.64

37606 2 00 00 00 00 ZZZ $604.00

37606 8 00 00 00 00 ZZZ $121.00

37607 2 00 00 00 00 ZZZ $271.70

37607 8 00 00 00 00 ZZZ $54.34

37609 2 00 00 00 00 ZZZ $179.12

37609 8 00 00 00 00 ZZZ $35.82

37615 2 00 00 00 00 ZZZ $656.23

37615 8 00 00 00 00 ZZZ $131.25

37616 2 00 00 00 00 ZZZ $891.00

37616 8 00 00 00 00 ZZZ $178.20

37617 2 00 00 00 00 ZZZ $891.00

37617 8 00 00 00 00 ZZZ $178.20

37618 2 00 00 00 00 ZZZ $317.90

37618 8 00 00 00 00 ZZZ $63.58

37619 2 00 00 00 00 ZZZ $1,477.03

37619 8 00 00 00 00 ZZZ $295.41

37650 2 00 00 00 00 ZZZ $317.90

37650 8 00 00 00 00 ZZZ $63.58

37660 2 00 00 00 00 ZZZ $635.80

37660 8 00 00 00 00 ZZZ $127.16

37700 2 00 00 00 00 ZZZ $200.11

37700 8 00 00 00 00 ZZZ $40.02

37718 2 00 00 00 00 ZZZ $369.13

37718 8 00 00 00 00 ZZZ $73.83

37722 2 00 00 00 00 ZZZ $428.23

37722 8 00 00 00 00 ZZZ $85.65

37735 2 00 00 00 00 ZZZ $762.30

37735 8 00 00 00 00 ZZZ $152.46

37760 2 00 00 00 00 ZZZ $552.20

37760 8 00 00 00 00 ZZZ $110.44

37761 2 00 00 00 00 ZZZ $754.52

37761 8 00 00 00 00 ZZZ $150.90

37765 2 00 00 00 00 ZZZ $510.30

Page 158: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

37765 8 00 00 00 00 ZZZ $102.06

37766 2 00 00 00 00 ZZZ $620.04

37766 8 00 00 00 00 ZZZ $124.01

37780 2 00 00 00 00 ZZZ $189.20

37780 8 00 00 00 00 ZZZ $37.84

37785 2 00 00 00 00 ZZZ $214.53

37785 8 00 00 00 00 ZZZ $42.91

37788 2 00 00 00 00 ZZZ $1,564.35

37788 8 00 00 00 00 ZZZ $312.87

37790 2 00 00 00 00 ZZZ $563.20

37790 8 00 00 00 00 ZZZ $112.64

37799 2 00 00 00 00 ZZZ $0.00

37799 8 00 00 00 00 ZZZ $0.00

38100 2 00 00 00 00 ZZZ $1,016.40

38100 8 00 00 00 00 ZZZ $203.28

38101 2 00 00 00 00 ZZZ $763.40

38101 8 00 00 00 00 ZZZ $152.68

38102 2 00 00 00 00 ZZZ $352.01

38102 8 00 00 00 00 ZZZ $70.40

38115 2 00 00 00 00 ZZZ $763.40

38115 8 00 00 00 00 ZZZ $152.68

38120 2 00 00 00 00 ZZZ $1,067.22

38120 8 00 00 00 00 ZZZ $213.44

38129 2 00 00 00 00 ZZZ $0.00

38129 8 00 00 00 00 ZZZ $0.00

38200 2 00 00 00 00 ZZZ $191.16

38200 8 00 00 00 00 ZZZ $38.23

38204 2 00 00 00 00 ZZZ $0.00

38204 8 00 00 00 00 ZZZ $0.00

38205 2 00 00 00 00 ZZZ $0.00

38205 8 00 00 00 00 ZZZ $0.00

38206 2 00 00 00 00 ZZZ $0.00

38206 8 00 00 00 00 ZZZ $0.00

38207 2 00 00 00 00 ZZZ $0.00

38207 8 00 00 00 00 ZZZ $0.00

38208 2 00 00 00 00 ZZZ $0.00

38208 8 00 00 00 00 ZZZ $0.00

38209 2 00 00 00 00 ZZZ $0.00

38209 8 00 00 00 00 ZZZ $0.00

38210 2 00 00 00 00 ZZZ $0.00

Page 159: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

38210 8 00 00 00 00 ZZZ $0.00

38211 2 00 00 00 00 ZZZ $0.00

38211 8 00 00 00 00 ZZZ $0.00

38212 2 00 00 00 00 ZZZ $0.00

38212 8 00 00 00 00 ZZZ $0.00

38213 2 00 00 00 00 ZZZ $0.00

38213 8 00 00 00 00 ZZZ $0.00

38214 2 00 00 00 00 ZZZ $0.00

38214 8 00 00 00 00 ZZZ $0.00

38215 2 00 00 00 00 ZZZ $0.00

38215 8 00 00 00 00 ZZZ $0.00

38220 2 00 00 00 00 ZZZ $177.90

38220 8 00 00 00 00 ZZZ $35.58

38221 2 00 00 00 00 ZZZ $193.12

38221 8 00 00 00 00 ZZZ $38.62

38230 2 00 00 00 00 ZZZ $297.44

38230 8 00 00 00 00 ZZZ $59.49

38232 2 00 00 00 00 ZZZ $1,965.60

38232 8 00 00 00 00 ZZZ $393.00

38242 2 00 00 00 00 ZZZ $101.49

38242 8 00 00 00 00 ZZZ $20.30

38300 2 00 00 00 00 ZZZ $101.49

38300 8 00 00 00 00 ZZZ $20.30

38305 2 00 00 00 00 ZZZ $317.90

38305 8 00 00 00 00 ZZZ $63.58

38308 2 00 00 00 00 ZZZ $520.00

38308 8 00 00 00 00 ZZZ $104.00

38380 2 00 00 00 00 ZZZ $694.00

38380 8 00 00 00 00 ZZZ $138.00

38381 2 00 00 00 00 ZZZ $763.40

38381 8 00 00 00 00 ZZZ $152.68

38382 2 00 00 00 00 ZZZ $649.00

38382 8 00 00 00 00 ZZZ $129.80

38500 2 00 00 00 00 ZZZ $210.10

38500 8 00 00 00 00 ZZZ $42.02

38505 2 00 00 00 00 ZZZ $100.52

38505 8 00 00 00 00 ZZZ $20.10

38510 2 00 00 00 00 ZZZ $265.10

38510 8 00 00 00 00 ZZZ $53.02

38520 2 00 00 00 00 ZZZ $265.10

Page 160: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

38520 8 00 00 00 00 ZZZ $53.02

38525 2 00 00 00 00 ZZZ $265.10

38525 8 00 00 00 00 ZZZ $53.02

38530 2 00 00 00 00 ZZZ $307.89

38530 8 00 00 00 00 ZZZ $61.58

38542 2 00 00 00 00 ZZZ $302.39

38542 8 00 00 00 00 ZZZ $60.48

38550 2 00 00 00 00 ZZZ $309.47

38550 8 00 00 00 00 ZZZ $61.89

38555 2 00 00 00 00 ZZZ $664.83

38555 8 00 00 00 00 ZZZ $132.97

38562 2 00 00 00 00 ZZZ $732.62

38562 8 00 00 00 00 ZZZ $146.52

38564 2 00 00 00 00 ZZZ $778.64

38564 8 00 00 00 00 ZZZ $155.73

38570 2 00 00 00 00 ZZZ $602.71

38570 8 00 00 00 00 ZZZ $120.54

38571 2 00 00 00 00 ZZZ $764.02

38571 8 00 00 00 00 ZZZ $152.80

38572 2 00 00 00 00 ZZZ $886.13

38572 8 00 00 00 00 ZZZ $177.23

38589 2 00 00 00 00 ZZZ $0.00

38589 8 00 00 00 00 ZZZ $0.00

38700 2 00 00 00 00 ZZZ $514.55

38700 8 00 00 00 00 ZZZ $102.91

38720 2 00 00 00 00 ZZZ $980.10

38720 8 00 00 00 00 ZZZ $196.02

38724 2 00 00 00 00 ZZZ $814.32

38724 8 00 00 00 00 ZZZ $162.86

38740 2 00 00 00 00 ZZZ $578.00

38740 8 00 00 00 00 ZZZ $116.00

38745 2 00 00 00 00 ZZZ $744.70

38745 8 00 00 00 00 ZZZ $148.94

38746 2 00 00 00 00 ZZZ $330.57

38746 8 00 00 00 00 ZZZ $66.11

38747 2 00 00 00 00 ZZZ $363.00

38747 8 00 00 00 00 ZZZ $73.00

38760 2 00 00 00 00 ZZZ $522.50

38760 8 00 00 00 00 ZZZ $104.50

38765 2 00 00 00 00 ZZZ $1,052.70

Page 161: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

38765 8 00 00 00 00 ZZZ $210.54

38770 2 00 00 00 00 ZZZ $762.30

38770 8 00 00 00 00 ZZZ $152.46

38780 2 00 00 00 00 ZZZ $1,415.70

38780 8 00 00 00 00 ZZZ $283.14

38790 2 00 00 00 00 ZZZ $374.77

38790 8 00 00 00 00 ZZZ $74.95

38792 2 00 00 00 00 ZZZ $30.11

38792 8 00 00 00 00 ZZZ $6.02

38794 2 00 00 00 00 ZZZ $254.10

38794 8 00 00 00 00 ZZZ $50.82

38900 2 00 00 00 00 ZZZ $178.02

38900 8 00 00 00 00 ZZZ $35.60

38999 2 00 00 00 00 ZZZ $0.00

38999 8 00 00 00 00 ZZZ $0.00

39000 2 00 00 00 00 ZZZ $482.90

39000 8 00 00 00 00 ZZZ $96.58

39010 2 00 00 00 00 ZZZ $684.24

39010 8 00 00 00 00 ZZZ $136.85

39200 2 00 00 00 00 ZZZ $907.50

39200 8 00 00 00 00 ZZZ $181.50

39220 2 00 00 00 00 ZZZ $1,234.20

39220 8 00 00 00 00 ZZZ $246.84

39401 2 00 00 00 00 ZZZ $313.99

39401 8 00 00 00 00 ZZZ $62.80

39402 2 00 00 00 00 ZZZ $409.95

39402 8 00 00 00 00 ZZZ $81.99

39499 2 00 00 00 00 ZZZ $0.00

39499 8 00 00 00 00 ZZZ $0.00

39501 2 00 00 00 00 ZZZ $1,026.39

39501 8 00 00 00 00 ZZZ $205.28

39503 2 00 00 00 00 ZZZ $1,624.96

39503 8 00 00 00 00 ZZZ $324.99

39540 2 00 00 00 00 ZZZ $1,145.10

39540 8 00 00 00 00 ZZZ $229.02

39541 2 00 00 00 00 ZZZ $1,145.10

39541 8 00 00 00 00 ZZZ $229.02

39545 2 00 00 00 00 ZZZ $943.80

39545 8 00 00 00 00 ZZZ $188.76

39560 2 00 00 00 00 ZZZ $907.98

Page 162: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

39560 8 00 00 00 00 ZZZ $181.60

39561 2 00 00 00 00 ZZZ $1,245.04

39561 8 00 00 00 00 ZZZ $249.01

39599 2 00 00 00 00 ZZZ $0.00

39599 8 00 00 00 00 ZZZ $0.00

40490 2 00 00 00 00 ZZZ $72.60

40490 8 00 00 00 00 ZZZ $14.52

40500 2 00 00 00 00 ZZZ $447.59

40500 8 00 00 00 00 ZZZ $89.52

40510 2 00 00 00 00 ZZZ $443.30

40510 8 00 00 00 00 ZZZ $88.66

40520 2 00 00 00 00 ZZZ $427.90

40520 8 00 00 00 00 ZZZ $85.58

40525 2 00 00 00 00 ZZZ $743.25

40525 8 00 00 00 00 ZZZ $148.65

40527 2 00 00 00 00 ZZZ $888.35

40527 8 00 00 00 00 ZZZ $177.67

40530 2 00 00 00 00 ZZZ $298.71

40530 8 00 00 00 00 ZZZ $59.74

40650 2 00 00 00 00 ZZZ $355.34

40650 8 00 00 00 00 ZZZ $71.07

40652 2 00 00 00 00 ZZZ $416.92

40652 8 00 00 00 00 ZZZ $83.38

40654 2 00 00 00 00 ZZZ $523.81

40654 8 00 00 00 00 ZZZ $104.76

40700 2 00 00 00 00 ZZZ $853.60

40700 8 00 00 00 00 ZZZ $170.72

40701 2 00 00 00 00 ZZZ $1,361.80

40701 8 00 00 00 00 ZZZ $272.36

40702 2 00 00 00 00 ZZZ $682.00

40702 8 00 00 00 00 ZZZ $136.40

40720 2 00 00 00 00 ZZZ $980.10

40720 8 00 00 00 00 ZZZ $196.02

40761 2 00 00 00 00 ZZZ $1,081.30

40761 8 00 00 00 00 ZZZ $216.26

40799 2 00 00 00 00 ZZZ $0.00

40799 8 00 00 00 00 ZZZ $0.00

40800 2 00 00 00 00 ZZZ $65.30

40800 8 00 00 00 00 ZZZ $13.06

40801 2 00 00 00 00 ZZZ $124.05

Page 163: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

40801 8 00 00 00 00 ZZZ $24.81

40804 2 00 00 00 00 ZZZ $72.38

40804 8 00 00 00 00 ZZZ $14.48

40805 2 00 00 00 00 ZZZ $145.82

40805 8 00 00 00 00 ZZZ $29.16

40806 2 00 00 00 00 ZZZ $26.40

40806 8 00 00 00 00 ZZZ $5.28

40808 2 00 00 00 00 ZZZ $60.58

40808 8 00 00 00 00 ZZZ $12.12

40810 2 00 00 00 00 ZZZ $83.93

40810 8 00 00 00 00 ZZZ $16.79

40812 2 00 00 00 00 ZZZ $127.60

40812 8 00 00 00 00 ZZZ $25.52

40814 2 00 00 00 00 ZZZ $422.53

40814 8 00 00 00 00 ZZZ $84.51

40816 2 00 00 00 00 ZZZ $445.26

40816 8 00 00 00 00 ZZZ $89.05

40818 2 00 00 00 00 ZZZ $254.10

40818 8 00 00 00 00 ZZZ $50.82

40819 2 00 00 00 00 ZZZ $126.67

40819 8 00 00 00 00 ZZZ $25.33

40820 2 00 00 00 00 ZZZ $70.02

40820 8 00 00 00 00 ZZZ $14.00

40830 2 00 00 00 00 ZZZ $87.60

40830 8 00 00 00 00 ZZZ $17.52

40831 2 00 00 00 00 ZZZ $141.90

40831 8 00 00 00 00 ZZZ $28.38

40840 2 00 00 00 00 ZZZ $508.20

40840 8 00 00 00 00 ZZZ $101.64

40842 2 00 00 00 00 ZZZ $508.20

40842 8 00 00 00 00 ZZZ $101.64

40843 2 00 00 00 00 ZZZ $763.40

40843 8 00 00 00 00 ZZZ $152.68

40844 2 00 00 00 00 ZZZ $826.10

40844 8 00 00 00 00 ZZZ $165.22

40845 2 00 00 00 00 ZZZ $953.70

40845 8 00 00 00 00 ZZZ $190.74

40899 2 00 00 00 00 ZZZ $0.00

40899 8 00 00 00 00 ZZZ $0.00

41000 2 00 00 00 00 ZZZ $73.17

Page 164: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

41000 8 00 00 00 00 ZZZ $14.63

41005 2 00 00 00 00 ZZZ $69.30

41005 8 00 00 00 00 ZZZ $13.86

41006 2 00 00 00 00 ZZZ $152.11

41006 8 00 00 00 00 ZZZ $30.42

41007 2 00 00 00 00 ZZZ $168.63

41007 8 00 00 00 00 ZZZ $33.73

41008 2 00 00 00 00 ZZZ $150.27

41008 8 00 00 00 00 ZZZ $30.05

41009 2 00 00 00 00 ZZZ $190.40

41009 8 00 00 00 00 ZZZ $38.08

41010 2 00 00 00 00 ZZZ $71.50

41010 8 00 00 00 00 ZZZ $14.30

41015 2 00 00 00 00 ZZZ $172.31

41015 8 00 00 00 00 ZZZ $34.46

41016 2 00 00 00 00 ZZZ $212.95

41016 8 00 00 00 00 ZZZ $42.59

41017 2 00 00 00 00 ZZZ $183.32

41017 8 00 00 00 00 ZZZ $46.00

41018 2 00 00 00 00 ZZZ $252.56

41018 8 00 00 00 00 ZZZ $50.51

41019 2 00 00 00 00 ZZZ $602.76

41019 8 00 00 00 00 ZZZ $120.55

41100 2 00 00 00 00 ZZZ $86.28

41100 8 00 00 00 00 ZZZ $17.26

41105 2 00 00 00 00 ZZZ $119.90

41105 8 00 00 00 00 ZZZ $23.98

41108 2 00 00 00 00 ZZZ $66.87

41108 8 00 00 00 00 ZZZ $13.37

41110 2 00 00 00 00 ZZZ $210.39

41110 8 00 00 00 00 ZZZ $42.08

41112 2 00 00 00 00 ZZZ $337.44

41112 8 00 00 00 00 ZZZ $67.49

41113 2 00 00 00 00 ZZZ $347.00

41113 8 00 00 00 00 ZZZ $70.00

41114 2 00 00 00 00 ZZZ $438.90

41114 8 00 00 00 00 ZZZ $87.78

41115 2 00 00 00 00 ZZZ $105.17

41115 8 00 00 00 00 ZZZ $21.03

41116 2 00 00 00 00 ZZZ $143.98

Page 165: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

41116 8 00 00 00 00 ZZZ $28.80

41120 2 00 00 00 00 ZZZ $547.80

41120 8 00 00 00 00 ZZZ $109.56

41130 2 00 00 00 00 ZZZ $558.61

41130 8 00 00 00 00 ZZZ $111.72

41135 2 00 00 00 00 ZZZ $1,452.00

41135 8 00 00 00 00 ZZZ $290.40

41140 2 00 00 00 00 ZZZ $1,195.12

41140 8 00 00 00 00 ZZZ $239.02

41145 2 00 00 00 00 ZZZ $1,597.20

41145 8 00 00 00 00 ZZZ $319.44

41150 2 00 00 00 00 ZZZ $1,221.00

41150 8 00 00 00 00 ZZZ $244.20

41153 2 00 00 00 00 ZZZ $2,031.54

41153 8 00 00 00 00 ZZZ $406.31

41155 2 00 00 00 00 ZZZ $1,459.22

41155 8 00 00 00 00 ZZZ $291.84

41250 2 00 00 00 00 ZZZ $101.20

41250 8 00 00 00 00 ZZZ $20.24

41251 2 00 00 00 00 ZZZ $145.20

41251 8 00 00 00 00 ZZZ $29.04

41252 2 00 00 00 00 ZZZ $191.40

41252 8 00 00 00 00 ZZZ $38.28

41500 2 00 00 00 00 ZZZ $254.10

41500 8 00 00 00 00 ZZZ $50.82

41510 2 00 00 00 00 ZZZ $254.10

41510 8 00 00 00 00 ZZZ $50.82

41512 2 00 00 00 00 ZZZ $742.66

41512 8 00 00 00 00 ZZZ $148.53

41520 2 00 00 00 00 ZZZ $289.00

41520 8 00 00 00 00 ZZZ $58.00

41530 2 00 00 00 00 ZZZ $2,562.26

41530 8 00 00 00 00 ZZZ $512.45

41599 2 00 00 00 00 ZZZ $0.00

41599 8 00 00 00 00 ZZZ $0.00

41800 2 00 00 00 00 ZZZ $65.04

41800 8 00 00 00 00 ZZZ $13.01

41805 2 00 00 00 00 ZZZ $68.71

41805 8 00 00 00 00 ZZZ $13.74

41806 2 00 00 00 00 ZZZ $129.29

Page 166: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

41806 8 00 00 00 00 ZZZ $25.86

41820 2 00 00 00 00 ZZZ $347.00

41820 8 00 00 00 00 ZZZ $70.00

41821 2 00 00 00 00 ZZZ $347.00

41821 8 00 00 00 00 ZZZ $70.00

41822 2 00 00 00 00 ZZZ $314.13

41822 8 00 00 00 00 ZZZ $62.83

41823 2 00 00 00 00 ZZZ $347.00

41823 8 00 00 00 00 ZZZ $70.00

41825 2 00 00 00 00 ZZZ $190.58

41825 8 00 00 00 00 ZZZ $38.12

41826 2 00 00 00 00 ZZZ $279.74

41826 8 00 00 00 00 ZZZ $55.95

41827 2 00 00 00 00 ZZZ $426.61

41827 8 00 00 00 00 ZZZ $85.32

41828 2 00 00 00 00 ZZZ $347.00

41828 8 00 00 00 00 ZZZ $70.00

41830 2 00 00 00 00 ZZZ $409.13

41830 8 00 00 00 00 ZZZ $81.83

41850 2 00 00 00 00 ZZZ $46.00

41850 8 00 00 00 00 ZZZ $9.60

41870 2 00 00 00 00 ZZZ $462.00

41870 8 00 00 00 00 ZZZ $93.00

41872 2 00 00 00 00 ZZZ $330.45

41872 8 00 00 00 00 ZZZ $66.09

41874 2 00 00 00 00 ZZZ $377.07

41874 8 00 00 00 00 ZZZ $75.41

41899 2 00 00 00 00 ZZZ $0.00

41899 8 00 00 00 00 ZZZ $0.00

42000 2 00 00 00 00 ZZZ $70.55

42000 8 00 00 00 00 ZZZ $14.11

42100 2 00 00 00 00 ZZZ $74.48

42100 8 00 00 00 00 ZZZ $14.90

42104 2 00 00 00 00 ZZZ $213.89

42104 8 00 00 00 00 ZZZ $42.78

42106 2 00 00 00 00 ZZZ $270.42

42106 8 00 00 00 00 ZZZ $54.08

42107 2 00 00 00 00 ZZZ $462.00

42107 8 00 00 00 00 ZZZ $93.00

42120 2 00 00 00 00 ZZZ $508.20

Page 167: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

42120 8 00 00 00 00 ZZZ $101.64

42140 2 00 00 00 00 ZZZ $163.36

42140 8 00 00 00 00 ZZZ $32.67

42145 2 00 00 00 00 ZZZ $784.68

42145 8 00 00 00 00 ZZZ $156.94

42160 2 00 00 00 00 ZZZ $105.17

42160 8 00 00 00 00 ZZZ $21.03

42180 2 00 00 00 00 ZZZ $132.44

42180 8 00 00 00 00 ZZZ $26.49

42182 2 00 00 00 00 ZZZ $193.28

42182 8 00 00 00 00 ZZZ $38.66

42200 2 00 00 00 00 ZZZ $1,188.00

42200 8 00 00 00 00 ZZZ $238.00

42205 2 00 00 00 00 ZZZ $914.30

42205 8 00 00 00 00 ZZZ $182.86

42210 2 00 00 00 00 ZZZ $1,071.40

42210 8 00 00 00 00 ZZZ $214.28

42215 2 00 00 00 00 ZZZ $744.70

42215 8 00 00 00 00 ZZZ $148.94

42220 2 00 00 00 00 ZZZ $743.00

42220 8 00 00 00 00 ZZZ $149.00

42225 2 00 00 00 00 ZZZ $817.30

42225 8 00 00 00 00 ZZZ $163.46

42226 2 00 00 00 00 ZZZ $544.50

42226 8 00 00 00 00 ZZZ $108.90

42227 2 00 00 00 00 ZZZ $544.50

42227 8 00 00 00 00 ZZZ $108.90

42235 2 00 00 00 00 ZZZ $743.00

42235 8 00 00 00 00 ZZZ $149.00

42260 2 00 00 00 00 ZZZ $586.30

42260 8 00 00 00 00 ZZZ $117.26

42280 2 00 00 00 00 ZZZ $150.78

42280 8 00 00 00 00 ZZZ $30.16

42281 2 00 00 00 00 ZZZ $140.15

42281 8 00 00 00 00 ZZZ $28.03

42299 2 00 00 00 00 ZZZ $0.00

42299 8 00 00 00 00 ZZZ $0.00

42300 2 00 00 00 00 ZZZ $98.09

42300 8 00 00 00 00 ZZZ $19.62

42305 2 00 00 00 00 ZZZ $266.98

Page 168: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

42305 8 00 00 00 00 ZZZ $53.40

42310 2 00 00 00 00 ZZZ $97.90

42310 8 00 00 00 00 ZZZ $19.58

42320 2 00 00 00 00 ZZZ $264.00

42320 8 00 00 00 00 ZZZ $53.00

42330 2 00 00 00 00 ZZZ $112.20

42330 8 00 00 00 00 ZZZ $22.44

42335 2 00 00 00 00 ZZZ $246.40

42335 8 00 00 00 00 ZZZ $49.28

42340 2 00 00 00 00 ZZZ $435.94

42340 8 00 00 00 00 ZZZ $87.19

42400 2 00 00 00 00 ZZZ $60.32

42400 8 00 00 00 00 ZZZ $12.06

42405 2 00 00 00 00 ZZZ $163.90

42405 8 00 00 00 00 ZZZ $32.78

42408 2 00 00 00 00 ZZZ $224.50

42408 8 00 00 00 00 ZZZ $44.90

42409 2 00 00 00 00 ZZZ $352.59

42409 8 00 00 00 00 ZZZ $70.52

42410 2 00 00 00 00 ZZZ $508.20

42410 8 00 00 00 00 ZZZ $101.64

42415 2 00 00 00 00 ZZZ $813.01

42415 8 00 00 00 00 ZZZ $162.60

42420 2 00 00 00 00 ZZZ $1,016.40

42420 8 00 00 00 00 ZZZ $203.28

42425 2 00 00 00 00 ZZZ $654.08

42425 8 00 00 00 00 ZZZ $130.82

42426 2 00 00 00 00 ZZZ $1,415.70

42426 8 00 00 00 00 ZZZ $283.14

42440 2 00 00 00 00 ZZZ $613.80

42440 8 00 00 00 00 ZZZ $122.76

42450 2 00 00 00 00 ZZZ $236.50

42450 8 00 00 00 00 ZZZ $47.30

42500 2 00 00 00 00 ZZZ $304.70

42500 8 00 00 00 00 ZZZ $60.94

42505 2 00 00 00 00 ZZZ $572.00

42505 8 00 00 00 00 ZZZ $114.40

42507 2 00 00 00 00 ZZZ $578.00

42507 8 00 00 00 00 ZZZ $116.00

42509 2 00 00 00 00 ZZZ $826.10

Page 169: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

42509 8 00 00 00 00 ZZZ $165.22

42510 2 00 00 00 00 ZZZ $731.50

42510 8 00 00 00 00 ZZZ $146.30

42550 2 00 00 00 00 ZZZ $185.16

42550 8 00 00 00 00 ZZZ $37.03

42600 2 00 00 00 00 ZZZ $471.83

42600 8 00 00 00 00 ZZZ $94.37

42650 2 00 00 00 00 ZZZ $48.40

42650 8 00 00 00 00 ZZZ $9.68

42660 2 00 00 00 00 ZZZ $56.10

42660 8 00 00 00 00 ZZZ $11.22

42665 2 00 00 00 00 ZZZ $141.62

42665 8 00 00 00 00 ZZZ $28.32

42699 2 00 00 00 00 ZZZ $0.00

42699 8 00 00 00 00 ZZZ $0.00

42700 2 00 00 00 00 ZZZ $90.74

42700 8 00 00 00 00 ZZZ $18.15

42720 2 00 00 00 00 ZZZ $238.40

42720 8 00 00 00 00 ZZZ $47.68

42725 2 00 00 00 00 ZZZ $472.59

42725 8 00 00 00 00 ZZZ $94.52

42800 2 00 00 00 00 ZZZ $80.78

42800 8 00 00 00 00 ZZZ $16.16

42804 2 00 00 00 00 ZZZ $80.78

42804 8 00 00 00 00 ZZZ $16.16

42806 2 00 00 00 00 ZZZ $163.90

42806 8 00 00 00 00 ZZZ $32.78

42808 2 00 00 00 00 ZZZ $254.10

42808 8 00 00 00 00 ZZZ $50.82

42809 2 00 00 00 00 ZZZ $98.61

42809 8 00 00 00 00 ZZZ $19.72

42810 2 00 00 00 00 ZZZ $203.50

42810 8 00 00 00 00 ZZZ $40.70

42815 2 00 00 00 00 ZZZ $511.50

42815 8 00 00 00 00 ZZZ $102.30

42820 2 00 00 00 00 ZZZ $356.21

42820 8 00 00 00 00 ZZZ $71.24

42821 2 00 00 00 00 ZZZ $422.00

42821 8 00 00 00 00 ZZZ $84.00

42825 2 00 00 00 00 ZZZ $333.00

Page 170: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

42825 8 00 00 00 00 ZZZ $67.00

42826 2 00 00 00 00 ZZZ $403.00

42826 8 00 00 00 00 ZZZ $81.00

42830 2 00 00 00 00 ZZZ $283.82

42830 8 00 00 00 00 ZZZ $57.00

42831 2 00 00 00 00 ZZZ $287.00

42831 8 00 00 00 00 ZZZ $57.00

42835 2 00 00 00 00 ZZZ $261.00

42835 8 00 00 00 00 ZZZ $52.00

42836 2 00 00 00 00 ZZZ $303.52

42836 8 00 00 00 00 ZZZ $60.70

42842 2 00 00 00 00 ZZZ $641.31

42842 8 00 00 00 00 ZZZ $128.26

42844 2 00 00 00 00 ZZZ $1,026.39

42844 8 00 00 00 00 ZZZ $205.28

42845 2 00 00 00 00 ZZZ $1,762.55

42845 8 00 00 00 00 ZZZ $352.51

42860 2 00 00 00 00 ZZZ $163.90

42860 8 00 00 00 00 ZZZ $32.78

42870 2 00 00 00 00 ZZZ $254.66

42870 8 00 00 00 00 ZZZ $50.93

42890 2 00 00 00 00 ZZZ $891.00

42890 8 00 00 00 00 ZZZ $178.20

42892 2 00 00 00 00 ZZZ $1,079.47

42892 8 00 00 00 00 ZZZ $215.89

42894 2 00 00 00 00 ZZZ $1,592.67

42894 8 00 00 00 00 ZZZ $318.53

42900 2 00 00 00 00 ZZZ $317.90

42900 8 00 00 00 00 ZZZ $63.58

42950 2 00 00 00 00 ZZZ $763.40

42950 8 00 00 00 00 ZZZ $152.68

42953 2 00 00 00 00 ZZZ $763.40

42953 8 00 00 00 00 ZZZ $152.68

42955 2 00 00 00 00 ZZZ $334.12

42955 8 00 00 00 00 ZZZ $66.82

42960 2 00 00 00 00 ZZZ $116.60

42960 8 00 00 00 00 ZZZ $23.32

42961 2 00 00 00 00 ZZZ $244.17

42961 8 00 00 00 00 ZZZ $48.83

42962 2 00 00 00 00 ZZZ $358.77

Page 171: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

42962 8 00 00 00 00 ZZZ $71.75

42970 2 00 00 00 00 ZZZ $211.12

42970 8 00 00 00 00 ZZZ $42.22

42971 2 00 00 00 00 ZZZ $281.14

42971 8 00 00 00 00 ZZZ $56.23

42972 2 00 00 00 00 ZZZ $335.17

42972 8 00 00 00 00 ZZZ $67.03

42999 2 00 00 00 00 ZZZ $0.00

42999 8 00 00 00 00 ZZZ $0.00

43020 2 00 00 00 00 ZZZ $577.50

43020 8 00 00 00 00 ZZZ $115.50

43030 2 00 00 00 00 ZZZ $595.10

43030 8 00 00 00 00 ZZZ $119.02

43045 2 00 00 00 00 ZZZ $938.37

43045 8 00 00 00 00 ZZZ $187.67

43100 2 00 00 00 00 ZZZ $682.00

43100 8 00 00 00 00 ZZZ $136.40

43101 2 00 00 00 00 ZZZ $871.20

43101 8 00 00 00 00 ZZZ $174.24

43107 2 00 00 00 00 ZZZ $2,261.58

43107 8 00 00 00 00 ZZZ $452.32

43108 2 00 00 00 00 ZZZ $2,619.05

43108 8 00 00 00 00 ZZZ $523.81

43112 2 00 00 00 00 ZZZ $2,318.21

43112 8 00 00 00 00 ZZZ $463.64

43113 2 00 00 00 00 ZZZ $2,657.97

43113 8 00 00 00 00 ZZZ $531.59

43116 2 00 00 00 00 ZZZ $2,495.17

43116 8 00 00 00 00 ZZZ $499.03

43117 2 00 00 00 00 ZZZ $2,442.09

43117 8 00 00 00 00 ZZZ $488.42

43118 2 00 00 00 00 ZZZ $2,576.57

43118 8 00 00 00 00 ZZZ $515.31

43121 2 00 00 00 00 ZZZ $2,222.65

43121 8 00 00 00 00 ZZZ $444.53

43122 2 00 00 00 00 ZZZ $2,222.65

43122 8 00 00 00 00 ZZZ $444.53

43123 2 00 00 00 00 ZZZ $2,576.57

43123 8 00 00 00 00 ZZZ $515.31

43124 2 00 00 00 00 ZZZ $2,158.95

Page 172: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43124 8 00 00 00 00 ZZZ $431.79

43130 2 00 00 00 00 ZZZ $607.92

43130 8 00 00 00 00 ZZZ $121.58

43135 2 00 00 00 00 ZZZ $871.20

43135 8 00 00 00 00 ZZZ $174.24

43180 2 00 00 00 00 ZZZ $489.69

43180 8 00 00 00 00 ZZZ $97.94

43191 2 00 00 00 00 ZZZ $177.43

43191 8 00 00 00 00 ZZZ $35.49

43192 2 00 00 00 00 ZZZ $211.39

43192 8 00 00 00 00 ZZZ $42.28

43193 2 00 00 00 00 ZZZ $251.66

43193 8 00 00 00 00 ZZZ $50.33

43194 2 00 00 00 00 ZZZ $227.82

43194 8 00 00 00 00 ZZZ $45.56

43195 2 00 00 00 00 ZZZ $252.15

43195 8 00 00 00 00 ZZZ $50.43

43196 2 00 00 00 00 ZZZ $275.38

43196 8 00 00 00 00 ZZZ $55.08

43197 2 00 00 00 00 ZZZ $257.87

43197 8 00 00 00 00 ZZZ $51.57

43198 2 00 00 00 00 ZZZ $287.69

43198 8 00 00 00 00 ZZZ $57.54

43200 2 00 00 00 00 ZZZ $195.80

43200 8 00 00 00 00 ZZZ $39.16

43201 2 00 00 00 00 ZZZ $274.34

43201 8 00 00 00 00 ZZZ $54.87

43202 2 00 00 00 00 ZZZ $225.50

43202 8 00 00 00 00 ZZZ $45.10

43204 2 00 00 00 00 ZZZ $403.30

43204 8 00 00 00 00 ZZZ $80.66

43205 2 00 00 00 00 ZZZ $357.84

43205 8 00 00 00 00 ZZZ $71.57

43206 2 00 00 00 00 ZZZ $0.00

43206 8 00 00 00 00 ZZZ $0.00

43211 2 00 00 00 00 ZZZ $341.52

43211 8 00 00 00 00 ZZZ $68.30

43212 2 00 00 00 00 ZZZ $267.83

43212 8 00 00 00 00 ZZZ $53.57

43213 2 00 00 00 00 ZZZ $1,726.26

Page 173: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43213 8 00 00 00 00 ZZZ $345.25

43214 2 00 00 00 00 ZZZ $274.42

43214 8 00 00 00 00 ZZZ $54.88

43215 2 00 00 00 00 ZZZ $226.59

43215 8 00 00 00 00 ZZZ $45.32

43216 2 00 00 00 00 ZZZ $248.00

43216 8 00 00 00 00 ZZZ $50.00

43217 2 00 00 00 00 ZZZ $248.98

43217 8 00 00 00 00 ZZZ $50.00

43220 2 00 00 00 00 ZZZ $225.54

43220 8 00 00 00 00 ZZZ $45.11

43226 2 00 00 00 00 ZZZ $250.60

43226 8 00 00 00 00 ZZZ $50.12

43227 2 00 00 00 00 ZZZ $363.00

43227 8 00 00 00 00 ZZZ $73.00

43229 2 00 00 00 00 ZZZ $1,015.55

43229 8 00 00 00 00 ZZZ $203.11

43231 2 00 00 00 00 ZZZ $254.54

43231 8 00 00 00 00 ZZZ $50.91

43232 2 00 00 00 00 ZZZ $295.79

43232 8 00 00 00 00 ZZZ $59.16

43233 2 00 00 00 00 ZZZ $325.62

43233 8 00 00 00 00 ZZZ $65.12

43235 2 00 00 00 00 ZZZ $307.00

43235 8 00 00 00 00 ZZZ $61.00

43236 2 00 00 00 00 ZZZ $320.12

43236 8 00 00 00 00 ZZZ $64.02

43237 2 00 00 00 00 ZZZ $241.75

43237 8 00 00 00 00 ZZZ $48.35

43238 2 00 00 00 00 ZZZ $299.50

43238 8 00 00 00 00 ZZZ $59.90

43239 2 00 00 00 00 ZZZ $373.00

43239 8 00 00 00 00 ZZZ $75.00

43240 2 00 00 00 00 ZZZ $449.25

43240 8 00 00 00 00 ZZZ $89.85

43241 2 00 00 00 00 ZZZ $277.41

43241 8 00 00 00 00 ZZZ $55.48

43242 2 00 00 00 00 ZZZ $323.02

43242 8 00 00 00 00 ZZZ $64.60

43243 2 00 00 00 00 ZZZ $455.00

Page 174: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43243 8 00 00 00 00 ZZZ $91.00

43244 2 00 00 00 00 ZZZ $440.01

43244 8 00 00 00 00 ZZZ $88.00

43245 2 00 00 00 00 ZZZ $363.00

43245 8 00 00 00 00 ZZZ $73.00

43246 2 00 00 00 00 ZZZ $459.00

43246 8 00 00 00 00 ZZZ $92.00

43247 2 00 00 00 00 ZZZ $337.00

43247 8 00 00 00 00 ZZZ $67.00

43248 2 00 00 00 00 ZZZ $336.86

43248 8 00 00 00 00 ZZZ $67.37

43249 2 00 00 00 00 ZZZ $263.19

43249 8 00 00 00 00 ZZZ $52.64

43250 2 00 00 00 00 ZZZ $342.69

43250 8 00 00 00 00 ZZZ $68.54

43251 2 00 00 00 00 ZZZ $395.72

43251 8 00 00 00 00 ZZZ $79.14

43252 2 00 00 00 00 ZZZ $0.00

43252 8 00 00 00 00 ZZZ $0.00

43253 2 00 00 00 00 ZZZ $377.82

43253 8 00 00 00 00 ZZZ $75.56

43254 2 00 00 00 00 ZZZ $391.92

43254 8 00 00 00 00 ZZZ $78.38

43255 2 00 00 00 00 ZZZ $413.00

43255 8 00 00 00 00 ZZZ $83.00

43257 2 00 00 00 00 ZZZ $375.79

43257 8 00 00 00 00 ZZZ $75.16

43259 2 00 00 00 00 ZZZ $382.32

43259 8 00 00 00 00 ZZZ $76.46

43260 2 00 00 00 00 ZZZ $464.20

43260 8 00 00 00 00 ZZZ $92.84

43261 2 00 00 00 00 ZZZ $490.60

43261 8 00 00 00 00 ZZZ $98.12

43262 2 00 00 00 00 ZZZ $631.29

43262 8 00 00 00 00 ZZZ $126.26

43263 2 00 00 00 00 ZZZ $503.54

43263 8 00 00 00 00 ZZZ $100.71

43264 2 00 00 00 00 ZZZ $737.59

43264 8 00 00 00 00 ZZZ $147.52

43266 2 00 00 00 00 ZZZ $324.14

Page 175: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43266 8 00 00 00 00 ZZZ $64.83

43270 2 00 00 00 00 ZZZ $1,011.61

43270 8 00 00 00 00 ZZZ $202.32

43273 2 00 00 00 00 ZZZ $165.04

43273 8 00 00 00 00 ZZZ $33.01

43274 2 00 00 00 00 ZZZ $636.55

43274 8 00 00 00 00 ZZZ $127.31

43275 2 00 00 00 00 ZZZ $524.62

43275 8 00 00 00 00 ZZZ $104.92

43276 2 00 00 00 00 ZZZ $662.40

43276 8 00 00 00 00 ZZZ $132.48

43277 2 00 00 00 00 ZZZ $527.85

43277 8 00 00 00 00 ZZZ $105.57

43278 2 00 00 00 00 ZZZ $600.34

43278 8 00 00 00 00 ZZZ $120.07

43279 2 00 00 00 00 ZZZ $1,550.29

43279 8 00 00 00 00 ZZZ $310.06

43280 2 00 00 00 00 ZZZ $1,149.73

43280 8 00 00 00 00 ZZZ $229.95

43281 2 00 00 00 00 ZZZ $2,025.48

43281 8 00 00 00 00 ZZZ $405.10

43282 2 00 00 00 00 ZZZ $2,278.25

43282 8 00 00 00 00 ZZZ $455.65

43283 2 00 00 00 00 ZZZ $212.66

43283 8 00 00 00 00 ZZZ $42.53

43289 2 00 00 00 00 ZZZ $0.00

43289 8 00 00 00 00 ZZZ $0.00

43300 2 00 00 00 00 ZZZ $499.08

43300 8 00 00 00 00 ZZZ $99.82

43305 2 00 00 00 00 ZZZ $871.20

43305 8 00 00 00 00 ZZZ $174.24

43310 2 00 00 00 00 ZZZ $1,274.06

43310 8 00 00 00 00 ZZZ $254.81

43312 2 00 00 00 00 ZZZ $1,389.45

43312 8 00 00 00 00 ZZZ $277.89

43313 2 00 00 00 00 ZZZ $2,999.95

43313 8 00 00 00 00 ZZZ $599.99

43314 2 00 00 00 00 ZZZ $3,294.92

43314 8 00 00 00 00 ZZZ $658.98

43320 2 00 00 00 00 ZZZ $1,180.30

Page 176: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43320 8 00 00 00 00 ZZZ $236.06

43325 2 00 00 00 00 ZZZ $751.64

43325 8 00 00 00 00 ZZZ $150.33

43327 2 00 00 00 00 ZZZ $1,059.96

43327 8 00 00 00 00 ZZZ $211.99

43328 2 00 00 00 00 ZZZ $1,554.26

43328 8 00 00 00 00 ZZZ $310.85

43330 2 00 00 00 00 ZZZ $980.10

43330 8 00 00 00 00 ZZZ $196.02

43331 2 00 00 00 00 ZZZ $1,052.70

43331 8 00 00 00 00 ZZZ $210.54

43332 2 00 00 00 00 ZZZ $1,520.61

43332 8 00 00 00 00 ZZZ $304.12

43333 2 00 00 00 00 ZZZ $1,652.11

43333 8 00 00 00 00 ZZZ $330.42

43334 2 00 00 00 00 ZZZ $1,672.54

43334 8 00 00 00 00 ZZZ $334.51

43335 2 00 00 00 00 ZZZ $1,802.90

43335 8 00 00 00 00 ZZZ $360.58

43336 2 00 00 00 00 ZZZ $1,970.86

43336 8 00 00 00 00 ZZZ $394.17

43337 2 00 00 00 00 ZZZ $2,148.29

43337 8 00 00 00 00 ZZZ $429.66

43338 2 00 00 00 00 ZZZ $174.47

43338 8 00 00 00 00 ZZZ $34.89

43340 2 00 00 00 00 ZZZ $770.00

43340 8 00 00 00 00 ZZZ $154.00

43341 2 00 00 00 00 ZZZ $805.40

43341 8 00 00 00 00 ZZZ $161.08

43351 2 00 00 00 00 ZZZ $703.38

43351 8 00 00 00 00 ZZZ $140.68

43352 2 00 00 00 00 ZZZ $612.90

43352 8 00 00 00 00 ZZZ $122.58

43360 2 00 00 00 00 ZZZ $2,155.41

43360 8 00 00 00 00 ZZZ $431.08

43361 2 00 00 00 00 ZZZ $2,495.17

43361 8 00 00 00 00 ZZZ $499.03

43400 2 00 00 00 00 ZZZ $962.50

43400 8 00 00 00 00 ZZZ $192.50

43401 2 00 00 00 00 ZZZ $1,146.70

Page 177: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43401 8 00 00 00 00 ZZZ $229.34

43405 2 00 00 00 00 ZZZ $1,327.22

43405 8 00 00 00 00 ZZZ $265.44

43410 2 00 00 00 00 ZZZ $564.12

43410 8 00 00 00 00 ZZZ $112.82

43415 2 00 00 00 00 ZZZ $834.90

43415 8 00 00 00 00 ZZZ $166.98

43420 2 00 00 00 00 ZZZ $628.10

43420 8 00 00 00 00 ZZZ $125.62

43425 2 00 00 00 00 ZZZ $797.27

43425 8 00 00 00 00 ZZZ $159.45

43450 2 00 00 00 00 ZZZ $101.20

43450 8 00 00 00 00 ZZZ $20.24

43453 2 00 00 00 00 ZZZ $156.77

43453 8 00 00 00 00 ZZZ $31.35

43460 2 00 00 00 00 ZZZ $151.80

43460 8 00 00 00 00 ZZZ $30.36

43496 2 00 00 00 00 ZZZ $0.00

43496 8 00 00 00 00 ZZZ $0.00

43499 2 00 00 00 00 ZZZ $0.00

43499 8 00 00 00 00 ZZZ $0.00

43500 2 00 00 00 00 ZZZ $522.50

43500 8 00 00 00 00 ZZZ $104.50

43501 2 00 00 00 00 ZZZ $658.80

43501 8 00 00 00 00 ZZZ $131.76

43502 2 00 00 00 00 ZZZ $1,097.17

43502 8 00 00 00 00 ZZZ $219.43

43510 2 00 00 00 00 ZZZ $521.40

43510 8 00 00 00 00 ZZZ $104.28

43520 2 00 00 00 00 ZZZ $620.40

43520 8 00 00 00 00 ZZZ $124.08

43605 2 00 00 00 00 ZZZ $584.10

43605 8 00 00 00 00 ZZZ $116.82

43610 2 00 00 00 00 ZZZ $871.20

43610 8 00 00 00 00 ZZZ $174.24

43611 2 00 00 00 00 ZZZ $998.80

43611 8 00 00 00 00 ZZZ $199.76

43620 2 00 00 00 00 ZZZ $1,791.76

43620 8 00 00 00 00 ZZZ $358.35

43621 2 00 00 00 00 ZZZ $1,820.20

Page 178: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43621 8 00 00 00 00 ZZZ $364.04

43622 2 00 00 00 00 ZZZ $1,905.52

43622 8 00 00 00 00 ZZZ $381.10

43631 2 00 00 00 00 ZZZ $1,306.80

43631 8 00 00 00 00 ZZZ $261.36

43632 2 00 00 00 00 ZZZ $1,306.80

43632 8 00 00 00 00 ZZZ $261.36

43633 2 00 00 00 00 ZZZ $1,343.10

43633 8 00 00 00 00 ZZZ $268.62

43634 2 00 00 00 00 ZZZ $1,502.60

43634 8 00 00 00 00 ZZZ $300.52

43635 2 00 00 00 00 ZZZ $133.66

43635 8 00 00 00 00 ZZZ $26.73

43640 2 00 00 00 00 ZZZ $1,185.65

43640 8 00 00 00 00 ZZZ $237.13

43641 2 00 00 00 00 ZZZ $869.00

43641 8 00 00 00 00 ZZZ $173.80

43644 2 00 00 00 00 ZZZ $1,966.14

43644 8 00 00 00 00 ZZZ $393.23

43645 2 00 00 00 00 ZZZ $2,120.46

43645 8 00 00 00 00 ZZZ $424.09

43647 2 00 00 00 00 ZZZ $0.00

43647 8 00 00 00 00 ZZZ $0.00

43651 2 00 00 00 00 ZZZ $654.69

43651 8 00 00 00 00 ZZZ $130.94

43652 2 00 00 00 00 ZZZ $788.36

43652 8 00 00 00 00 ZZZ $157.67

43653 2 00 00 00 00 ZZZ $530.93

43653 8 00 00 00 00 ZZZ $106.19

43659 2 00 00 00 00 ZZZ $0.00

43659 8 00 00 00 00 ZZZ $0.00

43752 2 00 00 00 00 ZZZ $39.60

43752 8 00 00 00 00 ZZZ $7.92

43753 2 00 00 00 00 ZZZ $27.61

43753 8 00 00 00 00 ZZZ $5.52

43754 2 00 00 00 00 ZZZ $96.62

43754 8 00 00 00 00 ZZZ $19.32

43755 2 00 00 00 00 ZZZ $148.97

43755 8 00 00 00 00 ZZZ $29.79

43756 2 00 00 00 00 ZZZ $263.94

Page 179: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43756 8 00 00 00 00 ZZZ $52.79

43757 2 00 00 00 00 ZZZ $341.63

43757 8 00 00 00 00 ZZZ $68.33

43760 2 00 00 00 00 ZZZ $57.96

43760 8 00 00 00 00 ZZZ $11.59

43761 2 00 00 00 00 ZZZ $78.15

43761 8 00 00 00 00 ZZZ $15.63

43770 2 00 00 00 00 ZZZ $1,316.49

43770 8 00 00 00 00 ZZZ $263.30

43771 2 00 00 00 00 ZZZ $1,501.92

43771 8 00 00 00 00 ZZZ $300.39

43772 2 00 00 00 00 ZZZ $1,135.81

43772 8 00 00 00 00 ZZZ $227.17

43773 2 00 00 00 00 ZZZ $1,503.35

43773 8 00 00 00 00 ZZZ $300.67

43774 2 00 00 00 00 ZZZ $1,135.81

43774 8 00 00 00 00 ZZZ $227.17

43775 2 00 00 00 00 ZZZ $1,114.22

43775 8 00 00 00 00 ZZZ $222.85

43800 2 00 00 00 00 ZZZ $547.80

43800 8 00 00 00 00 ZZZ $109.56

43810 2 00 00 00 00 ZZZ $595.10

43810 8 00 00 00 00 ZZZ $119.02

43820 2 00 00 00 00 ZZZ $595.10

43820 8 00 00 00 00 ZZZ $119.02

43825 2 00 00 00 00 ZZZ $1,016.40

43825 8 00 00 00 00 ZZZ $203.28

43830 2 00 00 00 00 ZZZ $519.20

43830 8 00 00 00 00 ZZZ $103.84

43831 2 00 00 00 00 ZZZ $353.52

43831 8 00 00 00 00 ZZZ $70.70

43832 2 00 00 00 00 ZZZ $613.80

43832 8 00 00 00 00 ZZZ $122.76

43840 2 00 00 00 00 ZZZ $682.00

43840 8 00 00 00 00 ZZZ $136.40

43842 2 00 00 00 00 ZZZ $1,180.30

43842 8 00 00 00 00 ZZZ $236.06

43843 2 00 00 00 00 ZZZ $953.57

43843 8 00 00 00 00 ZZZ $190.71

43845 2 00 00 00 00 ZZZ $0.00

Page 180: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

43846 2 00 00 00 00 ZZZ $1,618.78

43846 8 00 00 00 00 ZZZ $323.76

43847 2 00 00 00 00 ZZZ $1,281.21

43847 8 00 00 00 00 ZZZ $256.24

43848 2 00 00 00 00 ZZZ $1,677.61

43848 8 00 00 00 00 ZZZ $335.52

43850 2 00 00 00 00 ZZZ $849.20

43850 8 00 00 00 00 ZZZ $169.84

43855 2 00 00 00 00 ZZZ $866.77

43855 8 00 00 00 00 ZZZ $173.35

43860 2 00 00 00 00 ZZZ $1,180.30

43860 8 00 00 00 00 ZZZ $236.06

43865 2 00 00 00 00 ZZZ $923.42

43865 8 00 00 00 00 ZZZ $184.68

43870 2 00 00 00 00 ZZZ $522.50

43870 8 00 00 00 00 ZZZ $104.50

43880 2 00 00 00 00 ZZZ $805.66

43880 8 00 00 00 00 ZZZ $161.13

43999 2 00 00 00 00 ZZZ $0.00

43999 8 00 00 00 00 ZZZ $0.00

44005 2 00 00 00 00 ZZZ $907.50

44005 8 00 00 00 00 ZZZ $181.50

44010 2 00 00 00 00 ZZZ $628.10

44010 8 00 00 00 00 ZZZ $125.62

44015 2 00 00 00 00 ZZZ $148.50

44015 8 00 00 00 00 ZZZ $29.70

44020 2 00 00 00 00 ZZZ $628.10

44020 8 00 00 00 00 ZZZ $125.62

44021 2 00 00 00 00 ZZZ $628.10

44021 8 00 00 00 00 ZZZ $125.62

44025 2 00 00 00 00 ZZZ $628.10

44025 8 00 00 00 00 ZZZ $125.62

44050 2 00 00 00 00 ZZZ $682.00

44050 8 00 00 00 00 ZZZ $136.40

44055 2 00 00 00 00 ZZZ $712.20

44055 8 00 00 00 00 ZZZ $142.44

44100 2 00 00 00 00 ZZZ $116.60

44100 8 00 00 00 00 ZZZ $23.32

44110 2 00 00 00 00 ZZZ $830.38

44110 8 00 00 00 00 ZZZ $166.08

Page 181: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

44111 2 00 00 00 00 ZZZ $826.10

44111 8 00 00 00 00 ZZZ $165.22

44120 2 00 00 00 00 ZZZ $889.90

44120 8 00 00 00 00 ZZZ $177.98

44121 2 00 00 00 00 ZZZ $305.09

44121 8 00 00 00 00 ZZZ $61.02

44125 2 00 00 00 00 ZZZ $744.70

44125 8 00 00 00 00 ZZZ $148.94

44126 2 00 00 00 00 ZZZ $2,223.16

44126 8 00 00 00 00 ZZZ $444.63

44127 2 00 00 00 00 ZZZ $2,556.48

44127 8 00 00 00 00 ZZZ $511.30

44128 2 00 00 00 00 ZZZ $275.57

44128 8 00 00 00 00 ZZZ $55.11

44130 2 00 00 00 00 ZZZ $871.20

44130 8 00 00 00 00 ZZZ $174.24

44137 2 00 00 00 00 ZZZ $0.00

44137 8 00 00 00 00 ZZZ $0.00

44139 2 00 00 00 00 ZZZ $153.60

44139 8 00 00 00 00 ZZZ $30.72

44140 2 00 00 00 00 ZZZ $1,107.70

44140 8 00 00 00 00 ZZZ $221.54

44141 2 00 00 00 00 ZZZ $1,107.70

44141 8 00 00 00 00 ZZZ $221.54

44143 2 00 00 00 00 ZZZ $1,089.00

44143 8 00 00 00 00 ZZZ $217.80

44144 2 00 00 00 00 ZZZ $1,016.40

44144 8 00 00 00 00 ZZZ $203.28

44145 2 00 00 00 00 ZZZ $1,361.80

44145 8 00 00 00 00 ZZZ $272.36

44146 2 00 00 00 00 ZZZ $1,306.80

44146 8 00 00 00 00 ZZZ $261.36

44147 2 00 00 00 00 ZZZ $1,436.94

44147 8 00 00 00 00 ZZZ $287.39

44150 2 00 00 00 00 ZZZ $1,452.00

44150 8 00 00 00 00 ZZZ $290.40

44151 2 00 00 00 00 ZZZ $1,252.90

44151 8 00 00 00 00 ZZZ $250.58

44155 2 00 00 00 00 ZZZ $2,004.37

44155 8 00 00 00 00 ZZZ $400.87

Page 182: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

44156 2 00 00 00 00 ZZZ $1,419.24

44156 8 00 00 00 00 ZZZ $283.85

44157 2 00 00 00 00 ZZZ $2,370.89

44157 8 00 00 00 00 ZZZ $474.18

44158 2 00 00 00 00 ZZZ $2,434.08

44158 8 00 00 00 00 ZZZ $486.82

44160 2 00 00 00 00 ZZZ $1,234.20

44160 8 00 00 00 00 ZZZ $246.84

44180 2 00 00 00 00 ZZZ $738.88

44180 8 00 00 00 00 ZZZ $147.78

44186 2 00 00 00 00 ZZZ $517.88

44186 8 00 00 00 00 ZZZ $103.58

44187 2 00 00 00 00 ZZZ $856.42

44187 8 00 00 00 00 ZZZ $171.28

44188 2 00 00 00 00 ZZZ $939.07

44188 8 00 00 00 00 ZZZ $187.81

44202 2 00 00 00 00 ZZZ $1,414.17

44202 8 00 00 00 00 ZZZ $282.83

44203 2 00 00 00 00 ZZZ $268.15

44203 8 00 00 00 00 ZZZ $53.63

44204 2 00 00 00 00 ZZZ $1,541.64

44204 8 00 00 00 00 ZZZ $308.33

44205 2 00 00 00 00 ZZZ $1,365.08

44205 8 00 00 00 00 ZZZ $273.02

44206 2 00 00 00 00 ZZZ $1,660.04

44206 8 00 00 00 00 ZZZ $332.01

44207 2 00 00 00 00 ZZZ $1,816.86

44207 8 00 00 00 00 ZZZ $363.37

44208 2 00 00 00 00 ZZZ $1,964.49

44208 8 00 00 00 00 ZZZ $392.90

44210 2 00 00 00 00 ZZZ $1,739.24

44210 8 00 00 00 00 ZZZ $347.85

44211 2 00 00 00 00 ZZZ $2,159.62

44211 8 00 00 00 00 ZZZ $431.92

44212 2 00 00 00 00 ZZZ $2,018.13

44212 8 00 00 00 00 ZZZ $403.63

44213 2 00 00 00 00 ZZZ $170.27

44213 8 00 00 00 00 ZZZ $34.05

44227 2 00 00 00 00 ZZZ $1,332.26

44227 8 00 00 00 00 ZZZ $266.45

Page 183: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

44238 2 00 00 00 00 ZZZ $0.00

44238 8 00 00 00 00 ZZZ $0.00

44300 2 00 00 00 00 ZZZ $443.30

44300 8 00 00 00 00 ZZZ $88.66

44310 2 00 00 00 00 ZZZ $834.90

44310 8 00 00 00 00 ZZZ $166.98

44312 2 00 00 00 00 ZZZ $393.80

44312 8 00 00 00 00 ZZZ $78.76

44314 2 00 00 00 00 ZZZ $531.60

44314 8 00 00 00 00 ZZZ $106.32

44316 2 00 00 00 00 ZZZ $1,035.10

44316 8 00 00 00 00 ZZZ $207.02

44320 2 00 00 00 00 ZZZ $678.70

44320 8 00 00 00 00 ZZZ $135.74

44322 2 00 00 00 00 ZZZ $678.70

44322 8 00 00 00 00 ZZZ $135.74

44340 2 00 00 00 00 ZZZ $239.71

44340 8 00 00 00 00 ZZZ $47.94

44345 2 00 00 00 00 ZZZ $515.90

44345 8 00 00 00 00 ZZZ $103.18

44346 2 00 00 00 00 ZZZ $789.25

44346 8 00 00 00 00 ZZZ $157.85

44360 2 00 00 00 00 ZZZ $163.90

44360 8 00 00 00 00 ZZZ $32.78

44361 2 00 00 00 00 ZZZ $189.20

44361 8 00 00 00 00 ZZZ $37.84

44363 2 00 00 00 00 ZZZ $301.19

44363 8 00 00 00 00 ZZZ $60.24

44364 2 00 00 00 00 ZZZ $345.40

44364 8 00 00 00 00 ZZZ $69.08

44365 2 00 00 00 00 ZZZ $318.91

44365 8 00 00 00 00 ZZZ $63.78

44366 2 00 00 00 00 ZZZ $424.28

44366 8 00 00 00 00 ZZZ $84.86

44369 2 00 00 00 00 ZZZ $435.00

44369 8 00 00 00 00 ZZZ $87.00

44370 2 00 00 00 00 ZZZ $253.70

44370 8 00 00 00 00 ZZZ $50.74

44372 2 00 00 00 00 ZZZ $425.68

44372 8 00 00 00 00 ZZZ $85.14

Page 184: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

44373 2 00 00 00 00 ZZZ $336.16

44373 8 00 00 00 00 ZZZ $67.23

44376 2 00 00 00 00 ZZZ $430.81

44376 8 00 00 00 00 ZZZ $86.16

44377 2 00 00 00 00 ZZZ $451.78

44377 8 00 00 00 00 ZZZ $90.36

44378 2 00 00 00 00 ZZZ $578.60

44378 8 00 00 00 00 ZZZ $116.00

44379 2 00 00 00 00 ZZZ $414.18

44379 8 00 00 00 00 ZZZ $82.84

44380 2 00 00 00 00 ZZZ $129.15

44380 8 00 00 00 00 ZZZ $25.83

44381 2 00 00 00 00 ZZZ $0.00

44381 8 00 00 00 00 ZZZ $0.00

44382 2 00 00 00 00 ZZZ $155.26

44382 8 00 00 00 00 ZZZ $31.05

44384 2 00 00 00 00 ZZZ $0.00

44384 8 00 00 00 00 ZZZ $0.00

44385 2 00 00 00 00 ZZZ $156.20

44385 8 00 00 00 00 ZZZ $31.24

44386 2 00 00 00 00 ZZZ $181.50

44386 8 00 00 00 00 ZZZ $36.30

44388 2 00 00 00 00 ZZZ $243.10

44388 8 00 00 00 00 ZZZ $48.62

44389 2 00 00 00 00 ZZZ $268.40

44389 8 00 00 00 00 ZZZ $53.68

44390 2 00 00 00 00 ZZZ $326.70

44390 8 00 00 00 00 ZZZ $65.34

44391 2 00 00 00 00 ZZZ $370.70

44391 8 00 00 00 00 ZZZ $74.14

44392 2 00 00 00 00 ZZZ $345.40

44392 8 00 00 00 00 ZZZ $69.08

44394 2 00 00 00 00 ZZZ $345.40

44394 8 00 00 00 00 ZZZ $69.08

44401 2 00 00 00 00 ZZZ $0.00

44401 8 00 00 00 00 ZZZ $0.00

44402 2 00 00 00 00 ZZZ $0.00

44402 8 00 00 00 00 ZZZ $0.00

44403 2 00 00 00 00 ZZZ $0.00

44403 8 00 00 00 00 ZZZ $0.00

Page 185: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

44404 2 00 00 00 00 ZZZ $0.00

44404 8 00 00 00 00 ZZZ $0.00

44405 2 00 00 00 00 ZZZ $0.00

44405 8 00 00 00 00 ZZZ $0.00

44406 2 00 00 00 00 ZZZ $0.00

44406 8 00 00 00 00 ZZZ $0.00

44407 2 00 00 00 00 ZZZ $0.00

44407 8 00 00 00 00 ZZZ $0.00

44408 2 00 00 00 00 ZZZ $0.00

44408 8 00 00 00 00 ZZZ $0.00

44500 2 00 00 00 00 ZZZ $27.50

44500 8 00 00 00 00 ZZZ $5.50

44602 2 00 00 00 00 ZZZ $834.90

44602 8 00 00 00 00 ZZZ $166.98

44603 2 00 00 00 00 ZZZ $1,103.12

44603 8 00 00 00 00 ZZZ $220.62

44604 2 00 00 00 00 ZZZ $1,087.74

44604 8 00 00 00 00 ZZZ $217.55

44605 2 00 00 00 00 ZZZ $1,197.90

44605 8 00 00 00 00 ZZZ $239.58

44615 2 00 00 00 00 ZZZ $980.10

44615 8 00 00 00 00 ZZZ $196.02

44620 2 00 00 00 00 ZZZ $469.71

44620 8 00 00 00 00 ZZZ $93.94

44625 2 00 00 00 00 ZZZ $834.90

44625 8 00 00 00 00 ZZZ $166.98

44626 2 00 00 00 00 ZZZ $1,499.98

44626 8 00 00 00 00 ZZZ $300.00

44640 2 00 00 00 00 ZZZ $617.36

44640 8 00 00 00 00 ZZZ $123.47

44650 2 00 00 00 00 ZZZ $641.23

44650 8 00 00 00 00 ZZZ $128.25

44660 2 00 00 00 00 ZZZ $626.01

44660 8 00 00 00 00 ZZZ $125.20

44661 2 00 00 00 00 ZZZ $790.19

44661 8 00 00 00 00 ZZZ $158.04

44680 2 00 00 00 00 ZZZ $871.20

44680 8 00 00 00 00 ZZZ $174.24

44700 2 00 00 00 00 ZZZ $1,160.05

44700 8 00 00 00 00 ZZZ $232.01

Page 186: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

44701 2 00 00 00 00 ZZZ $180.69

44701 8 00 00 00 00 ZZZ $36.14

44705 2 00 00 00 00 ZZZ $0.00

44705 8 00 00 00 00 ZZZ $0.00

44799 2 00 00 00 00 ZZZ $0.00

44799 8 00 00 00 00 ZZZ $0.00

44800 2 00 00 00 00 ZZZ $584.10

44800 8 00 00 00 00 ZZZ $116.82

44820 2 00 00 00 00 ZZZ $635.80

44820 8 00 00 00 00 ZZZ $127.16

44850 2 00 00 00 00 ZZZ $635.80

44850 8 00 00 00 00 ZZZ $127.16

44899 2 00 00 00 00 ZZZ $0.00

44899 8 00 00 00 00 ZZZ $0.00

44900 2 00 00 00 00 ZZZ $454.30

44900 8 00 00 00 00 ZZZ $90.86

44950 2 00 00 00 00 ZZZ $536.80

44950 8 00 00 00 00 ZZZ $107.36

44955 2 00 00 00 00 ZZZ $135.13

44955 8 00 00 00 00 ZZZ $27.03

44960 2 00 00 00 00 ZZZ $697.40

44960 8 00 00 00 00 ZZZ $139.48

44970 2 00 00 00 00 ZZZ $570.54

44970 8 00 00 00 00 ZZZ $114.11

45000 2 00 00 00 00 ZZZ $196.17

45000 8 00 00 00 00 ZZZ $39.23

45005 2 00 00 00 00 ZZZ $189.20

45005 8 00 00 00 00 ZZZ $37.84

45020 2 00 00 00 00 ZZZ $265.10

45020 8 00 00 00 00 ZZZ $53.02

45100 2 00 00 00 00 ZZZ $192.50

45100 8 00 00 00 00 ZZZ $38.50

45108 2 00 00 00 00 ZZZ $317.90

45108 8 00 00 00 00 ZZZ $63.58

45110 2 00 00 00 00 ZZZ $1,361.80

45110 8 00 00 00 00 ZZZ $272.36

45111 2 00 00 00 00 ZZZ $834.90

45111 8 00 00 00 00 ZZZ $166.98

45112 2 00 00 00 00 ZZZ $1,815.64

45112 8 00 00 00 00 ZZZ $363.13

Page 187: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

45113 2 00 00 00 00 ZZZ $1,840.41

45113 8 00 00 00 00 ZZZ $368.08

45114 2 00 00 00 00 ZZZ $1,642.21

45114 8 00 00 00 00 ZZZ $328.44

45116 2 00 00 00 00 ZZZ $885.13

45116 8 00 00 00 00 ZZZ $177.03

45119 2 00 00 00 00 ZZZ $1,882.40

45119 8 00 00 00 00 ZZZ $376.48

45120 2 00 00 00 00 ZZZ $1,197.90

45120 8 00 00 00 00 ZZZ $239.58

45121 2 00 00 00 00 ZZZ $1,114.87

45121 8 00 00 00 00 ZZZ $222.97

45123 2 00 00 00 00 ZZZ $1,150.26

45123 8 00 00 00 00 ZZZ $230.05

45126 2 00 00 00 00 ZZZ $2,355.57

45126 8 00 00 00 00 ZZZ $471.11

45130 2 00 00 00 00 ZZZ $628.10

45130 8 00 00 00 00 ZZZ $125.62

45135 2 00 00 00 00 ZZZ $1,107.70

45135 8 00 00 00 00 ZZZ $221.54

45136 2 00 00 00 00 ZZZ $1,738.84

45136 8 00 00 00 00 ZZZ $347.77

45150 2 00 00 00 00 ZZZ $283.24

45150 8 00 00 00 00 ZZZ $56.65

45160 2 00 00 00 00 ZZZ $565.70

45160 8 00 00 00 00 ZZZ $113.14

45171 2 00 00 00 00 ZZZ $763.05

45171 8 00 00 00 00 ZZZ $152.61

45172 2 00 00 00 00 ZZZ $1,048.54

45172 8 00 00 00 00 ZZZ $209.71

45190 2 00 00 00 00 ZZZ $371.36

45190 8 00 00 00 00 ZZZ $74.27

45300 2 00 00 00 00 ZZZ $72.60

45300 8 00 00 00 00 ZZZ $14.52

45303 2 00 00 00 00 ZZZ $83.60

45303 8 00 00 00 00 ZZZ $16.72

45305 2 00 00 00 00 ZZZ $83.60

45305 8 00 00 00 00 ZZZ $16.72

45307 2 00 00 00 00 ZZZ $108.90

45307 8 00 00 00 00 ZZZ $21.78

Page 188: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

45308 2 00 00 00 00 ZZZ $149.00

45308 8 00 00 00 00 ZZZ $30.00

45309 2 00 00 00 00 ZZZ $163.90

45309 8 00 00 00 00 ZZZ $32.78

45315 2 00 00 00 00 ZZZ $170.50

45315 8 00 00 00 00 ZZZ $34.10

45317 2 00 00 00 00 ZZZ $221.46

45317 8 00 00 00 00 ZZZ $44.29

45320 2 00 00 00 00 ZZZ $243.84

45320 8 00 00 00 00 ZZZ $48.77

45321 2 00 00 00 00 ZZZ $165.00

45321 8 00 00 00 00 ZZZ $33.00

45327 2 00 00 00 00 ZZZ $99.42

45327 8 00 00 00 00 ZZZ $19.88

45330 2 00 00 00 00 ZZZ $110.50

45330 8 00 00 00 00 ZZZ $22.10

45331 2 00 00 00 00 ZZZ $130.90

45331 8 00 00 00 00 ZZZ $26.18

45332 2 00 00 00 00 ZZZ $130.90

45332 8 00 00 00 00 ZZZ $26.18

45333 2 00 00 00 00 ZZZ $221.10

45333 8 00 00 00 00 ZZZ $44.22

45334 2 00 00 00 00 ZZZ $241.51

45334 8 00 00 00 00 ZZZ $48.30

45335 2 00 00 00 00 ZZZ $161.29

45335 8 00 00 00 00 ZZZ $32.26

45337 2 00 00 00 00 ZZZ $203.28

45337 8 00 00 00 00 ZZZ $40.66

45338 2 00 00 00 00 ZZZ $254.10

45338 8 00 00 00 00 ZZZ $50.82

45340 2 00 00 00 00 ZZZ $367.98

45340 8 00 00 00 00 ZZZ $73.60

45341 2 00 00 00 00 ZZZ $221.12

45341 8 00 00 00 00 ZZZ $44.22

45342 2 00 00 00 00 ZZZ $254.95

45342 8 00 00 00 00 ZZZ $50.99

45346 2 00 00 00 00 ZZZ $0.00

45346 8 00 00 00 00 ZZZ $0.00

45347 2 00 00 00 00 ZZZ $0.00

45347 8 00 00 00 00 ZZZ $0.00

Page 189: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

45349 2 00 00 00 00 ZZZ $0.00

45349 8 00 00 00 00 ZZZ $0.00

45350 2 00 00 00 00 ZZZ $0.00

45350 8 00 00 00 00 ZZZ $0.00

45360 2 00 00 00 00 ZZZ $10.06

45360 8 00 00 00 00 ZZZ $10.06

45378 2 00 00 00 00 ZZZ $428.94

45378 8 00 00 00 00 ZZZ $85.79

45379 2 00 00 00 00 ZZZ $464.20

45379 8 00 00 00 00 ZZZ $92.84

45380 2 00 00 00 00 ZZZ $465.30

45380 8 00 00 00 00 ZZZ $93.06

45381 2 00 00 00 00 ZZZ $435.63

45381 8 00 00 00 00 ZZZ $87.13

45382 2 00 00 00 00 ZZZ $566.50

45382 8 00 00 00 00 ZZZ $113.30

45384 2 00 00 00 00 ZZZ $522.50

45384 8 00 00 00 00 ZZZ $104.50

45385 2 00 00 00 00 ZZZ $522.50

45385 8 00 00 00 00 ZZZ $104.50

45386 2 00 00 00 00 ZZZ $828.37

45386 8 00 00 00 00 ZZZ $165.67

45388 2 00 00 00 00 ZZZ $778.78

45388 8 00 00 00 00 ZZZ $155.76

45389 2 00 00 00 00 ZZZ $0.00

45389 8 00 00 00 00 ZZZ $0.00

45390 2 00 00 00 00 ZZZ $0.00

45390 8 00 00 00 00 ZZZ $0.00

45391 2 00 00 00 00 ZZZ $348.74

45391 8 00 00 00 00 ZZZ $69.75

45392 2 00 00 00 00 ZZZ $440.13

45392 8 00 00 00 00 ZZZ $88.03

45393 2 00 00 00 00 ZZZ $0.00

45393 8 00 00 00 00 ZZZ $0.00

45395 2 00 00 00 00 ZZZ $1,572.92

45395 8 00 00 00 00 ZZZ $314.58

45397 2 00 00 00 00 ZZZ $1,717.91

45397 8 00 00 00 00 ZZZ $343.58

45398 2 00 00 00 00 ZZZ $0.00

45398 8 00 00 00 00 ZZZ $0.00

Page 190: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

45399 2 00 00 00 00 ZZZ $0.00

45399 8 00 00 00 00 ZZZ $0.00

45400 2 00 00 00 00 ZZZ $921.36

45400 8 00 00 00 00 ZZZ $184.27

45402 2 00 00 00 00 ZZZ $1,251.33

45402 8 00 00 00 00 ZZZ $250.27

45499 2 00 00 00 00 ZZZ $0.00

45499 8 00 00 00 00 ZZZ $0.00

45500 2 00 00 00 00 ZZZ $443.30

45500 8 00 00 00 00 ZZZ $88.66

45505 2 00 00 00 00 ZZZ $490.60

45505 8 00 00 00 00 ZZZ $98.12

45540 2 00 00 00 00 ZZZ $762.30

45540 8 00 00 00 00 ZZZ $152.46

45541 2 00 00 00 00 ZZZ $762.30

45541 8 00 00 00 00 ZZZ $152.46

45550 2 00 00 00 00 ZZZ $962.50

45550 8 00 00 00 00 ZZZ $192.50

45560 2 00 00 00 00 ZZZ $635.80

45560 8 00 00 00 00 ZZZ $127.16

45562 2 00 00 00 00 ZZZ $867.12

45562 8 00 00 00 00 ZZZ $173.42

45563 2 00 00 00 00 ZZZ $1,369.69

45563 8 00 00 00 00 ZZZ $273.94

45800 2 00 00 00 00 ZZZ $871.20

45800 8 00 00 00 00 ZZZ $174.24

45805 2 00 00 00 00 ZZZ $962.50

45805 8 00 00 00 00 ZZZ $192.50

45820 2 00 00 00 00 ZZZ $871.20

45820 8 00 00 00 00 ZZZ $174.24

45825 2 00 00 00 00 ZZZ $962.50

45825 8 00 00 00 00 ZZZ $192.50

45900 2 00 00 00 00 ZZZ $71.33

45900 8 00 00 00 00 ZZZ $14.27

45905 2 00 00 00 00 ZZZ $151.80

45905 8 00 00 00 00 ZZZ $30.36

45910 2 00 00 00 00 ZZZ $151.80

45910 8 00 00 00 00 ZZZ $30.36

45915 2 00 00 00 00 ZZZ $151.80

45915 8 00 00 00 00 ZZZ $30.36

Page 191: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

45990 2 00 00 00 00 ZZZ $91.56

45990 8 00 00 00 00 ZZZ $18.31

45999 2 00 00 00 00 ZZZ $0.00

45999 8 00 00 00 00 ZZZ $0.00

46020 2 00 00 00 00 ZZZ $256.18

46020 8 00 00 00 00 ZZZ $51.24

46030 2 00 00 00 00 ZZZ $77.10

46030 8 00 00 00 00 ZZZ $15.42

46040 2 00 00 00 00 ZZZ $366.30

46040 8 00 00 00 00 ZZZ $73.26

46045 2 00 00 00 00 ZZZ $195.80

46045 8 00 00 00 00 ZZZ $39.16

46050 2 00 00 00 00 ZZZ $85.76

46050 8 00 00 00 00 ZZZ $17.15

46060 2 00 00 00 00 ZZZ $449.90

46060 8 00 00 00 00 ZZZ $89.98

46070 2 00 00 00 00 ZZZ $191.40

46070 8 00 00 00 00 ZZZ $38.28

46080 2 00 00 00 00 ZZZ $246.40

46080 8 00 00 00 00 ZZZ $49.28

46083 2 00 00 00 00 ZZZ $106.21

46083 8 00 00 00 00 ZZZ $21.24

46200 2 00 00 00 00 ZZZ $342.22

46200 8 00 00 00 00 ZZZ $68.44

46220 2 00 00 00 00 ZZZ $94.60

46220 8 00 00 00 00 ZZZ $18.92

46221 2 00 00 00 00 ZZZ $108.90

46221 8 00 00 00 00 ZZZ $21.78

46230 2 00 00 00 00 ZZZ $138.21

46230 8 00 00 00 00 ZZZ $27.64

46250 2 00 00 00 00 ZZZ $452.00

46250 8 00 00 00 00 ZZZ $90.00

46255 2 00 00 00 00 ZZZ $482.90

46255 8 00 00 00 00 ZZZ $96.58

46257 2 00 00 00 00 ZZZ $482.90

46257 8 00 00 00 00 ZZZ $96.58

46258 2 00 00 00 00 ZZZ $526.90

46258 8 00 00 00 00 ZZZ $105.38

46260 2 00 00 00 00 ZZZ $584.10

46260 8 00 00 00 00 ZZZ $116.82

Page 192: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

46261 2 00 00 00 00 ZZZ $664.40

46261 8 00 00 00 00 ZZZ $132.88

46262 2 00 00 00 00 ZZZ $569.80

46262 8 00 00 00 00 ZZZ $113.96

46270 2 00 00 00 00 ZZZ $349.22

46270 8 00 00 00 00 ZZZ $69.84

46275 2 00 00 00 00 ZZZ $468.10

46275 8 00 00 00 00 ZZZ $93.62

46280 2 00 00 00 00 ZZZ $545.03

46280 8 00 00 00 00 ZZZ $109.01

46285 2 00 00 00 00 ZZZ $334.40

46285 8 00 00 00 00 ZZZ $66.88

46288 2 00 00 00 00 ZZZ $469.30

46288 8 00 00 00 00 ZZZ $93.86

46320 2 00 00 00 00 ZZZ $103.59

46320 8 00 00 00 00 ZZZ $20.72

46505 2 00 00 00 00 ZZZ $286.92

46505 8 00 00 00 00 ZZZ $57.38

46600 2 00 00 00 00 ZZZ $27.80

46600 8 00 00 00 00 ZZZ $5.56

46601 2 00 00 00 00 ZZZ $0.00

46601 8 00 00 00 00 ZZZ $0.00

46604 2 00 00 00 00 ZZZ $58.30

46604 8 00 00 00 00 ZZZ $11.66

46606 2 00 00 00 00 ZZZ $69.30

46606 8 00 00 00 00 ZZZ $13.86

46607 2 00 00 00 00 ZZZ $0.00

46607 8 00 00 00 00 ZZZ $0.00

46608 2 00 00 00 00 ZZZ $116.60

46608 8 00 00 00 00 ZZZ $23.32

46610 2 00 00 00 00 ZZZ $116.60

46610 8 00 00 00 00 ZZZ $23.32

46611 2 00 00 00 00 ZZZ $116.60

46611 8 00 00 00 00 ZZZ $23.32

46612 2 00 00 00 00 ZZZ $130.90

46612 8 00 00 00 00 ZZZ $26.18

46614 2 00 00 00 00 ZZZ $170.50

46614 8 00 00 00 00 ZZZ $34.10

46615 2 00 00 00 00 ZZZ $214.01

46615 8 00 00 00 00 ZZZ $42.80

Page 193: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

46700 2 00 00 00 00 ZZZ $508.20

46700 8 00 00 00 00 ZZZ $101.64

46705 2 00 00 00 00 ZZZ $534.60

46705 8 00 00 00 00 ZZZ $106.92

46706 2 00 00 00 00 ZZZ $156.76

46706 8 00 00 00 00 ZZZ $31.35

46707 2 00 00 00 00 ZZZ $583.79

46707 8 00 00 00 00 ZZZ $116.76

46710 2 00 00 00 00 ZZZ $834.29

46710 8 00 00 00 00 ZZZ $166.86

46712 2 00 00 00 00 ZZZ $1,741.36

46712 8 00 00 00 00 ZZZ $348.27

46715 2 00 00 00 00 ZZZ $577.21

46715 8 00 00 00 00 ZZZ $115.44

46716 2 00 00 00 00 ZZZ $960.46

46716 8 00 00 00 00 ZZZ $192.09

46730 2 00 00 00 00 ZZZ $1,415.70

46730 8 00 00 00 00 ZZZ $283.14

46735 2 00 00 00 00 ZZZ $2,195.00

46735 8 00 00 00 00 ZZZ $439.00

46740 2 00 00 00 00 ZZZ $1,770.31

46740 8 00 00 00 00 ZZZ $354.06

46742 2 00 00 00 00 ZZZ $2,369.43

46742 8 00 00 00 00 ZZZ $473.89

46744 2 00 00 00 00 ZZZ $2,555.46

46744 8 00 00 00 00 ZZZ $511.09

46746 2 00 00 00 00 ZZZ $2,887.89

46746 8 00 00 00 00 ZZZ $577.58

46748 2 00 00 00 00 ZZZ $3,107.95

46748 8 00 00 00 00 ZZZ $621.59

46750 2 00 00 00 00 ZZZ $482.90

46750 8 00 00 00 00 ZZZ $96.58

46751 2 00 00 00 00 ZZZ $522.50

46751 8 00 00 00 00 ZZZ $104.50

46753 2 00 00 00 00 ZZZ $508.20

46753 8 00 00 00 00 ZZZ $101.64

46754 2 00 00 00 00 ZZZ $127.60

46754 8 00 00 00 00 ZZZ $25.52

46760 2 00 00 00 00 ZZZ $508.20

46760 8 00 00 00 00 ZZZ $101.64

Page 194: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

46761 2 00 00 00 00 ZZZ $585.20

46761 8 00 00 00 00 ZZZ $117.04

46762 2 00 00 00 00 ZZZ $585.20

46762 8 00 00 00 00 ZZZ $117.04

46900 2 00 00 00 00 ZZZ $102.54

46900 8 00 00 00 00 ZZZ $20.51

46910 2 00 00 00 00 ZZZ $107.53

46910 8 00 00 00 00 ZZZ $21.51

46916 2 00 00 00 00 ZZZ $103.07

46916 8 00 00 00 00 ZZZ $20.61

46917 2 00 00 00 00 ZZZ $167.76

46917 8 00 00 00 00 ZZZ $33.55

46922 2 00 00 00 00 ZZZ $117.76

46922 8 00 00 00 00 ZZZ $23.55

46924 2 00 00 00 00 ZZZ $333.00

46924 8 00 00 00 00 ZZZ $67.00

46930 2 00 00 00 00 ZZZ $249.45

46930 8 00 00 00 00 ZZZ $49.89

46940 2 00 00 00 00 ZZZ $191.40

46940 8 00 00 00 00 ZZZ $38.28

46942 2 00 00 00 00 ZZZ $127.60

46942 8 00 00 00 00 ZZZ $25.52

46945 2 00 00 00 00 ZZZ $118.54

46945 8 00 00 00 00 ZZZ $23.71

46946 2 00 00 00 00 ZZZ $160.77

46946 8 00 00 00 00 ZZZ $32.15

46947 2 00 00 00 00 ZZZ $403.76

46947 8 00 00 00 00 ZZZ $80.75

46999 2 00 00 00 00 ZZZ $0.00

46999 8 00 00 00 00 ZZZ $0.00

47000 2 00 00 00 00 ZZZ $195.80

47000 8 00 00 00 00 ZZZ $39.16

47001 2 00 00 00 00 ZZZ $160.00

47001 8 00 00 00 00 ZZZ $32.00

47010 2 00 00 00 00 ZZZ $469.71

47010 8 00 00 00 00 ZZZ $93.94

47015 2 00 00 00 00 ZZZ $695.82

47015 8 00 00 00 00 ZZZ $139.16

47100 2 00 00 00 00 ZZZ $407.00

47100 8 00 00 00 00 ZZZ $81.40

Page 195: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

47120 2 00 00 00 00 ZZZ $991.34

47120 8 00 00 00 00 ZZZ $198.27

47122 2 00 00 00 00 ZZZ $1,497.24

47122 8 00 00 00 00 ZZZ $299.45

47125 2 00 00 00 00 ZZZ $1,366.64

47125 8 00 00 00 00 ZZZ $273.33

47130 2 00 00 00 00 ZZZ $1,479.15

47130 8 00 00 00 00 ZZZ $295.83

47300 2 00 00 00 00 ZZZ $628.10

47300 8 00 00 00 00 ZZZ $125.62

47350 2 00 00 00 00 ZZZ $595.10

47350 8 00 00 00 00 ZZZ $119.02

47360 2 00 00 00 00 ZZZ $777.86

47360 8 00 00 00 00 ZZZ $155.57

47361 2 00 00 00 00 ZZZ $1,713.00

47361 8 00 00 00 00 ZZZ $342.60

47362 2 00 00 00 00 ZZZ $611.58

47362 8 00 00 00 00 ZZZ $122.32

47370 2 00 00 00 00 ZZZ $1,074.24

47370 8 00 00 00 00 ZZZ $214.85

47371 2 00 00 00 00 ZZZ $1,012.77

47371 8 00 00 00 00 ZZZ $202.55

47379 2 00 00 00 00 ZZZ $0.00

47379 8 00 00 00 00 ZZZ $0.00

47380 2 00 00 00 00 ZZZ $1,261.54

47380 8 00 00 00 00 ZZZ $252.31

47381 2 00 00 00 00 ZZZ $1,247.09

47381 8 00 00 00 00 ZZZ $249.42

47382 2 00 00 00 00 ZZZ $751.63

47382 8 00 00 00 00 ZZZ $150.33

47383 2 00 00 00 00 ZZZ $474.09

47383 8 00 00 00 00 ZZZ $94.82

47399 2 00 00 00 00 ZZZ $0.00

47399 8 00 00 00 00 ZZZ $0.00

47400 2 00 00 00 00 ZZZ $855.23

47400 8 00 00 00 00 ZZZ $171.05

47420 2 00 00 00 00 ZZZ $744.70

47420 8 00 00 00 00 ZZZ $148.94

47425 2 00 00 00 00 ZZZ $853.60

47425 8 00 00 00 00 ZZZ $170.72

Page 196: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

47460 2 00 00 00 00 ZZZ $834.90

47460 8 00 00 00 00 ZZZ $166.98

47480 2 00 00 00 00 ZZZ $490.60

47480 8 00 00 00 00 ZZZ $98.12

47490 2 00 00 00 00 ZZZ $460.11

47490 8 00 00 00 00 ZZZ $92.02

47531 2 00 00 00 00 ZZZ $358.58

47531 8 00 00 00 00 ZZZ $71.72

47532 2 00 00 00 00 ZZZ $789.45

47532 8 00 00 00 00 ZZZ $157.89

47533 2 00 00 00 00 ZZZ $1,283.86

47533 8 00 00 00 00 ZZZ $256.77

47534 2 00 00 00 00 ZZZ $1,584.46

47534 8 00 00 00 00 ZZZ $316.89

47535 2 00 00 00 00 ZZZ $1,058.93

47535 8 00 00 00 00 ZZZ $211.79

47536 2 00 00 00 00 ZZZ $781.09

47536 8 00 00 00 00 ZZZ $156.22

47537 2 00 00 00 00 ZZZ $387.14

47537 8 00 00 00 00 ZZZ $77.43

47538 2 00 00 00 00 ZZZ $4,273.00

47538 8 00 00 00 00 ZZZ $854.60

47539 2 00 00 00 00 ZZZ $4,677.62

47539 8 00 00 00 00 ZZZ $935.52

47540 2 00 00 00 00 ZZZ $4,869.61

47540 8 00 00 00 00 ZZZ $973.92

47541 2 00 00 00 00 ZZZ $1,135.85

47541 8 00 00 00 00 ZZZ $227.17

47542 2 00 00 00 00 ZZZ $492.95

47542 8 00 00 00 00 ZZZ $98.59

47543 2 00 00 00 00 ZZZ $1,260.99

47543 8 00 00 00 00 ZZZ $252.20

47544 2 00 00 00 00 ZZZ $782.79

47544 8 00 00 00 00 ZZZ $156.56

47550 2 00 00 00 00 ZZZ $276.25

47550 8 00 00 00 00 ZZZ $55.25

47552 2 00 00 00 00 ZZZ $308.00

47552 8 00 00 00 00 ZZZ $61.60

47553 2 00 00 00 00 ZZZ $354.20

47553 8 00 00 00 00 ZZZ $70.84

Page 197: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

47554 2 00 00 00 00 ZZZ $354.20

47554 8 00 00 00 00 ZZZ $70.84

47555 2 00 00 00 00 ZZZ $354.20

47555 8 00 00 00 00 ZZZ $70.84

47556 2 00 00 00 00 ZZZ $301.07

47556 8 00 00 00 00 ZZZ $60.21

47562 2 00 00 00 00 ZZZ $708.73

47562 8 00 00 00 00 ZZZ $141.75

47563 2 00 00 00 00 ZZZ $769.37

47563 8 00 00 00 00 ZZZ $153.87

47564 2 00 00 00 00 ZZZ $940.58

47564 8 00 00 00 00 ZZZ $188.12

47570 2 00 00 00 00 ZZZ $820.94

47570 8 00 00 00 00 ZZZ $164.19

47579 2 00 00 00 00 ZZZ $0.00

47579 8 00 00 00 00 ZZZ $0.00

47600 2 00 00 00 00 ZZZ $919.89

47600 8 00 00 00 00 ZZZ $183.98

47605 2 00 00 00 00 ZZZ $990.76

47605 8 00 00 00 00 ZZZ $198.15

47610 2 00 00 00 00 ZZZ $1,161.60

47610 8 00 00 00 00 ZZZ $232.32

47612 2 00 00 00 00 ZZZ $1,201.20

47612 8 00 00 00 00 ZZZ $240.24

47620 2 00 00 00 00 ZZZ $1,180.30

47620 8 00 00 00 00 ZZZ $236.06

47700 2 00 00 00 00 ZZZ $693.00

47700 8 00 00 00 00 ZZZ $138.60

47701 2 00 00 00 00 ZZZ $1,140.30

47701 8 00 00 00 00 ZZZ $228.06

47711 2 00 00 00 00 ZZZ $1,362.61

47711 8 00 00 00 00 ZZZ $272.52

47712 2 00 00 00 00 ZZZ $1,599.74

47712 8 00 00 00 00 ZZZ $319.95

47715 2 00 00 00 00 ZZZ $689.48

47715 8 00 00 00 00 ZZZ $137.90

47720 2 00 00 00 00 ZZZ $711.70

47720 8 00 00 00 00 ZZZ $142.34

47721 2 00 00 00 00 ZZZ $781.00

47721 8 00 00 00 00 ZZZ $156.20

Page 198: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

47740 2 00 00 00 00 ZZZ $781.00

47740 8 00 00 00 00 ZZZ $156.20

47741 2 00 00 00 00 ZZZ $1,401.54

47741 8 00 00 00 00 ZZZ $280.31

47760 2 00 00 00 00 ZZZ $962.50

47760 8 00 00 00 00 ZZZ $192.50

47765 2 00 00 00 00 ZZZ $968.27

47765 8 00 00 00 00 ZZZ $193.65

47780 2 00 00 00 00 ZZZ $974.82

47780 8 00 00 00 00 ZZZ $194.96

47785 2 00 00 00 00 ZZZ $1,677.61

47785 8 00 00 00 00 ZZZ $335.52

47800 2 00 00 00 00 ZZZ $885.39

47800 8 00 00 00 00 ZZZ $177.08

47801 2 00 00 00 00 ZZZ $725.55

47801 8 00 00 00 00 ZZZ $145.11

47802 2 00 00 00 00 ZZZ $1,157.33

47802 8 00 00 00 00 ZZZ $231.47

47900 2 00 00 00 00 ZZZ $1,305.99

47900 8 00 00 00 00 ZZZ $261.20

47999 2 00 00 00 00 ZZZ $0.00

47999 8 00 00 00 00 ZZZ $0.00

48000 2 00 00 00 00 ZZZ $980.10

48000 8 00 00 00 00 ZZZ $196.02

48001 2 00 00 00 00 ZZZ $1,325.50

48001 8 00 00 00 00 ZZZ $265.10

48020 2 00 00 00 00 ZZZ $586.15

48020 8 00 00 00 00 ZZZ $117.23

48100 2 00 00 00 00 ZZZ $708.40

48100 8 00 00 00 00 ZZZ $141.68

48102 2 00 00 00 00 ZZZ $253.87

48102 8 00 00 00 00 ZZZ $50.77

48105 2 00 00 00 00 ZZZ $3,046.52

48105 8 00 00 00 00 ZZZ $609.30

48120 2 00 00 00 00 ZZZ $726.00

48120 8 00 00 00 00 ZZZ $145.20

48140 2 00 00 00 00 ZZZ $1,560.90

48140 8 00 00 00 00 ZZZ $312.18

48145 2 00 00 00 00 ZZZ $1,633.50

48145 8 00 00 00 00 ZZZ $326.70

Page 199: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

48146 2 00 00 00 00 ZZZ $1,870.00

48146 8 00 00 00 00 ZZZ $374.00

48148 2 00 00 00 00 ZZZ $1,217.35

48148 8 00 00 00 00 ZZZ $243.47

48150 2 00 00 00 00 ZZZ $2,940.30

48150 8 00 00 00 00 ZZZ $588.06

48152 2 00 00 00 00 ZZZ $2,649.90

48152 8 00 00 00 00 ZZZ $529.98

48153 2 00 00 00 00 ZZZ $2,940.30

48153 8 00 00 00 00 ZZZ $588.06

48154 2 00 00 00 00 ZZZ $2,649.90

48154 8 00 00 00 00 ZZZ $529.98

48155 2 00 00 00 00 ZZZ $1,669.00

48155 8 00 00 00 00 ZZZ $333.96

48160 2 00 00 00 00 ZZZ $0.00

48160 8 00 00 00 00 ZZZ $0.00

48400 2 00 00 00 00 ZZZ $108.90

48400 8 00 00 00 00 ZZZ $21.78

48500 2 00 00 00 00 ZZZ $628.10

48500 8 00 00 00 00 ZZZ $125.62

48510 2 00 00 00 00 ZZZ $559.14

48510 8 00 00 00 00 ZZZ $111.83

48520 2 00 00 00 00 ZZZ $711.70

48520 8 00 00 00 00 ZZZ $142.34

48540 2 00 00 00 00 ZZZ $834.90

48540 8 00 00 00 00 ZZZ $166.98

48545 2 00 00 00 00 ZZZ $1,239.26

48545 8 00 00 00 00 ZZZ $247.85

48547 2 00 00 00 00 ZZZ $1,252.90

48547 8 00 00 00 00 ZZZ $250.58

48548 2 00 00 00 00 ZZZ $1,807.80

48548 8 00 00 00 00 ZZZ $361.56

48999 2 00 00 00 00 ZZZ $0.00

48999 8 00 00 00 00 ZZZ $0.00

49000 2 00 00 00 00 ZZZ $726.00

49000 8 00 00 00 00 ZZZ $145.20

49002 2 00 00 00 00 ZZZ $467.35

49002 8 00 00 00 00 ZZZ $93.47

49010 2 00 00 00 00 ZZZ $591.80

49010 8 00 00 00 00 ZZZ $118.36

Page 200: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

49020 2 00 00 00 00 ZZZ $651.46

49020 8 00 00 00 00 ZZZ $130.29

49040 2 00 00 00 00 ZZZ $577.50

49040 8 00 00 00 00 ZZZ $115.50

49060 2 00 00 00 00 ZZZ $522.50

49060 8 00 00 00 00 ZZZ $104.50

49062 2 00 00 00 00 ZZZ $834.14

49062 8 00 00 00 00 ZZZ $166.83

49082 2 00 00 00 00 ZZZ $737.60

49082 8 00 00 00 00 ZZZ $148.00

49083 2 00 00 00 00 ZZZ $842.40

49083 8 00 00 00 00 ZZZ $168.00

49084 2 00 00 00 00 ZZZ $1,392.00

49084 8 00 00 00 00 ZZZ $278.00

49180 2 00 00 00 00 ZZZ $155.02

49180 8 00 00 00 00 ZZZ $31.00

49185 2 00 00 00 00 ZZZ $948.79

49185 8 00 00 00 00 ZZZ $189.76

49203 2 00 00 00 00 ZZZ $813.79

49203 8 00 00 00 00 ZZZ $162.76

49204 2 00 00 00 00 ZZZ $1,038.92

49204 8 00 00 00 00 ZZZ $207.78

49205 2 00 00 00 00 ZZZ $1,189.55

49205 8 00 00 00 00 ZZZ $237.91

49215 2 00 00 00 00 ZZZ $924.21

49215 8 00 00 00 00 ZZZ $184.84

49220 2 00 00 00 00 ZZZ $745.80

49220 8 00 00 00 00 ZZZ $149.16

49250 2 00 00 00 00 ZZZ $445.50

49250 8 00 00 00 00 ZZZ $89.10

49255 2 00 00 00 00 ZZZ $891.00

49255 8 00 00 00 00 ZZZ $178.00

49320 2 00 00 00 00 ZZZ $349.82

49320 8 00 00 00 00 ZZZ $69.96

49321 2 00 00 00 00 ZZZ $367.16

49321 8 00 00 00 00 ZZZ $73.43

49322 2 00 00 00 00 ZZZ $400.98

49322 8 00 00 00 00 ZZZ $80.20

49323 2 00 00 00 00 ZZZ $605.19

49323 8 00 00 00 00 ZZZ $121.04

Page 201: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

49324 2 00 00 00 00 ZZZ $464.76

49324 8 00 00 00 00 ZZZ $92.95

49325 2 00 00 00 00 ZZZ $500.80

49325 8 00 00 00 00 ZZZ $100.16

49326 2 00 00 00 00 ZZZ $230.48

49326 8 00 00 00 00 ZZZ $46.10

49327 2 00 00 00 00 ZZZ $171.39

49327 8 00 00 00 00 ZZZ $34.28

49329 2 00 00 00 00 ZZZ $0.00

49329 8 00 00 00 00 ZZZ $0.00

49402 2 00 00 00 00 ZZZ $1,002.54

49402 8 00 00 00 00 ZZZ $200.51

49405 2 00 00 00 00 ZZZ $861.14

49405 8 00 00 00 00 ZZZ $172.23

49406 2 00 00 00 00 ZZZ $860.82

49406 8 00 00 00 00 ZZZ $172.16

49407 2 00 00 00 00 ZZZ $744.00

49407 8 00 00 00 00 ZZZ $148.80

49411 2 00 00 00 00 ZZZ $663.46

49411 8 00 00 00 00 ZZZ $132.69

49412 2 00 00 00 00 ZZZ $106.91

49412 8 00 00 00 00 ZZZ $21.38

49418 2 00 00 00 00 ZZZ $1,828.74

49418 8 00 00 00 00 ZZZ $365.75

49419 2 00 00 00 00 ZZZ $454.19

49419 8 00 00 00 00 ZZZ $90.84

49421 2 00 00 00 00 ZZZ $309.10

49421 8 00 00 00 00 ZZZ $61.82

49422 2 00 00 00 00 ZZZ $450.90

49422 8 00 00 00 00 ZZZ $90.18

49423 2 00 00 00 00 ZZZ $110.97

49423 8 00 00 00 00 ZZZ $22.19

49424 2 00 00 00 00 ZZZ $57.34

49424 8 00 00 00 00 ZZZ $11.47

49425 2 00 00 00 00 ZZZ $649.00

49425 8 00 00 00 00 ZZZ $129.80

49426 2 00 00 00 00 ZZZ $584.10

49426 8 00 00 00 00 ZZZ $116.82

49427 2 00 00 00 00 ZZZ $77.51

49427 8 00 00 00 00 ZZZ $15.50

Page 202: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

49428 2 00 00 00 00 ZZZ $135.91

49428 8 00 00 00 00 ZZZ $27.18

49429 2 00 00 00 00 ZZZ $436.04

49429 8 00 00 00 00 ZZZ $87.21

49435 2 00 00 00 00 ZZZ $148.44

49435 8 00 00 00 00 ZZZ $29.69

49436 2 00 00 00 00 ZZZ $218.15

49436 8 00 00 00 00 ZZZ $43.63

49440 2 00 00 00 00 ZZZ $740.58

49440 8 00 00 00 00 ZZZ $148.12

49441 2 00 00 00 00 ZZZ $768.56

49441 8 00 00 00 00 ZZZ $153.71

49442 2 00 00 00 00 ZZZ $834.46

49442 8 00 00 00 00 ZZZ $166.89

49446 2 00 00 00 00 ZZZ $990.47

49446 8 00 00 00 00 ZZZ $198.09

49450 2 00 00 00 00 ZZZ $675.32

49450 8 00 00 00 00 ZZZ $135.06

49451 2 00 00 00 00 ZZZ $723.19

49451 8 00 00 00 00 ZZZ $144.64

49452 2 00 00 00 00 ZZZ $896.48

49452 8 00 00 00 00 ZZZ $179.30

49460 2 00 00 00 00 ZZZ $706.78

49460 8 00 00 00 00 ZZZ $141.36

49465 2 00 00 00 00 ZZZ $111.74

49465 8 00 00 00 00 ZZZ $22.35

49491 2 00 00 00 00 ZZZ $733.48

49491 8 00 00 00 00 ZZZ $146.70

49492 2 00 00 00 00 ZZZ $901.38

49492 8 00 00 00 00 ZZZ $180.28

49495 2 00 00 00 00 ZZZ $510.06

49495 8 00 00 00 00 ZZZ $102.01

49496 2 00 00 00 00 ZZZ $650.10

49496 8 00 00 00 00 ZZZ $130.02

49500 2 00 00 00 00 ZZZ $492.00

49500 8 00 00 00 00 ZZZ $98.00

49501 2 00 00 00 00 ZZZ $610.31

49501 8 00 00 00 00 ZZZ $122.06

49505 2 00 00 00 00 ZZZ $539.90

49505 8 00 00 00 00 ZZZ $107.98

Page 203: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

49507 2 00 00 00 00 ZZZ $673.72

49507 8 00 00 00 00 ZZZ $134.74

49520 2 00 00 00 00 ZZZ $668.12

49520 8 00 00 00 00 ZZZ $133.62

49521 2 00 00 00 00 ZZZ $773.02

49521 8 00 00 00 00 ZZZ $154.60

49525 2 00 00 00 00 ZZZ $647.00

49525 8 00 00 00 00 ZZZ $129.00

49540 2 00 00 00 00 ZZZ $464.20

49540 8 00 00 00 00 ZZZ $92.84

49550 2 00 00 00 00 ZZZ $407.00

49550 8 00 00 00 00 ZZZ $81.40

49553 2 00 00 00 00 ZZZ $515.90

49553 8 00 00 00 00 ZZZ $103.18

49555 2 00 00 00 00 ZZZ $464.20

49555 8 00 00 00 00 ZZZ $92.84

49557 2 00 00 00 00 ZZZ $573.10

49557 8 00 00 00 00 ZZZ $114.62

49560 2 00 00 00 00 ZZZ $777.69

49560 8 00 00 00 00 ZZZ $155.54

49561 2 00 00 00 00 ZZZ $889.90

49561 8 00 00 00 00 ZZZ $177.98

49565 2 00 00 00 00 ZZZ $799.14

49565 8 00 00 00 00 ZZZ $159.83

49566 2 00 00 00 00 ZZZ $933.42

49566 8 00 00 00 00 ZZZ $186.68

49568 2 00 00 00 00 ZZZ $201.94

49568 8 00 00 00 00 ZZZ $40.39

49570 2 00 00 00 00 ZZZ $435.00

49570 8 00 00 00 00 ZZZ $87.00

49572 2 00 00 00 00 ZZZ $519.86

49572 8 00 00 00 00 ZZZ $103.97

49580 2 00 00 00 00 ZZZ $416.70

49580 8 00 00 00 00 ZZZ $83.34

49582 2 00 00 00 00 ZZZ $521.00

49582 8 00 00 00 00 ZZZ $104.00

49585 2 00 00 00 00 ZZZ $464.20

49585 8 00 00 00 00 ZZZ $92.84

49587 2 00 00 00 00 ZZZ $531.05

49587 8 00 00 00 00 ZZZ $106.21

Page 204: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

49590 2 00 00 00 00 ZZZ $385.00

49590 8 00 00 00 00 ZZZ $77.00

49600 2 00 00 00 00 ZZZ $461.58

49600 8 00 00 00 00 ZZZ $92.32

49605 2 00 00 00 00 ZZZ $1,071.40

49605 8 00 00 00 00 ZZZ $214.28

49606 2 00 00 00 00 ZZZ $980.10

49606 8 00 00 00 00 ZZZ $196.02

49610 2 00 00 00 00 ZZZ $508.20

49610 8 00 00 00 00 ZZZ $101.64

49611 2 00 00 00 00 ZZZ $508.20

49611 8 00 00 00 00 ZZZ $101.64

49650 2 00 00 00 00 ZZZ $422.43

49650 8 00 00 00 00 ZZZ $84.49

49651 2 00 00 00 00 ZZZ $557.34

49651 8 00 00 00 00 ZZZ $111.47

49652 2 00 00 00 00 ZZZ $942.31

49652 8 00 00 00 00 ZZZ $188.46

49653 2 00 00 00 00 ZZZ $1,176.12

49653 8 00 00 00 00 ZZZ $235.22

49654 2 00 00 00 00 ZZZ $1,081.27

49654 8 00 00 00 00 ZZZ $216.25

49655 2 00 00 00 00 ZZZ $1,301.79

49655 8 00 00 00 00 ZZZ $260.36

49656 2 00 00 00 00 ZZZ $1,085.54

49656 8 00 00 00 00 ZZZ $217.11

49657 2 00 00 00 00 ZZZ $1,567.36

49657 8 00 00 00 00 ZZZ $313.47

49659 2 00 00 00 00 ZZZ $0.00

49659 8 00 00 00 00 ZZZ $0.00

49900 2 00 00 00 00 ZZZ $493.83

49900 8 00 00 00 00 ZZZ $98.77

49904 2 00 00 00 00 ZZZ $1,563.09

49904 8 00 00 00 00 ZZZ $312.62

49905 2 00 00 00 00 ZZZ $444.52

49905 8 00 00 00 00 ZZZ $88.90

49906 2 00 00 00 00 ZZZ $0.00

49906 8 00 00 00 00 ZZZ $0.00

49999 2 00 00 00 00 ZZZ $0.00

49999 8 00 00 00 00 ZZZ $0.00

Page 205: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

50010 2 00 00 00 00 ZZZ $726.00

50010 8 00 00 00 00 ZZZ $145.20

50020 2 00 00 00 00 ZZZ $646.21

50020 8 00 00 00 00 ZZZ $129.24

50040 2 00 00 00 00 ZZZ $762.30

50040 8 00 00 00 00 ZZZ $152.46

50045 2 00 00 00 00 ZZZ $762.30

50045 8 00 00 00 00 ZZZ $152.46

50060 2 00 00 00 00 ZZZ $830.84

50060 8 00 00 00 00 ZZZ $166.17

50065 2 00 00 00 00 ZZZ $943.80

50065 8 00 00 00 00 ZZZ $188.76

50070 2 00 00 00 00 ZZZ $943.80

50070 8 00 00 00 00 ZZZ $188.76

50075 2 00 00 00 00 ZZZ $1,095.98

50075 8 00 00 00 00 ZZZ $219.20

50080 2 00 00 00 00 ZZZ $1,256.98

50080 8 00 00 00 00 ZZZ $251.40

50081 2 00 00 00 00 ZZZ $1,525.41

50081 8 00 00 00 00 ZZZ $305.08

50100 2 00 00 00 00 ZZZ $744.82

50100 8 00 00 00 00 ZZZ $148.96

50120 2 00 00 00 00 ZZZ $781.00

50120 8 00 00 00 00 ZZZ $156.20

50125 2 00 00 00 00 ZZZ $762.30

50125 8 00 00 00 00 ZZZ $152.46

50130 2 00 00 00 00 ZZZ $907.50

50130 8 00 00 00 00 ZZZ $181.50

50135 2 00 00 00 00 ZZZ $943.80

50135 8 00 00 00 00 ZZZ $188.76

50200 2 00 00 00 00 ZZZ $210.10

50200 8 00 00 00 00 ZZZ $42.02

50205 2 00 00 00 00 ZZZ $631.40

50205 8 00 00 00 00 ZZZ $126.28

50220 2 00 00 00 00 ZZZ $1,107.70

50220 8 00 00 00 00 ZZZ $221.54

50225 2 00 00 00 00 ZZZ $926.04

50225 8 00 00 00 00 ZZZ $185.21

50230 2 00 00 00 00 ZZZ $1,343.10

50230 8 00 00 00 00 ZZZ $268.62

Page 206: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

50234 2 00 00 00 00 ZZZ $1,180.30

50234 8 00 00 00 00 ZZZ $236.06

50236 2 00 00 00 00 ZZZ $1,116.18

50236 8 00 00 00 00 ZZZ $223.24

50240 2 00 00 00 00 ZZZ $1,001.05

50240 8 00 00 00 00 ZZZ $200.21

50250 2 00 00 00 00 ZZZ $1,020.46

50250 8 00 00 00 00 ZZZ $204.09

50280 2 00 00 00 00 ZZZ $781.00

50280 8 00 00 00 00 ZZZ $156.20

50290 2 00 00 00 00 ZZZ $711.70

50290 8 00 00 00 00 ZZZ $142.34

50320 2 00 00 00 00 ZZZ $1,001.31

50320 8 00 00 00 00 ZZZ $200.26

50340 2 00 00 00 00 ZZZ $1,107.70

50340 8 00 00 00 00 ZZZ $221.54

50360 2 00 00 00 00 ZZZ $1,597.20

50360 8 00 00 00 00 ZZZ $319.44

50365 2 00 00 00 00 ZZZ $1,978.90

50365 8 00 00 00 00 ZZZ $395.78

50370 2 00 00 00 00 ZZZ $672.17

50370 8 00 00 00 00 ZZZ $134.43

50380 2 00 00 00 00 ZZZ $1,197.90

50380 8 00 00 00 00 ZZZ $239.58

50382 2 00 00 00 00 ZZZ $1,293.25

50382 8 00 00 00 00 ZZZ $258.65

50384 2 00 00 00 00 ZZZ $1,247.63

50384 8 00 00 00 00 ZZZ $249.53

50385 2 00 00 00 00 ZZZ $1,203.85

50385 8 00 00 00 00 ZZZ $240.77

50386 2 00 00 00 00 ZZZ $786.14

50386 8 00 00 00 00 ZZZ $157.23

50387 2 00 00 00 00 ZZZ $684.86

50387 8 00 00 00 00 ZZZ $136.97

50389 2 00 00 00 00 ZZZ $464.45

50389 8 00 00 00 00 ZZZ $92.89

50390 2 00 00 00 00 ZZZ $188.24

50390 8 00 00 00 00 ZZZ $37.65

50391 2 00 00 00 00 ZZZ $171.58

50391 8 00 00 00 00 ZZZ $34.32

Page 207: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

50395 2 00 00 00 00 ZZZ $337.44

50395 8 00 00 00 00 ZZZ $67.49

50396 2 00 00 00 00 ZZZ $155.00

50396 8 00 00 00 00 ZZZ $31.00

50400 2 00 00 00 00 ZZZ $943.80

50400 8 00 00 00 00 ZZZ $188.76

50405 2 00 00 00 00 ZZZ $1,074.22

50405 8 00 00 00 00 ZZZ $214.84

50430 2 00 00 00 00 ZZZ $504.56

50430 8 00 00 00 00 ZZZ $100.91

50431 2 00 00 00 00 ZZZ $157.15

50431 8 00 00 00 00 ZZZ $31.43

50432 2 00 00 00 00 ZZZ $814.31

50432 8 00 00 00 00 ZZZ $162.86

50433 2 00 00 00 00 ZZZ $1,094.39

50433 8 00 00 00 00 ZZZ $218.88

50434 2 00 00 00 00 ZZZ $865.43

50434 8 00 00 00 00 ZZZ $173.09

50435 2 00 00 00 00 ZZZ $453.04

50435 8 00 00 00 00 ZZZ $90.61

50500 2 00 00 00 00 ZZZ $877.00

50500 8 00 00 00 00 ZZZ $175.40

50520 2 00 00 00 00 ZZZ $871.20

50520 8 00 00 00 00 ZZZ $174.24

50525 2 00 00 00 00 ZZZ $980.06

50525 8 00 00 00 00 ZZZ $196.01

50526 2 00 00 00 00 ZZZ $976.66

50526 8 00 00 00 00 ZZZ $195.33

50540 2 00 00 00 00 ZZZ $1,107.70

50540 8 00 00 00 00 ZZZ $221.54

50541 2 00 00 00 00 ZZZ $971.94

50541 8 00 00 00 00 ZZZ $194.39

50542 2 00 00 00 00 ZZZ $1,225.22

50542 8 00 00 00 00 ZZZ $245.04

50543 2 00 00 00 00 ZZZ $1,540.41

50543 8 00 00 00 00 ZZZ $308.08

50544 2 00 00 00 00 ZZZ $1,339.09

50544 8 00 00 00 00 ZZZ $267.82

50545 2 00 00 00 00 ZZZ $1,452.95

50545 8 00 00 00 00 ZZZ $290.59

Page 208: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

50546 2 00 00 00 00 ZZZ $1,242.55

50546 8 00 00 00 00 ZZZ $248.51

50547 2 00 00 00 00 ZZZ $1,596.10

50547 8 00 00 00 00 ZZZ $319.22

50548 2 00 00 00 00 ZZZ $1,457.91

50548 8 00 00 00 00 ZZZ $291.58

50549 2 00 00 00 00 ZZZ $0.00

50549 8 00 00 00 00 ZZZ $0.00

50551 2 00 00 00 00 ZZZ $244.69

50551 8 00 00 00 00 ZZZ $48.94

50553 2 00 00 00 00 ZZZ $405.19

50553 8 00 00 00 00 ZZZ $81.04

50555 2 00 00 00 00 ZZZ $412.53

50555 8 00 00 00 00 ZZZ $82.51

50557 2 00 00 00 00 ZZZ $488.33

50557 8 00 00 00 00 ZZZ $97.67

50561 2 00 00 00 00 ZZZ $498.03

50561 8 00 00 00 00 ZZZ $99.61

50562 2 00 00 00 00 ZZZ $650.98

50562 8 00 00 00 00 ZZZ $130.20

50570 2 00 00 00 00 ZZZ $327.04

50570 8 00 00 00 00 ZZZ $65.41

50572 2 00 00 00 00 ZZZ $433.78

50572 8 00 00 00 00 ZZZ $86.76

50574 2 00 00 00 00 ZZZ $453.97

50574 8 00 00 00 00 ZZZ $90.79

50575 2 00 00 00 00 ZZZ $1,026.39

50575 8 00 00 00 00 ZZZ $205.28

50576 2 00 00 00 00 ZZZ $477.58

50576 8 00 00 00 00 ZZZ $95.52

50580 2 00 00 00 00 ZZZ $432.47

50580 8 00 00 00 00 ZZZ $86.49

50590 2 00 00 00 00 ZZZ $957.00

50590 8 00 00 00 00 ZZZ $191.00

50592 2 00 00 00 00 ZZZ $4,743.94

50592 8 00 00 00 00 ZZZ $948.79

50593 2 00 00 00 00 ZZZ $289.76

50593 8 00 00 00 00 ZZZ $57.95

50600 2 00 00 00 00 ZZZ $762.30

50600 8 00 00 00 00 ZZZ $152.46

Page 209: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

50605 2 00 00 00 00 ZZZ $628.11

50605 8 00 00 00 00 ZZZ $125.62

50606 2 00 00 00 00 ZZZ $510.72

50606 8 00 00 00 00 ZZZ $102.14

50610 2 00 00 00 00 ZZZ $943.80

50610 8 00 00 00 00 ZZZ $188.76

50620 2 00 00 00 00 ZZZ $853.60

50620 8 00 00 00 00 ZZZ $170.72

50630 2 00 00 00 00 ZZZ $834.90

50630 8 00 00 00 00 ZZZ $166.98

50650 2 00 00 00 00 ZZZ $773.14

50650 8 00 00 00 00 ZZZ $154.63

50660 2 00 00 00 00 ZZZ $871.20

50660 8 00 00 00 00 ZZZ $174.24

50684 2 00 00 00 00 ZZZ $203.51

50684 8 00 00 00 00 ZZZ $40.70

50686 2 00 00 00 00 ZZZ $105.95

50686 8 00 00 00 00 ZZZ $21.19

50688 2 00 00 00 00 ZZZ $72.60

50688 8 00 00 00 00 ZZZ $14.52

50690 2 00 00 00 00 ZZZ $219.25

50690 8 00 00 00 00 ZZZ $43.85

50693 2 00 00 00 00 ZZZ $1,015.86

50693 8 00 00 00 00 ZZZ $203.17

50694 2 00 00 00 00 ZZZ $1,122.12

50694 8 00 00 00 00 ZZZ $224.42

50695 2 00 00 00 00 ZZZ $1,369.74

50695 8 00 00 00 00 ZZZ $273.95

50700 2 00 00 00 00 ZZZ $762.30

50700 8 00 00 00 00 ZZZ $152.46

50706 2 00 00 00 00 ZZZ $736.92

50706 8 00 00 00 00 ZZZ $147.38

50715 2 00 00 00 00 ZZZ $832.94

50715 8 00 00 00 00 ZZZ $166.59

50722 2 00 00 00 00 ZZZ $721.74

50722 8 00 00 00 00 ZZZ $144.35

50725 2 00 00 00 00 ZZZ $998.80

50725 8 00 00 00 00 ZZZ $199.76

50727 2 00 00 00 00 ZZZ $514.80

50727 8 00 00 00 00 ZZZ $102.96

Page 210: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

50728 2 00 00 00 00 ZZZ $590.70

50728 8 00 00 00 00 ZZZ $118.14

50740 2 00 00 00 00 ZZZ $871.20

50740 8 00 00 00 00 ZZZ $174.24

50750 2 00 00 00 00 ZZZ $943.80

50750 8 00 00 00 00 ZZZ $188.76

50760 2 00 00 00 00 ZZZ $871.20

50760 8 00 00 00 00 ZZZ $174.24

50770 2 00 00 00 00 ZZZ $943.80

50770 8 00 00 00 00 ZZZ $188.76

50780 2 00 00 00 00 ZZZ $1,089.00

50780 8 00 00 00 00 ZZZ $217.80

50782 2 00 00 00 00 ZZZ $1,089.00

50782 8 00 00 00 00 ZZZ $217.80

50783 2 00 00 00 00 ZZZ $1,089.00

50783 8 00 00 00 00 ZZZ $217.80

50785 2 00 00 00 00 ZZZ $943.80

50785 8 00 00 00 00 ZZZ $188.76

50800 2 00 00 00 00 ZZZ $871.20

50800 8 00 00 00 00 ZZZ $174.24

50810 2 00 00 00 00 ZZZ $1,180.30

50810 8 00 00 00 00 ZZZ $236.06

50815 2 00 00 00 00 ZZZ $979.28

50815 8 00 00 00 00 ZZZ $195.86

50820 2 00 00 00 00 ZZZ $1,180.30

50820 8 00 00 00 00 ZZZ $236.06

50825 2 00 00 00 00 ZZZ $1,401.26

50825 8 00 00 00 00 ZZZ $280.25

50830 2 00 00 00 00 ZZZ $1,365.85

50830 8 00 00 00 00 ZZZ $273.17

50840 2 00 00 00 00 ZZZ $1,180.30

50840 8 00 00 00 00 ZZZ $236.06

50845 2 00 00 00 00 ZZZ $1,433.40

50845 8 00 00 00 00 ZZZ $286.68

50860 2 00 00 00 00 ZZZ $711.70

50860 8 00 00 00 00 ZZZ $142.34

50900 2 00 00 00 00 ZZZ $762.30

50900 8 00 00 00 00 ZZZ $152.46

50920 2 00 00 00 00 ZZZ $762.30

50920 8 00 00 00 00 ZZZ $152.46

Page 211: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

50930 2 00 00 00 00 ZZZ $943.80

50930 8 00 00 00 00 ZZZ $188.76

50940 2 00 00 00 00 ZZZ $762.30

50940 8 00 00 00 00 ZZZ $152.46

50945 2 00 00 00 00 ZZZ $1,027.62

50945 8 00 00 00 00 ZZZ $205.52

50947 2 00 00 00 00 ZZZ $1,565.98

50947 8 00 00 00 00 ZZZ $313.20

50948 2 00 00 00 00 ZZZ $1,431.91

50948 8 00 00 00 00 ZZZ $286.38

50949 2 00 00 00 00 ZZZ $0.00

50949 8 00 00 00 00 ZZZ $0.00

50951 2 00 00 00 00 ZZZ $246.78

50951 8 00 00 00 00 ZZZ $49.36

50953 2 00 00 00 00 ZZZ $414.63

50953 8 00 00 00 00 ZZZ $82.93

50955 2 00 00 00 00 ZZZ $386.57

50955 8 00 00 00 00 ZZZ $77.31

50957 2 00 00 00 00 ZZZ $387.62

50957 8 00 00 00 00 ZZZ $77.52

50961 2 00 00 00 00 ZZZ $495.15

50961 8 00 00 00 00 ZZZ $99.03

50970 2 00 00 00 00 ZZZ $303.70

50970 8 00 00 00 00 ZZZ $60.74

50972 2 00 00 00 00 ZZZ $354.63

50972 8 00 00 00 00 ZZZ $70.93

50974 2 00 00 00 00 ZZZ $694.40

50974 8 00 00 00 00 ZZZ $138.88

50976 2 00 00 00 00 ZZZ $663.26

50976 8 00 00 00 00 ZZZ $132.65

50980 2 00 00 00 00 ZZZ $424.71

50980 8 00 00 00 00 ZZZ $84.94

51020 2 00 00 00 00 ZZZ $584.10

51020 8 00 00 00 00 ZZZ $116.82

51030 2 00 00 00 00 ZZZ $544.50

51030 8 00 00 00 00 ZZZ $108.90

51040 2 00 00 00 00 ZZZ $428.94

51040 8 00 00 00 00 ZZZ $85.79

51045 2 00 00 00 00 ZZZ $413.60

51045 8 00 00 00 00 ZZZ $82.72

Page 212: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

51050 2 00 00 00 00 ZZZ $584.10

51050 8 00 00 00 00 ZZZ $116.82

51060 2 00 00 00 00 ZZZ $711.70

51060 8 00 00 00 00 ZZZ $142.34

51065 2 00 00 00 00 ZZZ $419.62

51065 8 00 00 00 00 ZZZ $83.92

51080 2 00 00 00 00 ZZZ $315.70

51080 8 00 00 00 00 ZZZ $63.14

51100 2 00 00 00 00 ZZZ $82.99

51100 8 00 00 00 00 ZZZ $16.60

51101 2 00 00 00 00 ZZZ $167.41

51101 8 00 00 00 00 ZZZ $33.48

51102 2 00 00 00 00 ZZZ $441.04

51102 8 00 00 00 00 ZZZ $88.21

51500 2 00 00 00 00 ZZZ $563.20

51500 8 00 00 00 00 ZZZ $112.64

51520 2 00 00 00 00 ZZZ $624.80

51520 8 00 00 00 00 ZZZ $124.96

51525 2 00 00 00 00 ZZZ $781.00

51525 8 00 00 00 00 ZZZ $156.20

51530 2 00 00 00 00 ZZZ $613.80

51530 8 00 00 00 00 ZZZ $122.76

51535 2 00 00 00 00 ZZZ $613.80

51535 8 00 00 00 00 ZZZ $122.76

51550 2 00 00 00 00 ZZZ $744.70

51550 8 00 00 00 00 ZZZ $148.94

51555 2 00 00 00 00 ZZZ $902.17

51555 8 00 00 00 00 ZZZ $180.43

51565 2 00 00 00 00 ZZZ $968.27

51565 8 00 00 00 00 ZZZ $193.65

51570 2 00 00 00 00 ZZZ $1,050.35

51570 8 00 00 00 00 ZZZ $210.07

51575 2 00 00 00 00 ZZZ $1,361.66

51575 8 00 00 00 00 ZZZ $272.33

51580 2 00 00 00 00 ZZZ $1,342.51

51580 8 00 00 00 00 ZZZ $268.50

51585 2 00 00 00 00 ZZZ $1,633.50

51585 8 00 00 00 00 ZZZ $326.70

51590 2 00 00 00 00 ZZZ $1,761.10

51590 8 00 00 00 00 ZZZ $352.22

Page 213: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

51595 2 00 00 00 00 ZZZ $2,831.40

51595 8 00 00 00 00 ZZZ $566.28

51596 2 00 00 00 00 ZZZ $1,825.59

51596 8 00 00 00 00 ZZZ $365.12

51597 2 00 00 00 00 ZZZ $2,544.30

51597 8 00 00 00 00 ZZZ $508.86

51600 2 00 00 00 00 ZZZ $205.61

51600 8 00 00 00 00 ZZZ $41.12

51605 2 00 00 00 00 ZZZ $205.61

51605 8 00 00 00 00 ZZZ $41.12

51610 2 00 00 00 00 ZZZ $221.35

51610 8 00 00 00 00 ZZZ $44.27

51700 2 00 00 00 00 ZZZ $74.22

51700 8 00 00 00 00 ZZZ $14.84

51701 2 00 00 00 00 ZZZ $65.59

51701 8 00 00 00 00 ZZZ $13.12

51702 2 00 00 00 00 ZZZ $103.13

51702 8 00 00 00 00 ZZZ $20.63

51703 2 00 00 00 00 ZZZ $143.14

51703 8 00 00 00 00 ZZZ $28.63

51705 2 00 00 00 00 ZZZ $63.99

51705 8 00 00 00 00 ZZZ $12.80

51710 2 00 00 00 00 ZZZ $107.79

51710 8 00 00 00 00 ZZZ $21.56

51715 2 00 00 00 00 ZZZ $191.71

51715 8 00 00 00 00 ZZZ $38.34

51720 2 00 00 00 00 ZZZ $109.62

51720 8 00 00 00 00 ZZZ $21.92

51725 2 00 00 00 00 ZZZ $83.60

51725 8 00 00 00 00 ZZZ $16.72

51726 2 00 00 00 00 ZZZ $144.54

51726 8 00 00 00 00 ZZZ $28.91

51727 2 00 00 00 00 ZZZ $144.54

51727 8 00 00 00 00 ZZZ $28.91

51728 2 00 00 00 00 ZZZ $144.54

51728 8 00 00 00 00 ZZZ $28.91

51729 2 00 00 00 00 ZZZ $166.23

51729 8 00 00 00 00 ZZZ $33.25

51736 2 00 00 00 00 ZZZ $42.90

51736 8 00 00 00 00 ZZZ $8.58

Page 214: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

51741 2 00 00 00 00 ZZZ $64.90

51741 8 00 00 00 00 ZZZ $12.98

51784 2 00 00 00 00 ZZZ $70.81

51785 2 00 00 00 00 ZZZ $70.55

51785 8 00 00 00 00 ZZZ $14.11

51792 2 00 00 00 00 ZZZ $84.97

51792 8 00 00 00 00 ZZZ $16.99

51797 2 00 00 00 00 ZZZ $72.91

51797 8 00 00 00 00 ZZZ $14.58

51798 2 00 00 00 00 ZZZ $22.68

51798 8 00 00 00 00 ZZZ $4.54

51800 2 00 00 00 00 ZZZ $771.04

51800 8 00 00 00 00 ZZZ $154.21

51820 2 00 00 00 00 ZZZ $1,197.90

51820 8 00 00 00 00 ZZZ $239.58

51840 2 00 00 00 00 ZZZ $871.20

51840 8 00 00 00 00 ZZZ $174.24

51841 2 00 00 00 00 ZZZ $1,089.00

51841 8 00 00 00 00 ZZZ $217.80

51845 2 00 00 00 00 ZZZ $1,023.00

51845 8 00 00 00 00 ZZZ $205.00

51860 2 00 00 00 00 ZZZ $543.40

51860 8 00 00 00 00 ZZZ $108.68

51865 2 00 00 00 00 ZZZ $762.30

51865 8 00 00 00 00 ZZZ $152.46

51874 8 00 00 00 00 ZZZ $4.00

51880 2 00 00 00 00 ZZZ $351.69

51880 8 00 00 00 00 ZZZ $70.34

51900 2 00 00 00 00 ZZZ $871.20

51900 8 00 00 00 00 ZZZ $174.24

51920 2 00 00 00 00 ZZZ $762.30

51920 8 00 00 00 00 ZZZ $152.46

51925 2 00 00 00 00 ZZZ $695.78

51925 8 00 00 00 00 ZZZ $139.16

51940 2 00 00 00 00 ZZZ $1,240.75

51940 8 00 00 00 00 ZZZ $248.15

51960 2 00 00 00 00 ZZZ $1,197.90

51960 8 00 00 00 00 ZZZ $239.58

51980 2 00 00 00 00 ZZZ $762.30

51980 8 00 00 00 00 ZZZ $152.46

Page 215: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

51990 2 00 00 00 00 ZZZ $796.61

51990 8 00 00 00 00 ZZZ $159.32

51992 2 00 00 00 00 ZZZ $867.15

51992 8 00 00 00 00 ZZZ $173.43

51999 2 00 00 00 00 ZZZ $0.00

51999 8 00 00 00 00 ZZZ $0.00

52000 2 00 00 00 00 ZZZ $163.90

52000 8 00 00 00 00 ZZZ $32.78

52001 2 00 00 00 00 ZZZ $151.40

52001 8 00 00 00 00 ZZZ $30.28

52005 2 00 00 00 00 ZZZ $246.40

52005 8 00 00 00 00 ZZZ $49.28

52007 2 00 00 00 00 ZZZ $243.84

52007 8 00 00 00 00 ZZZ $48.77

52010 2 00 00 00 00 ZZZ $239.80

52010 8 00 00 00 00 ZZZ $47.96

52204 2 00 00 00 00 ZZZ $265.10

52204 8 00 00 00 00 ZZZ $53.02

52214 2 00 00 00 00 ZZZ $315.70

52214 8 00 00 00 00 ZZZ $63.14

52224 2 00 00 00 00 ZZZ $202.20

52224 8 00 00 00 00 ZZZ $40.44

52234 2 00 00 00 00 ZZZ $315.70

52234 8 00 00 00 00 ZZZ $63.14

52235 2 00 00 00 00 ZZZ $522.50

52235 8 00 00 00 00 ZZZ $104.50

52240 2 00 00 00 00 ZZZ $726.00

52240 8 00 00 00 00 ZZZ $145.20

52250 2 00 00 00 00 ZZZ $246.40

52250 8 00 00 00 00 ZZZ $49.28

52260 2 00 00 00 00 ZZZ $156.05

52260 8 00 00 00 00 ZZZ $31.21

52265 2 00 00 00 00 ZZZ $144.77

52265 8 00 00 00 00 ZZZ $28.95

52270 2 00 00 00 00 ZZZ $222.66

52270 8 00 00 00 00 ZZZ $44.53

52275 2 00 00 00 00 ZZZ $265.67

52275 8 00 00 00 00 ZZZ $53.13

52276 2 00 00 00 00 ZZZ $291.90

52276 8 00 00 00 00 ZZZ $58.38

Page 216: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

52277 2 00 00 00 00 ZZZ $374.00

52277 8 00 00 00 00 ZZZ $74.80

52281 2 00 00 00 00 ZZZ $195.80

52281 8 00 00 00 00 ZZZ $39.16

52282 2 00 00 00 00 ZZZ $471.53

52282 8 00 00 00 00 ZZZ $94.31

52283 2 00 00 00 00 ZZZ $204.04

52283 8 00 00 00 00 ZZZ $40.81

52285 2 00 00 00 00 ZZZ $223.45

52285 8 00 00 00 00 ZZZ $44.69

52287 2 00 00 00 00 ZZZ $332.68

52287 8 00 00 00 00 ZZZ $66.54

52290 2 00 00 00 00 ZZZ $180.96

52290 8 00 00 00 00 ZZZ $36.19

52300 2 00 00 00 00 ZZZ $246.40

52300 8 00 00 00 00 ZZZ $49.28

52301 2 00 00 00 00 ZZZ $385.07

52301 8 00 00 00 00 ZZZ $77.01

52305 2 00 00 00 00 ZZZ $246.40

52305 8 00 00 00 00 ZZZ $49.28

52310 2 00 00 00 00 ZZZ $301.60

52310 8 00 00 00 00 ZZZ $60.32

52315 2 00 00 00 00 ZZZ $399.22

52315 8 00 00 00 00 ZZZ $79.84

52317 2 00 00 00 00 ZZZ $569.11

52317 8 00 00 00 00 ZZZ $113.82

52318 2 00 00 00 00 ZZZ $544.50

52318 8 00 00 00 00 ZZZ $108.90

52320 2 00 00 00 00 ZZZ $465.00

52320 8 00 00 00 00 ZZZ $93.00

52325 2 00 00 00 00 ZZZ $523.58

52325 8 00 00 00 00 ZZZ $104.72

52327 2 00 00 00 00 ZZZ $385.78

52327 8 00 00 00 00 ZZZ $77.16

52330 2 00 00 00 00 ZZZ $434.04

52330 8 00 00 00 00 ZZZ $86.81

52332 2 00 00 00 00 ZZZ $492.53

52332 8 00 00 00 00 ZZZ $98.51

52334 2 00 00 00 00 ZZZ $350.38

52334 8 00 00 00 00 ZZZ $70.08

Page 217: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

52341 2 00 00 00 00 ZZZ $360.56

52341 8 00 00 00 00 ZZZ $72.11

52342 2 00 00 00 00 ZZZ $390.26

52342 8 00 00 00 00 ZZZ $78.05

52343 2 00 00 00 00 ZZZ $432.33

52343 8 00 00 00 00 ZZZ $86.47

52344 2 00 00 00 00 ZZZ $462.04

52344 8 00 00 00 00 ZZZ $92.41

52345 2 00 00 00 00 ZZZ $492.57

52345 8 00 00 00 00 ZZZ $98.51

52346 2 00 00 00 00 ZZZ $554.04

52346 8 00 00 00 00 ZZZ $110.81

52351 2 00 00 00 00 ZZZ $367.98

52351 8 00 00 00 00 ZZZ $73.60

52352 2 00 00 00 00 ZZZ $511.50

52352 8 00 00 00 00 ZZZ $102.30

52353 2 00 00 00 00 ZZZ $527.63

52353 8 00 00 00 00 ZZZ $105.53

52354 2 00 00 00 00 ZZZ $461.63

52354 8 00 00 00 00 ZZZ $92.33

52355 2 00 00 00 00 ZZZ $542.07

52355 8 00 00 00 00 ZZZ $108.41

52356 2 00 00 00 00 ZZZ $550.09

52356 8 00 00 00 00 ZZZ $110.02

52400 2 00 00 00 00 ZZZ $644.80

52400 8 00 00 00 00 ZZZ $128.96

52402 2 00 00 00 00 ZZZ $343.62

52402 8 00 00 00 00 ZZZ $68.72

52441 2 00 00 00 00 ZZZ $222.05

52441 8 00 00 00 00 ZZZ $44.41

52442 2 00 00 00 00 ZZZ $844.51

52442 8 00 00 00 00 ZZZ $168.91

52450 2 00 00 00 00 ZZZ $359.03

52450 8 00 00 00 00 ZZZ $71.81

52500 2 00 00 00 00 ZZZ $759.00

52500 8 00 00 00 00 ZZZ $152.00

52601 2 00 00 00 00 ZZZ $1,082.14

52601 8 00 00 00 00 ZZZ $216.43

52630 2 00 00 00 00 ZZZ $693.00

52630 8 00 00 00 00 ZZZ $139.00

Page 218: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

52640 2 00 00 00 00 ZZZ $490.60

52640 8 00 00 00 00 ZZZ $98.12

52647 2 00 00 00 00 ZZZ $909.17

52647 8 00 00 00 00 ZZZ $181.83

52648 2 00 00 00 00 ZZZ $976.83

52648 8 00 00 00 00 ZZZ $195.37

52649 2 00 00 00 00 ZZZ $1,308.43

52649 8 00 00 00 00 ZZZ $261.69

52700 2 00 00 00 00 ZZZ $315.70

52700 8 00 00 00 00 ZZZ $63.14

53000 2 00 00 00 00 ZZZ $173.35

53000 8 00 00 00 00 ZZZ $34.67

53010 2 00 00 00 00 ZZZ $246.40

53010 8 00 00 00 00 ZZZ $49.28

53020 2 00 00 00 00 ZZZ $111.72

53020 8 00 00 00 00 ZZZ $22.34

53025 2 00 00 00 00 ZZZ $97.56

53025 8 00 00 00 00 ZZZ $19.51

53040 2 00 00 00 00 ZZZ $322.84

53040 8 00 00 00 00 ZZZ $64.57

53060 2 00 00 00 00 ZZZ $156.57

53060 8 00 00 00 00 ZZZ $31.31

53080 2 00 00 00 00 ZZZ $337.79

53080 8 00 00 00 00 ZZZ $67.56

53085 2 00 00 00 00 ZZZ $762.30

53085 8 00 00 00 00 ZZZ $152.46

53200 2 00 00 00 00 ZZZ $152.37

53200 8 00 00 00 00 ZZZ $30.47

53210 2 00 00 00 00 ZZZ $544.50

53210 8 00 00 00 00 ZZZ $108.90

53215 2 00 00 00 00 ZZZ $711.70

53215 8 00 00 00 00 ZZZ $142.34

53220 2 00 00 00 00 ZZZ $440.00

53220 8 00 00 00 00 ZZZ $88.00

53230 2 00 00 00 00 ZZZ $577.50

53230 8 00 00 00 00 ZZZ $115.50

53235 2 00 00 00 00 ZZZ $536.80

53235 8 00 00 00 00 ZZZ $107.36

53240 2 00 00 00 00 ZZZ $355.30

53240 8 00 00 00 00 ZZZ $71.06

Page 219: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

53250 2 00 00 00 00 ZZZ $479.60

53250 8 00 00 00 00 ZZZ $95.92

53260 2 00 00 00 00 ZZZ $169.42

53260 8 00 00 00 00 ZZZ $33.88

53265 2 00 00 00 00 ZZZ $189.09

53265 8 00 00 00 00 ZZZ $37.82

53270 2 00 00 00 00 ZZZ $169.68

53270 8 00 00 00 00 ZZZ $33.94

53275 2 00 00 00 00 ZZZ $272.80

53275 8 00 00 00 00 ZZZ $54.56

53400 2 00 00 00 00 ZZZ $656.70

53400 8 00 00 00 00 ZZZ $131.34

53405 2 00 00 00 00 ZZZ $648.57

53405 8 00 00 00 00 ZZZ $129.71

53410 2 00 00 00 00 ZZZ $686.07

53410 8 00 00 00 00 ZZZ $137.21

53415 2 00 00 00 00 ZZZ $1,298.90

53415 8 00 00 00 00 ZZZ $259.78

53420 2 00 00 00 00 ZZZ $762.30

53420 8 00 00 00 00 ZZZ $152.46

53425 2 00 00 00 00 ZZZ $762.30

53425 8 00 00 00 00 ZZZ $152.46

53430 2 00 00 00 00 ZZZ $665.35

53430 8 00 00 00 00 ZZZ $133.07

53431 2 00 00 00 00 ZZZ $1,199.65

53431 8 00 00 00 00 ZZZ $239.93

53440 2 00 00 00 00 ZZZ $762.30

53440 8 00 00 00 00 ZZZ $152.46

53442 2 00 00 00 00 ZZZ $380.80

53442 8 00 00 00 00 ZZZ $76.16

53444 2 00 00 00 00 ZZZ $860.13

53444 8 00 00 00 00 ZZZ $172.03

53445 2 00 00 00 00 ZZZ $713.35

53445 8 00 00 00 00 ZZZ $142.67

53446 2 00 00 00 00 ZZZ $796.19

53446 8 00 00 00 00 ZZZ $159.24

53447 2 00 00 00 00 ZZZ $590.87

53447 8 00 00 00 00 ZZZ $118.17

53448 2 00 00 00 00 ZZZ $1,434.39

53448 8 00 00 00 00 ZZZ $286.88

Page 220: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

53449 2 00 00 00 00 ZZZ $467.09

53449 8 00 00 00 00 ZZZ $93.42

53450 2 00 00 00 00 ZZZ $266.19

53450 8 00 00 00 00 ZZZ $53.24

53460 2 00 00 00 00 ZZZ $315.70

53460 8 00 00 00 00 ZZZ $63.14

53500 2 00 00 00 00 ZZZ $794.96

53500 8 00 00 00 00 ZZZ $158.99

53502 2 00 00 00 00 ZZZ $381.70

53502 8 00 00 00 00 ZZZ $76.34

53505 2 00 00 00 00 ZZZ $385.00

53505 8 00 00 00 00 ZZZ $77.00

53510 2 00 00 00 00 ZZZ $536.80

53510 8 00 00 00 00 ZZZ $107.36

53515 2 00 00 00 00 ZZZ $762.30

53515 8 00 00 00 00 ZZZ $152.46

53520 2 00 00 00 00 ZZZ $394.18

53520 8 00 00 00 00 ZZZ $78.84

53600 2 00 00 00 00 ZZZ $87.33

53600 8 00 00 00 00 ZZZ $17.47

53601 2 00 00 00 00 ZZZ $79.47

53601 8 00 00 00 00 ZZZ $15.89

53605 2 00 00 00 00 ZZZ $83.60

53605 8 00 00 00 00 ZZZ $16.72

53620 2 00 00 00 00 ZZZ $124.57

53620 8 00 00 00 00 ZZZ $24.91

53621 2 00 00 00 00 ZZZ $115.65

53621 8 00 00 00 00 ZZZ $23.13

53660 2 00 00 00 00 ZZZ $69.76

53660 8 00 00 00 00 ZZZ $13.95

53661 2 00 00 00 00 ZZZ $70.29

53661 8 00 00 00 00 ZZZ $14.06

53665 2 00 00 00 00 ZZZ $49.50

53665 8 00 00 00 00 ZZZ $9.90

53850 2 00 00 00 00 ZZZ $1,494.62

53850 8 00 00 00 00 ZZZ $298.92

53852 2 00 00 00 00 ZZZ $2,318.34

53852 8 00 00 00 00 ZZZ $463.67

53855 2 00 00 00 00 ZZZ $856.48

53855 8 00 00 00 00 ZZZ $171.30

Page 221: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

53860 2 00 00 00 00 ZZZ $1,758.82

53860 8 00 00 00 00 ZZZ $351.76

53899 2 00 00 00 00 ZZZ $0.00

53899 8 00 00 00 00 ZZZ $0.00

54000 2 00 00 00 00 ZZZ $118.80

54000 8 00 00 00 00 ZZZ $23.76

54001 2 00 00 00 00 ZZZ $145.03

54001 8 00 00 00 00 ZZZ $29.01

54015 2 00 00 00 00 ZZZ $255.18

54015 8 00 00 00 00 ZZZ $51.04

54050 2 00 00 00 00 ZZZ $68.71

54050 8 00 00 00 00 ZZZ $13.74

54055 2 00 00 00 00 ZZZ $120.38

54055 8 00 00 00 00 ZZZ $24.08

54056 2 00 00 00 00 ZZZ $77.37

54056 8 00 00 00 00 ZZZ $15.47

54057 2 00 00 00 00 ZZZ $120.34

54057 8 00 00 00 00 ZZZ $24.07

54060 2 00 00 00 00 ZZZ $134.80

54060 8 00 00 00 00 ZZZ $26.96

54065 2 00 00 00 00 ZZZ $167.32

54065 8 00 00 00 00 ZZZ $33.46

54100 2 00 00 00 00 ZZZ $106.21

54100 8 00 00 00 00 ZZZ $21.24

54105 2 00 00 00 00 ZZZ $186.99

54105 8 00 00 00 00 ZZZ $37.40

54110 2 00 00 00 00 ZZZ $536.80

54110 8 00 00 00 00 ZZZ $107.36

54111 2 00 00 00 00 ZZZ $616.84

54111 8 00 00 00 00 ZZZ $123.37

54112 2 00 00 00 00 ZZZ $720.95

54112 8 00 00 00 00 ZZZ $144.19

54115 2 00 00 00 00 ZZZ $360.87

54115 8 00 00 00 00 ZZZ $72.17

54120 2 00 00 00 00 ZZZ $463.41

54120 8 00 00 00 00 ZZZ $92.68

54125 2 00 00 00 00 ZZZ $762.30

54125 8 00 00 00 00 ZZZ $152.46

54130 2 00 00 00 00 ZZZ $1,107.70

54130 8 00 00 00 00 ZZZ $221.54

Page 222: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

54135 2 00 00 00 00 ZZZ $1,325.50

54135 8 00 00 00 00 ZZZ $265.10

54150 2 00 00 00 00 ZZZ $197.22

54150 8 00 00 00 00 ZZZ $39.44

54160 2 00 00 00 00 ZZZ $164.70

54160 8 00 00 00 00 ZZZ $32.94

54161 2 00 00 00 00 ZZZ $210.10

54161 8 00 00 00 00 ZZZ $42.02

54162 2 00 00 00 00 ZZZ $251.24

54162 8 00 00 00 00 ZZZ $50.25

54163 2 00 00 00 00 ZZZ $235.97

54163 8 00 00 00 00 ZZZ $47.19

54164 2 00 00 00 00 ZZZ $207.10

54164 8 00 00 00 00 ZZZ $41.42

54200 2 00 00 00 00 ZZZ $63.47

54200 8 00 00 00 00 ZZZ $12.69

54205 2 00 00 00 00 ZZZ $377.39

54205 8 00 00 00 00 ZZZ $75.48

54220 2 00 00 00 00 ZZZ $112.77

54220 8 00 00 00 00 ZZZ $22.55

54230 2 00 00 00 00 ZZZ $119.00

54230 8 00 00 00 00 ZZZ $24.00

54231 2 00 00 00 00 ZZZ $144.10

54231 8 00 00 00 00 ZZZ $28.82

54235 2 00 00 00 00 ZZZ $52.45

54235 8 00 00 00 00 ZZZ $10.49

54240 2 00 00 00 00 ZZZ $64.78

54240 8 00 00 00 00 ZZZ $12.96

54250 2 00 00 00 00 ZZZ $87.86

54250 8 00 00 00 00 ZZZ $17.57

54300 2 00 00 00 00 ZZZ $580.80

54300 8 00 00 00 00 ZZZ $116.16

54304 2 00 00 00 00 ZZZ $589.04

54304 8 00 00 00 00 ZZZ $117.81

54308 2 00 00 00 00 ZZZ $525.05

54308 8 00 00 00 00 ZZZ $105.01

54312 2 00 00 00 00 ZZZ $635.72

54312 8 00 00 00 00 ZZZ $127.14

54316 2 00 00 00 00 ZZZ $784.16

54316 8 00 00 00 00 ZZZ $156.83

Page 223: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

54318 2 00 00 00 00 ZZZ $789.25

54318 8 00 00 00 00 ZZZ $157.85

54320 8 00 00 00 00 ZZZ $116.00

54322 2 00 00 00 00 ZZZ $852.96

54322 8 00 00 00 00 ZZZ $170.59

54324 2 00 00 00 00 ZZZ $1,136.10

54324 8 00 00 00 00 ZZZ $227.22

54326 2 00 00 00 00 ZZZ $1,086.55

54326 8 00 00 00 00 ZZZ $217.31

54328 2 00 00 00 00 ZZZ $1,104.25

54328 8 00 00 00 00 ZZZ $220.85

54332 2 00 00 00 00 ZZZ $1,231.66

54332 8 00 00 00 00 ZZZ $246.33

54336 2 00 00 00 00 ZZZ $1,613.90

54336 8 00 00 00 00 ZZZ $322.78

54340 2 00 00 00 00 ZZZ $627.15

54340 8 00 00 00 00 ZZZ $125.43

54344 2 00 00 00 00 ZZZ $1,359.07

54344 8 00 00 00 00 ZZZ $271.81

54348 2 00 00 00 00 ZZZ $1,203.35

54348 8 00 00 00 00 ZZZ $240.67

54352 2 00 00 00 00 ZZZ $1,713.00

54352 8 00 00 00 00 ZZZ $342.60

54360 2 00 00 00 00 ZZZ $535.54

54360 8 00 00 00 00 ZZZ $107.11

54380 2 00 00 00 00 ZZZ $628.38

54380 8 00 00 00 00 ZZZ $125.68

54385 2 00 00 00 00 ZZZ $725.15

54385 8 00 00 00 00 ZZZ $145.03

54390 2 00 00 00 00 ZZZ $974.56

54390 8 00 00 00 00 ZZZ $194.91

54400 2 00 00 00 00 ZZZ $858.00

54400 8 00 00 00 00 ZZZ $172.00

54415 2 00 00 00 00 ZZZ $581.68

54415 8 00 00 00 00 ZZZ $116.34

54416 2 00 00 00 00 ZZZ $757.42

54416 8 00 00 00 00 ZZZ $151.48

54417 2 00 00 00 00 ZZZ $933.57

54417 8 00 00 00 00 ZZZ $186.71

54420 2 00 00 00 00 ZZZ $536.06

Page 224: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

54420 8 00 00 00 00 ZZZ $107.21

54430 2 00 00 00 00 ZZZ $476.53

54430 8 00 00 00 00 ZZZ $95.31

54435 2 00 00 00 00 ZZZ $419.76

54435 8 00 00 00 00 ZZZ $83.95

54437 2 00 00 00 00 ZZZ $692.40

54437 8 00 00 00 00 ZZZ $138.48

54438 2 00 00 00 00 ZZZ $1,397.51

54438 8 00 00 00 00 ZZZ $279.50

54440 2 00 00 00 00 ZZZ $578.00

54440 8 00 00 00 00 ZZZ $116.00

54450 2 00 00 00 00 ZZZ $77.15

54450 8 00 00 00 00 ZZZ $15.43

54500 2 00 00 00 00 ZZZ $113.56

54500 8 00 00 00 00 ZZZ $22.71

54505 2 00 00 00 00 ZZZ $154.47

54505 8 00 00 00 00 ZZZ $30.89

54512 2 00 00 00 00 ZZZ $575.49

54512 8 00 00 00 00 ZZZ $115.10

54520 2 00 00 00 00 ZZZ $330.00

54520 8 00 00 00 00 ZZZ $66.00

54522 2 00 00 00 00 ZZZ $654.28

54522 8 00 00 00 00 ZZZ $130.86

54530 2 00 00 00 00 ZZZ $482.90

54530 8 00 00 00 00 ZZZ $96.58

54535 2 00 00 00 00 ZZZ $584.10

54535 8 00 00 00 00 ZZZ $116.82

54550 2 00 00 00 00 ZZZ $427.90

54550 8 00 00 00 00 ZZZ $85.58

54560 2 00 00 00 00 ZZZ $501.71

54560 8 00 00 00 00 ZZZ $100.34

54600 2 00 00 00 00 ZZZ $482.90

54600 8 00 00 00 00 ZZZ $96.58

54620 2 00 00 00 00 ZZZ $272.80

54620 8 00 00 00 00 ZZZ $54.56

54640 2 00 00 00 00 ZZZ $552.20

54640 8 00 00 00 00 ZZZ $110.44

54650 2 00 00 00 00 ZZZ $912.43

54650 8 00 00 00 00 ZZZ $182.49

54670 2 00 00 00 00 ZZZ $315.70

Page 225: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

54670 8 00 00 00 00 ZZZ $63.14

54680 2 00 00 00 00 ZZZ $564.91

54680 8 00 00 00 00 ZZZ $112.98

54690 2 00 00 00 00 ZZZ $742.97

54690 8 00 00 00 00 ZZZ $148.59

54692 2 00 00 00 00 ZZZ $796.61

54692 8 00 00 00 00 ZZZ $159.32

54699 2 00 00 00 00 ZZZ $0.00

54699 8 00 00 00 00 ZZZ $0.00

54700 2 00 00 00 00 ZZZ $211.12

54700 8 00 00 00 00 ZZZ $42.22

54800 2 00 00 00 00 ZZZ $164.44

54800 8 00 00 00 00 ZZZ $32.89

54830 2 00 00 00 00 ZZZ $244.69

54830 8 00 00 00 00 ZZZ $48.94

54840 2 00 00 00 00 ZZZ $315.70

54840 8 00 00 00 00 ZZZ $63.14

54860 2 00 00 00 00 ZZZ $388.30

54860 8 00 00 00 00 ZZZ $77.66

54861 2 00 00 00 00 ZZZ $584.10

54861 8 00 00 00 00 ZZZ $116.82

54865 2 00 00 00 00 ZZZ $401.58

54865 8 00 00 00 00 ZZZ $80.34

55000 2 00 00 00 00 ZZZ $68.98

55000 8 00 00 00 00 ZZZ $13.80

55040 2 00 00 00 00 ZZZ $385.00

55040 8 00 00 00 00 ZZZ $77.00

55041 2 00 00 00 00 ZZZ $479.60

55041 8 00 00 00 00 ZZZ $95.92

55060 2 00 00 00 00 ZZZ $388.30

55060 8 00 00 00 00 ZZZ $77.66

55100 2 00 00 00 00 ZZZ $184.63

55100 8 00 00 00 00 ZZZ $36.93

55110 2 00 00 00 00 ZZZ $252.29

55110 8 00 00 00 00 ZZZ $50.46

55120 2 00 00 00 00 ZZZ $208.76

55120 8 00 00 00 00 ZZZ $41.75

55150 2 00 00 00 00 ZZZ $410.30

55150 8 00 00 00 00 ZZZ $82.06

55175 2 00 00 00 00 ZZZ $408.43

Page 226: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

55175 8 00 00 00 00 ZZZ $81.69

55180 2 00 00 00 00 ZZZ $732.62

55180 8 00 00 00 00 ZZZ $146.52

55200 2 00 00 00 00 ZZZ $210.10

55200 8 00 00 00 00 ZZZ $42.02

55250 2 00 00 00 00 ZZZ $287.10

55250 8 00 00 00 00 ZZZ $57.42

55250 A FP 00 00 00 ZZZ $287.10

55250 J 00 00 00 00 ZZZ $172.26

55300 2 00 00 00 00 ZZZ $271.00

55300 8 00 00 00 00 ZZZ $54.00

55400 2 00 00 00 00 ZZZ $393.13

55400 8 00 00 00 00 ZZZ $78.63

55450 8 00 00 00 00 ZZZ $49.41

55450 A FP 00 00 00 ZZZ $247.05

55450 J 00 00 00 00 ZZZ $148.23

55500 2 00 00 00 00 ZZZ $282.70

55500 8 00 00 00 00 ZZZ $56.54

55520 2 00 00 00 00 ZZZ $265.67

55520 8 00 00 00 00 ZZZ $53.13

55530 2 00 00 00 00 ZZZ $432.30

55530 8 00 00 00 00 ZZZ $86.46

55535 2 00 00 00 00 ZZZ $374.00

55535 8 00 00 00 00 ZZZ $74.80

55540 2 00 00 00 00 ZZZ $647.00

55540 8 00 00 00 00 ZZZ $129.00

55550 2 00 00 00 00 ZZZ $425.73

55550 8 00 00 00 00 ZZZ $85.15

55559 2 00 00 00 00 ZZZ $0.00

55559 8 00 00 00 00 ZZZ $0.00

55600 2 00 00 00 00 ZZZ $315.70

55600 8 00 00 00 00 ZZZ $63.14

55605 2 00 00 00 00 ZZZ $536.80

55605 8 00 00 00 00 ZZZ $107.36

55650 2 00 00 00 00 ZZZ $762.30

55650 8 00 00 00 00 ZZZ $152.46

55680 2 00 00 00 00 ZZZ $564.15

55680 8 00 00 00 00 ZZZ $112.83

55700 2 00 00 00 00 ZZZ $173.80

55700 8 00 00 00 00 ZZZ $34.76

Page 227: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

55705 2 00 00 00 00 ZZZ $315.70

55705 8 00 00 00 00 ZZZ $63.14

55706 2 00 00 00 00 ZZZ $518.34

55706 8 00 00 00 00 ZZZ $103.67

55720 2 00 00 00 00 ZZZ $330.97

55720 8 00 00 00 00 ZZZ $66.19

55725 2 00 00 00 00 ZZZ $536.80

55725 8 00 00 00 00 ZZZ $107.36

55801 2 00 00 00 00 ZZZ $793.08

55801 8 00 00 00 00 ZZZ $158.62

55810 2 00 00 00 00 ZZZ $1,019.93

55810 8 00 00 00 00 ZZZ $203.99

55812 2 00 00 00 00 ZZZ $1,867.31

55812 8 00 00 00 00 ZZZ $373.46

55815 2 00 00 00 00 ZZZ $2,314.68

55815 8 00 00 00 00 ZZZ $462.94

55821 2 00 00 00 00 ZZZ $871.20

55821 8 00 00 00 00 ZZZ $174.24

55831 2 00 00 00 00 ZZZ $871.20

55831 8 00 00 00 00 ZZZ $174.24

55840 2 00 00 00 00 ZZZ $1,052.70

55840 8 00 00 00 00 ZZZ $210.54

55842 2 00 00 00 00 ZZZ $1,108.05

55842 8 00 00 00 00 ZZZ $221.61

55845 2 00 00 00 00 ZZZ $1,870.00

55845 8 00 00 00 00 ZZZ $374.00

55860 2 00 00 00 00 ZZZ $874.19

55860 8 00 00 00 00 ZZZ $174.84

55862 2 00 00 00 00 ZZZ $1,228.12

55862 8 00 00 00 00 ZZZ $245.62

55865 2 00 00 00 00 ZZZ $2,002.97

55865 8 00 00 00 00 ZZZ $400.59

55866 2 00 00 00 00 ZZZ $1,811.03

55866 8 00 00 00 00 ZZZ $362.21

55873 2 00 00 00 00 ZZZ $1,195.12

55873 8 00 00 00 00 ZZZ $239.02

55875 2 00 00 00 00 ZZZ $912.44

55875 8 00 00 00 00 ZZZ $182.49

55876 2 00 00 00 00 ZZZ $192.07

55876 8 00 00 00 00 ZZZ $38.41

Page 228: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

55899 2 00 00 00 00 ZZZ $0.00

55899 8 00 00 00 00 ZZZ $0.00

55920 2 00 00 00 00 ZZZ $570.51

55920 8 00 00 00 00 ZZZ $114.10

56405 2 00 00 00 00 ZZZ $116.60

56405 8 00 00 00 00 ZZZ $23.32

56420 2 00 00 00 00 ZZZ $83.60

56420 8 00 00 00 00 ZZZ $16.72

56440 2 00 00 00 00 ZZZ $265.10

56440 8 00 00 00 00 ZZZ $53.02

56441 2 00 00 00 00 ZZZ $109.36

56441 8 00 00 00 00 ZZZ $21.87

56442 2 00 00 00 00 ZZZ $60.23

56442 8 00 00 00 00 ZZZ $12.05

56501 2 00 00 00 00 ZZZ $78.94

56501 8 00 00 00 00 ZZZ $15.79

56505 2 00 00 00 00 ZZZ $76.00

56515 2 00 00 00 00 ZZZ $195.80

56515 8 00 00 00 00 ZZZ $39.16

56605 2 00 00 00 00 ZZZ $83.60

56605 8 00 00 00 00 ZZZ $16.72

56606 2 00 00 00 00 ZZZ $39.34

56606 8 00 00 00 00 ZZZ $7.87

56620 2 00 00 00 00 ZZZ $508.20

56620 8 00 00 00 00 ZZZ $101.64

56625 2 00 00 00 00 ZZZ $699.60

56625 8 00 00 00 00 ZZZ $139.92

56630 2 00 00 00 00 ZZZ $1,124.57

56630 8 00 00 00 00 ZZZ $224.91

56631 2 00 00 00 00 ZZZ $1,452.00

56631 8 00 00 00 00 ZZZ $290.40

56632 2 00 00 00 00 ZZZ $1,669.80

56632 8 00 00 00 00 ZZZ $333.96

56633 2 00 00 00 00 ZZZ $1,180.30

56633 8 00 00 00 00 ZZZ $236.06

56634 2 00 00 00 00 ZZZ $1,452.00

56634 8 00 00 00 00 ZZZ $290.40

56637 2 00 00 00 00 ZZZ $1,452.00

56637 8 00 00 00 00 ZZZ $290.40

56640 2 00 00 00 00 ZZZ $1,761.10

Page 229: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

56640 8 00 00 00 00 ZZZ $352.22

56700 2 00 00 00 00 ZZZ $135.06

56700 8 00 00 00 00 ZZZ $27.01

56710 2 00 00 00 00 ZZZ $86.00

56710 8 00 00 00 00 ZZZ $17.00

56740 2 00 00 00 00 ZZZ $309.10

56740 8 00 00 00 00 ZZZ $61.82

56800 2 00 00 00 00 ZZZ $254.10

56800 8 00 00 00 00 ZZZ $50.82

56810 2 00 00 00 00 ZZZ $188.30

56810 8 00 00 00 00 ZZZ $37.66

56820 2 00 00 00 00 ZZZ $133.66

56820 8 00 00 00 00 ZZZ $26.73

56821 2 00 00 00 00 ZZZ $173.27

56821 8 00 00 00 00 ZZZ $34.65

57000 2 00 00 00 00 ZZZ $221.10

57000 8 00 00 00 00 ZZZ $44.22

57010 2 00 00 00 00 ZZZ $326.70

57010 8 00 00 00 00 ZZZ $65.34

57020 2 00 00 00 00 ZZZ $70.55

57020 8 00 00 00 00 ZZZ $14.11

57022 2 00 00 00 00 ZZZ $177.39

57022 8 00 00 00 00 ZZZ $35.48

57023 2 00 00 00 00 ZZZ $177.39

57023 8 00 00 00 00 ZZZ $35.48

57061 2 00 00 00 00 ZZZ $90.61

57061 8 00 00 00 00 ZZZ $18.12

57065 2 00 00 00 00 ZZZ $224.40

57065 8 00 00 00 00 ZZZ $44.88

57100 2 00 00 00 00 ZZZ $83.60

57100 8 00 00 00 00 ZZZ $16.72

57105 2 00 00 00 00 ZZZ $142.00

57105 8 00 00 00 00 ZZZ $28.00

57106 2 00 00 00 00 ZZZ $398.93

57106 8 00 00 00 00 ZZZ $79.79

57107 2 00 00 00 00 ZZZ $1,343.63

57107 8 00 00 00 00 ZZZ $268.73

57109 2 00 00 00 00 ZZZ $1,643.13

57109 8 00 00 00 00 ZZZ $328.63

57110 2 00 00 00 00 ZZZ $635.80

Page 230: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

57110 8 00 00 00 00 ZZZ $127.16

57111 2 00 00 00 00 ZZZ $1,627.87

57111 8 00 00 00 00 ZZZ $325.57

57112 2 00 00 00 00 ZZZ $1,733.60

57112 8 00 00 00 00 ZZZ $346.72

57120 2 00 00 00 00 ZZZ $445.50

57120 8 00 00 00 00 ZZZ $89.10

57130 2 00 00 00 00 ZZZ $291.98

57130 8 00 00 00 00 ZZZ $58.40

57135 2 00 00 00 00 ZZZ $194.70

57135 8 00 00 00 00 ZZZ $38.94

57150 2 00 00 00 00 ZZZ $39.60

57150 8 00 00 00 00 ZZZ $7.92

57155 2 00 00 00 00 ZZZ $436.05

57155 8 00 00 00 00 ZZZ $87.21

57156 2 00 00 00 00 ZZZ $191.05

57156 8 00 00 00 00 ZZZ $38.21

57160 2 00 00 00 00 ZZZ $45.11

57160 8 00 00 00 00 ZZZ $9.02

57180 2 00 00 00 00 ZZZ $90.61

57180 8 00 00 00 00 ZZZ $18.12

57200 2 00 00 00 00 ZZZ $186.73

57200 8 00 00 00 00 ZZZ $37.35

57210 2 00 00 00 00 ZZZ $381.70

57210 8 00 00 00 00 ZZZ $76.34

57220 2 00 00 00 00 ZZZ $381.70

57220 8 00 00 00 00 ZZZ $76.34

57230 2 00 00 00 00 ZZZ $381.70

57230 8 00 00 00 00 ZZZ $76.34

57240 2 00 00 00 00 ZZZ $407.00

57240 8 00 00 00 00 ZZZ $81.40

57250 2 00 00 00 00 ZZZ $388.30

57250 8 00 00 00 00 ZZZ $77.66

57260 2 00 00 00 00 ZZZ $569.80

57260 8 00 00 00 00 ZZZ $113.96

57265 2 00 00 00 00 ZZZ $744.70

57265 8 00 00 00 00 ZZZ $148.94

57267 2 00 00 00 00 ZZZ $349.22

57267 8 00 00 00 00 ZZZ $69.84

57268 2 00 00 00 00 ZZZ $443.30

Page 231: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

57268 8 00 00 00 00 ZZZ $88.66

57270 2 00 00 00 00 ZZZ $516.92

57270 8 00 00 00 00 ZZZ $103.38

57280 2 00 00 00 00 ZZZ $638.34

57280 8 00 00 00 00 ZZZ $127.67

57282 2 00 00 00 00 ZZZ $771.56

57282 8 00 00 00 00 ZZZ $154.31

57283 2 00 00 00 00 ZZZ $828.51

57283 8 00 00 00 00 ZZZ $165.70

57284 2 00 00 00 00 ZZZ $799.88

57284 8 00 00 00 00 ZZZ $159.98

57285 2 00 00 00 00 ZZZ $820.91

57285 8 00 00 00 00 ZZZ $164.18

57287 2 00 00 00 00 ZZZ $757.82

57287 8 00 00 00 00 ZZZ $151.56

57288 2 00 00 00 00 ZZZ $662.20

57288 8 00 00 00 00 ZZZ $132.44

57289 2 00 00 00 00 ZZZ $523.73

57289 8 00 00 00 00 ZZZ $104.75

57291 2 00 00 00 00 ZZZ $824.08

57291 8 00 00 00 00 ZZZ $164.82

57292 2 00 00 00 00 ZZZ $1,064.00

57292 8 00 00 00 00 ZZZ $213.00

57295 2 00 00 00 00 ZZZ $417.42

57295 8 00 00 00 00 ZZZ $83.48

57296 2 00 00 00 00 ZZZ $1,180.38

57296 8 00 00 00 00 ZZZ $236.08

57300 2 00 00 00 00 ZZZ $694.00

57300 8 00 00 00 00 ZZZ $138.00

57305 2 00 00 00 00 ZZZ $635.80

57305 8 00 00 00 00 ZZZ $127.16

57307 2 00 00 00 00 ZZZ $891.00

57307 8 00 00 00 00 ZZZ $178.20

57308 2 00 00 00 00 ZZZ $766.49

57308 8 00 00 00 00 ZZZ $153.30

57310 2 00 00 00 00 ZZZ $578.00

57310 8 00 00 00 00 ZZZ $116.00

57311 2 00 00 00 00 ZZZ $545.05

57311 8 00 00 00 00 ZZZ $109.01

57320 2 00 00 00 00 ZZZ $734.33

Page 232: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

57320 8 00 00 00 00 ZZZ $146.87

57330 2 00 00 00 00 ZZZ $763.40

57330 8 00 00 00 00 ZZZ $152.68

57335 2 00 00 00 00 ZZZ $1,061.78

57335 8 00 00 00 00 ZZZ $212.36

57400 2 00 00 00 00 ZZZ $84.19

57400 8 00 00 00 00 ZZZ $16.84

57410 2 00 00 00 00 ZZZ $127.60

57410 8 00 00 00 00 ZZZ $25.52

57415 2 00 00 00 00 ZZZ $127.60

57415 8 00 00 00 00 ZZZ $25.52

57420 2 00 00 00 00 ZZZ $139.44

57420 8 00 00 00 00 ZZZ $27.89

57421 2 00 00 00 00 ZZZ $181.92

57421 8 00 00 00 00 ZZZ $36.38

57423 2 00 00 00 00 ZZZ $1,146.24

57423 8 00 00 00 00 ZZZ $229.25

57425 2 00 00 00 00 ZZZ $996.68

57425 8 00 00 00 00 ZZZ $199.34

57426 2 00 00 00 00 ZZZ $1,121.58

57426 8 00 00 00 00 ZZZ $224.32

57452 2 00 00 00 00 ZZZ $102.10

57452 8 00 00 00 00 ZZZ $20.42

57454 2 00 00 00 00 ZZZ $149.00

57454 8 00 00 00 00 ZZZ $30.00

57455 2 00 00 00 00 ZZZ $167.49

57455 8 00 00 00 00 ZZZ $33.50

57456 2 00 00 00 00 ZZZ $158.41

57456 8 00 00 00 00 ZZZ $31.68

57460 2 00 00 00 00 ZZZ $238.00

57460 8 00 00 00 00 ZZZ $48.00

57461 2 00 00 00 00 ZZZ $372.92

57461 8 00 00 00 00 ZZZ $74.58

57500 2 00 00 00 00 ZZZ $62.70

57500 8 00 00 00 00 ZZZ $12.54

57505 2 00 00 00 00 ZZZ $108.90

57505 8 00 00 00 00 ZZZ $21.78

57510 2 00 00 00 00 ZZZ $112.20

57510 8 00 00 00 00 ZZZ $22.44

57511 2 00 00 00 00 ZZZ $101.20

Page 233: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

57511 8 00 00 00 00 ZZZ $20.24

57513 2 00 00 00 00 ZZZ $208.00

57513 8 00 00 00 00 ZZZ $42.00

57520 2 00 00 00 00 ZZZ $379.98

57520 8 00 00 00 00 ZZZ $76.00

57522 2 00 00 00 00 ZZZ $310.75

57522 8 00 00 00 00 ZZZ $62.15

57530 2 00 00 00 00 ZZZ $290.40

57530 8 00 00 00 00 ZZZ $58.08

57531 2 00 00 00 00 ZZZ $1,801.95

57531 8 00 00 00 00 ZZZ $360.39

57540 2 00 00 00 00 ZZZ $521.11

57540 8 00 00 00 00 ZZZ $104.22

57545 2 00 00 00 00 ZZZ $515.60

57545 8 00 00 00 00 ZZZ $103.12

57550 2 00 00 00 00 ZZZ $479.60

57550 8 00 00 00 00 ZZZ $95.92

57555 2 00 00 00 00 ZZZ $726.00

57555 8 00 00 00 00 ZZZ $145.20

57556 2 00 00 00 00 ZZZ $635.80

57556 8 00 00 00 00 ZZZ $127.16

57558 2 00 00 00 00 ZZZ $158.40

57558 8 00 00 00 00 ZZZ $31.68

57700 2 00 00 00 00 ZZZ $368.91

57700 8 00 00 00 00 ZZZ $73.78

57720 2 00 00 00 00 ZZZ $239.80

57720 8 00 00 00 00 ZZZ $47.96

57800 2 00 00 00 00 ZZZ $93.83

57800 8 00 00 00 00 ZZZ $18.77

58100 2 00 00 00 00 ZZZ $55.00

58100 8 00 00 00 00 ZZZ $11.00

58110 2 00 00 00 00 ZZZ $66.87

58110 8 00 00 00 00 ZZZ $13.37

58120 2 00 00 00 00 ZZZ $315.18

58120 8 00 00 00 00 ZZZ $63.04

58140 2 00 00 00 00 ZZZ $623.92

58140 8 00 00 00 00 ZZZ $124.78

58145 2 00 00 00 00 ZZZ $403.36

58145 8 00 00 00 00 ZZZ $80.67

58146 2 00 00 00 00 ZZZ $1,221.51

Page 234: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

58146 8 00 00 00 00 ZZZ $244.30

58150 2 00 00 00 00 ZZZ $1,107.70

58150 8 00 00 00 00 ZZZ $221.54

58152 2 00 00 00 00 ZZZ $1,403.00

58152 8 00 00 00 00 ZZZ $281.00

58180 2 00 00 00 00 ZZZ $1,181.40

58180 8 00 00 00 00 ZZZ $236.28

58200 2 00 00 00 00 ZZZ $1,125.30

58200 8 00 00 00 00 ZZZ $225.06

58210 2 00 00 00 00 ZZZ $2,204.38

58210 8 00 00 00 00 ZZZ $440.88

58240 2 00 00 00 00 ZZZ $2,894.45

58240 8 00 00 00 00 ZZZ $578.89

58260 2 00 00 00 00 ZZZ $1,007.00

58260 8 00 00 00 00 ZZZ $201.00

58262 2 00 00 00 00 ZZZ $1,087.27

58262 8 00 00 00 00 ZZZ $217.45

58263 2 00 00 00 00 ZZZ $1,186.58

58263 8 00 00 00 00 ZZZ $237.32

58267 2 00 00 00 00 ZZZ $1,500.71

58267 8 00 00 00 00 ZZZ $300.14

58270 2 00 00 00 00 ZZZ $1,122.00

58270 8 00 00 00 00 ZZZ $224.00

58275 2 00 00 00 00 ZZZ $1,234.00

58275 8 00 00 00 00 ZZZ $247.00

58280 2 00 00 00 00 ZZZ $1,358.00

58280 8 00 00 00 00 ZZZ $271.00

58285 2 00 00 00 00 ZZZ $1,309.53

58285 8 00 00 00 00 ZZZ $261.91

58290 2 00 00 00 00 ZZZ $1,221.11

58290 8 00 00 00 00 ZZZ $244.22

58291 2 00 00 00 00 ZZZ $1,342.79

58291 8 00 00 00 00 ZZZ $268.56

58292 2 00 00 00 00 ZZZ $1,422.42

58292 8 00 00 00 00 ZZZ $284.48

58293 2 00 00 00 00 ZZZ $1,477.71

58293 8 00 00 00 00 ZZZ $295.54

58294 2 00 00 00 00 ZZZ $1,309.80

58294 8 00 00 00 00 ZZZ $261.96

58300 8 00 00 00 00 ZZZ $14.40

Page 235: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

58300 A FP 00 00 00 ZZZ $101.20

58300 J 00 00 00 00 ZZZ $60.72

58301 8 00 00 00 00 ZZZ $8.00

58301 A FP 00 00 00 ZZZ $60.84

58301 J 00 00 00 00 ZZZ $36.50

58340 2 00 00 00 00 ZZZ $157.62

58340 8 00 00 00 00 ZZZ $31.52

58340 A FP 00 00 00 ZZZ $157.62

58340 J 00 00 00 00 ZZZ $64.58

58345 2 00 00 00 00 ZZZ $443.51

58345 8 00 00 00 00 ZZZ $88.70

58345 A FP 00 00 00 ZZZ $490.26

58345 J 00 00 00 00 ZZZ $294.16

58346 2 00 00 00 00 ZZZ $464.93

58346 8 00 00 00 00 ZZZ $92.99

58350 2 00 00 00 00 ZZZ $61.63

58350 8 00 00 00 00 ZZZ $12.33

58353 2 00 00 00 00 ZZZ $243.80

58353 8 00 00 00 00 ZZZ $48.76

58356 2 00 00 00 00 ZZZ $1,128.98

58356 8 00 00 00 00 ZZZ $225.80

58400 2 00 00 00 00 ZZZ $490.60

58400 8 00 00 00 00 ZZZ $98.12

58410 2 00 00 00 00 ZZZ $572.00

58410 8 00 00 00 00 ZZZ $114.40

58520 2 00 00 00 00 ZZZ $508.20

58520 8 00 00 00 00 ZZZ $101.64

58540 2 00 00 00 00 ZZZ $635.80

58540 8 00 00 00 00 ZZZ $127.16

58541 2 00 00 00 00 ZZZ $1,061.82

58541 8 00 00 00 00 ZZZ $212.36

58542 2 00 00 00 00 ZZZ $1,175.17

58542 8 00 00 00 00 ZZZ $235.03

58543 2 00 00 00 00 ZZZ $1,195.09

58543 8 00 00 00 00 ZZZ $239.02

58544 2 00 00 00 00 ZZZ $1,294.20

58544 8 00 00 00 00 ZZZ $258.84

58545 2 00 00 00 00 ZZZ $982.25

58545 8 00 00 00 00 ZZZ $196.45

58546 2 00 00 00 00 ZZZ $1,237.60

Page 236: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

58546 8 00 00 00 00 ZZZ $247.52

58548 2 00 00 00 00 ZZZ $2,066.10

58548 8 00 00 00 00 ZZZ $413.22

58550 2 00 00 00 00 ZZZ $894.38

58550 8 00 00 00 00 ZZZ $178.88

58552 2 00 00 00 00 ZZZ $956.67

58552 8 00 00 00 00 ZZZ $191.33

58553 2 00 00 00 00 ZZZ $1,229.35

58553 8 00 00 00 00 ZZZ $245.87

58554 2 00 00 00 00 ZZZ $1,216.57

58554 8 00 00 00 00 ZZZ $243.31

58555 2 00 00 00 00 ZZZ $252.05

58555 8 00 00 00 00 ZZZ $50.41

58558 2 00 00 00 00 ZZZ $337.46

58558 8 00 00 00 00 ZZZ $67.49

58559 2 00 00 00 00 ZZZ $373.34

58559 8 00 00 00 00 ZZZ $74.67

58560 2 00 00 00 00 ZZZ $423.26

58560 8 00 00 00 00 ZZZ $84.65

58561 2 00 00 00 00 ZZZ $604.36

58561 8 00 00 00 00 ZZZ $120.87

58562 2 00 00 00 00 ZZZ $314.35

58562 8 00 00 00 00 ZZZ $62.87

58563 2 00 00 00 00 ZZZ $372.52

58563 8 00 00 00 00 ZZZ $74.50

58565 A FP U1 00 00 ZZZ $1,461.12

58570 2 00 00 00 00 ZZZ $1,139.60

58570 8 00 00 00 00 ZZZ $227.92

58571 2 00 00 00 00 ZZZ $1,248.20

58571 8 00 00 00 00 ZZZ $249.64

58572 2 00 00 00 00 ZZZ $1,416.55

58572 8 00 00 00 00 ZZZ $283.31

58573 2 00 00 00 00 ZZZ $1,597.24

58573 8 00 00 00 00 ZZZ $319.45

58578 2 00 00 00 00 ZZZ $0.00

58578 8 00 00 00 00 ZZZ $0.00

58579 2 00 00 00 00 ZZZ $0.00

58579 8 00 00 00 00 ZZZ $0.00

58600 8 00 00 00 00 ZZZ $84.00

58600 A FP 00 00 00 ZZZ $422.00

Page 237: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

58600 J 00 00 00 00 ZZZ $422.00

58605 8 00 00 00 00 ZZZ $71.00

58605 A FP 00 00 00 ZZZ $353.00

58611 8 00 00 00 00 ZZZ $41.00

58611 A FP 00 00 00 ZZZ $205.00

58615 8 00 00 00 00 ZZZ $84.00

58615 A FP 00 00 00 ZZZ $422.00

58615 J 00 00 00 00 ZZZ $422.00

58660 2 00 00 00 00 ZZZ $727.30

58660 8 00 00 00 00 ZZZ $145.46

58661 2 00 00 00 00 ZZZ $695.53

58661 8 00 00 00 00 ZZZ $139.11

58661 A FP 00 00 00 ZZZ $695.53

58661 J 00 00 00 00 ZZZ $695.53

58662 2 00 00 00 00 ZZZ $739.67

58662 8 00 00 00 00 ZZZ $147.93

58670 A FP 00 00 00 ZZZ $383.24

58670 J 00 00 00 00 ZZZ $383.24

58671 A FP 00 00 00 ZZZ $383.66

58671 J 00 00 00 00 ZZZ $383.66

58672 2 00 00 00 00 ZZZ $828.37

58672 8 00 00 00 00 ZZZ $165.67

58673 2 00 00 00 00 ZZZ $889.83

58673 8 00 00 00 00 ZZZ $177.97

58679 2 00 00 00 00 ZZZ $0.00

58679 8 00 00 00 00 ZZZ $0.00

58700 2 00 00 00 00 ZZZ $464.20

58700 8 00 00 00 00 ZZZ $92.84

58700 A FP 00 00 00 ZZZ $464.20

58700 J 00 00 00 00 ZZZ $464.20

58720 2 00 00 00 00 ZZZ $817.30

58720 8 00 00 00 00 ZZZ $163.46

58740 2 00 00 00 00 ZZZ $594.00

58740 8 00 00 00 00 ZZZ $119.00

58750 2 00 00 00 00 ZZZ $909.59

58750 8 00 00 00 00 ZZZ $181.92

58752 2 00 00 00 00 ZZZ $826.10

58752 8 00 00 00 00 ZZZ $165.22

58760 2 00 00 00 00 ZZZ $775.09

58760 8 00 00 00 00 ZZZ $155.02

Page 238: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

58770 2 00 00 00 00 ZZZ $814.03

58770 8 00 00 00 00 ZZZ $162.81

58800 2 00 00 00 00 ZZZ $326.70

58800 8 00 00 00 00 ZZZ $65.34

58805 2 00 00 00 00 ZZZ $536.80

58805 8 00 00 00 00 ZZZ $107.36

58820 2 00 00 00 00 ZZZ $194.60

58820 8 00 00 00 00 ZZZ $38.92

58822 2 00 00 00 00 ZZZ $508.20

58822 8 00 00 00 00 ZZZ $101.64

58825 2 00 00 00 00 ZZZ $496.54

58825 8 00 00 00 00 ZZZ $99.31

58900 2 00 00 00 00 ZZZ $508.20

58900 8 00 00 00 00 ZZZ $101.64

58920 2 00 00 00 00 ZZZ $605.18

58920 8 00 00 00 00 ZZZ $121.04

58925 2 00 00 00 00 ZZZ $613.80

58925 8 00 00 00 00 ZZZ $122.76

58940 2 00 00 00 00 ZZZ $627.10

58940 8 00 00 00 00 ZZZ $125.42

58943 2 00 00 00 00 ZZZ $1,330.76

58943 8 00 00 00 00 ZZZ $266.15

58950 2 00 00 00 00 ZZZ $697.61

58950 8 00 00 00 00 ZZZ $139.52

58951 2 00 00 00 00 ZZZ $1,357.40

58951 8 00 00 00 00 ZZZ $271.48

58952 2 00 00 00 00 ZZZ $1,118.28

58952 8 00 00 00 00 ZZZ $223.66

58953 2 00 00 00 00 ZZZ $2,095.27

58953 8 00 00 00 00 ZZZ $419.05

58954 2 00 00 00 00 ZZZ $2,277.61

58954 8 00 00 00 00 ZZZ $455.52

58956 2 00 00 00 00 ZZZ $1,635.10

58956 8 00 00 00 00 ZZZ $327.02

58957 2 00 00 00 00 ZZZ $1,832.46

58957 8 00 00 00 00 ZZZ $366.49

58958 2 00 00 00 00 ZZZ $1,868.25

58958 8 00 00 00 00 ZZZ $373.65

58960 2 00 00 00 00 ZZZ $1,221.00

58960 8 00 00 00 00 ZZZ $244.20

Page 239: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

58999 2 00 00 00 00 ZZZ $0.00

58999 8 00 00 00 00 ZZZ $0.00

59000 2 00 00 00 00 ZZZ $112.20

59000 8 00 00 00 00 ZZZ $22.44

59001 2 00 00 00 00 ZZZ $189.77

59001 8 00 00 00 00 ZZZ $37.95

59012 2 00 00 00 00 ZZZ $263.32

59012 8 00 00 00 00 ZZZ $52.66

59015 2 00 00 00 00 ZZZ $144.40

59015 8 00 00 00 00 ZZZ $28.88

59020 2 00 00 00 00 ZZZ $112.00

59020 8 00 00 00 00 ZZZ $22.40

59025 2 00 00 00 00 ZZZ $68.77

59025 8 00 00 00 00 ZZZ $13.75

59030 2 00 00 00 00 ZZZ $92.58

59030 8 00 00 00 00 ZZZ $18.52

59050 1 00 00 00 00 ZZZ $14.08

59050 2 00 00 00 00 ZZZ $61.60

59050 8 00 00 00 00 ZZZ $12.32

59051 2 00 00 00 00 ZZZ $67.14

59070 2 00 00 00 00 ZZZ $438.93

59070 8 00 00 00 00 ZZZ $87.79

59074 2 00 00 00 00 ZZZ $417.90

59074 8 00 00 00 00 ZZZ $83.58

59076 2 00 00 00 00 ZZZ $528.04

59076 8 00 00 00 00 ZZZ $105.61

59100 2 00 00 00 00 ZZZ $572.00

59100 8 00 00 00 00 ZZZ $114.40

59120 2 00 00 00 00 ZZZ $664.40

59120 8 00 00 00 00 ZZZ $132.88

59121 2 00 00 00 00 ZZZ $664.40

59121 8 00 00 00 00 ZZZ $132.88

59130 2 00 00 00 00 ZZZ $635.80

59130 8 00 00 00 00 ZZZ $127.16

59135 2 00 00 00 00 ZZZ $990.99

59135 8 00 00 00 00 ZZZ $198.20

59136 2 00 00 00 00 ZZZ $831.72

59136 8 00 00 00 00 ZZZ $166.34

59140 2 00 00 00 00 ZZZ $381.70

59140 8 00 00 00 00 ZZZ $76.34

Page 240: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

59150 2 00 00 00 00 ZZZ $441.10

59150 8 00 00 00 00 ZZZ $88.22

59151 2 00 00 00 00 ZZZ $441.10

59151 8 00 00 00 00 ZZZ $88.22

59160 2 00 00 00 00 ZZZ $192.50

59160 8 00 00 00 00 ZZZ $38.50

59300 2 00 00 00 00 ZZZ $106.74

59300 8 00 00 00 00 ZZZ $21.35

59320 2 00 00 00 00 ZZZ $259.93

59320 8 00 00 00 00 ZZZ $51.99

59325 2 00 00 00 00 ZZZ $335.22

59325 8 00 00 00 00 ZZZ $67.04

59350 2 00 00 00 00 ZZZ $495.00

59350 8 00 00 00 00 ZZZ $99.00

59400 2 00 00 00 00 ZZZ $1,210.00

59400 8 00 00 00 00 ZZZ $242.00

59409 2 00 00 00 00 ZZZ $653.40

59409 8 00 00 00 00 ZZZ $130.68

59410 2 00 00 00 00 ZZZ $669.55

59410 8 00 00 00 00 ZZZ $133.91

59412 2 00 00 00 00 ZZZ $88.00

59412 8 00 00 00 00 ZZZ $17.60

59414 2 00 00 00 00 ZZZ $177.17

59414 8 00 00 00 00 ZZZ $35.43

59425 1 00 00 00 00 ZZZ $28.60

59425 1 UA 00 00 00 ZZZ $28.60

59426 1 00 00 00 00 ZZZ $28.60

59510 2 00 00 00 00 ZZZ $1,230.26

59510 8 00 00 00 00 ZZZ $246.05

59514 2 00 00 00 00 ZZZ $714.92

59514 8 00 00 00 00 ZZZ $142.98

59515 2 00 00 00 00 ZZZ $990.00

59515 8 00 00 00 00 ZZZ $198.00

59525 2 00 00 00 00 ZZZ $783.28

59525 8 00 00 00 00 ZZZ $156.66

59610 2 00 00 00 00 ZZZ $1,525.41

59610 8 00 00 00 00 ZZZ $305.08

59612 2 00 00 00 00 ZZZ $983.92

59612 8 00 00 00 00 ZZZ $196.78

59614 2 00 00 00 00 ZZZ $1,065.32

Page 241: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

59614 8 00 00 00 00 ZZZ $213.06

59618 2 00 00 00 00 ZZZ $1,713.00

59618 8 00 00 00 00 ZZZ $342.60

59620 2 00 00 00 00 ZZZ $1,132.56

59620 8 00 00 00 00 ZZZ $226.51

59622 2 00 00 00 00 ZZZ $1,213.96

59622 8 00 00 00 00 ZZZ $242.79

59812 2 00 00 00 00 ZZZ $420.00

59812 8 00 00 00 00 ZZZ $84.00

59820 2 00 00 00 00 ZZZ $412.16

59820 8 00 00 00 00 ZZZ $82.43

59821 2 00 00 00 00 ZZZ $523.35

59821 8 00 00 00 00 ZZZ $105.00

59830 2 00 00 00 00 ZZZ $471.09

59830 8 00 00 00 00 ZZZ $94.22

59840 2 00 00 00 00 ZZZ $298.10

59840 8 00 00 00 00 ZZZ $59.62

59841 2 00 00 00 00 ZZZ $365.20

59841 8 00 00 00 00 ZZZ $73.04

59850 2 00 00 00 00 ZZZ $366.30

59850 8 00 00 00 00 ZZZ $73.26

59851 2 00 00 00 00 ZZZ $396.00

59851 8 00 00 00 00 ZZZ $79.20

59852 2 00 00 00 00 ZZZ $544.50

59852 8 00 00 00 00 ZZZ $108.90

59855 2 00 00 00 00 ZZZ $372.33

59855 8 00 00 00 00 ZZZ $74.47

59856 2 00 00 00 00 ZZZ $562.03

59856 8 00 00 00 00 ZZZ $112.41

59857 2 00 00 00 00 ZZZ $683.78

59857 8 00 00 00 00 ZZZ $136.76

59866 2 00 00 00 00 ZZZ $310.04

59866 8 00 00 00 00 ZZZ $62.01

59870 2 00 00 00 00 ZZZ $368.79

59870 8 00 00 00 00 ZZZ $73.76

59871 2 00 00 00 00 ZZZ $178.21

59871 8 00 00 00 00 ZZZ $35.64

59897 2 00 00 00 00 ZZZ $0.00

59897 8 00 00 00 00 ZZZ $0.00

59899 2 00 00 00 00 ZZZ $0.00

Page 242: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

59899 8 00 00 00 00 ZZZ $0.00

60000 2 00 00 00 00 ZZZ $85.23

60000 8 00 00 00 00 ZZZ $17.05

60100 2 00 00 00 00 ZZZ $68.98

60100 8 00 00 00 00 ZZZ $13.80

60200 2 00 00 00 00 ZZZ $482.90

60200 8 00 00 00 00 ZZZ $96.58

60210 2 00 00 00 00 ZZZ $870.66

60210 8 00 00 00 00 ZZZ $174.13

60212 2 00 00 00 00 ZZZ $1,097.17

60212 8 00 00 00 00 ZZZ $219.43

60220 2 00 00 00 00 ZZZ $834.90

60220 8 00 00 00 00 ZZZ $166.98

60225 2 00 00 00 00 ZZZ $907.50

60225 8 00 00 00 00 ZZZ $181.50

60240 2 00 00 00 00 ZZZ $980.10

60240 8 00 00 00 00 ZZZ $196.02

60252 2 00 00 00 00 ZZZ $1,052.70

60252 8 00 00 00 00 ZZZ $210.54

60254 2 00 00 00 00 ZZZ $1,325.50

60254 8 00 00 00 00 ZZZ $265.10

60260 2 00 00 00 00 ZZZ $661.10

60260 8 00 00 00 00 ZZZ $132.22

60270 2 00 00 00 00 ZZZ $875.16

60270 8 00 00 00 00 ZZZ $175.03

60271 2 00 00 00 00 ZZZ $1,192.73

60271 8 00 00 00 00 ZZZ $238.55

60280 2 00 00 00 00 ZZZ $578.60

60280 8 00 00 00 00 ZZZ $115.72

60281 2 00 00 00 00 ZZZ $429.00

60281 8 00 00 00 00 ZZZ $85.80

60300 2 00 00 00 00 ZZZ $97.96

60300 8 00 00 00 00 ZZZ $19.59

60500 2 00 00 00 00 ZZZ $871.20

60500 8 00 00 00 00 ZZZ $174.24

60502 2 00 00 00 00 ZZZ $879.36

60502 8 00 00 00 00 ZZZ $175.87

60505 2 00 00 00 00 ZZZ $1,125.30

60505 8 00 00 00 00 ZZZ $225.06

60512 2 00 00 00 00 ZZZ $305.09

Page 243: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

60512 8 00 00 00 00 ZZZ $61.02

60520 2 00 00 00 00 ZZZ $889.90

60520 8 00 00 00 00 ZZZ $177.98

60521 2 00 00 00 00 ZZZ $1,412.16

60521 8 00 00 00 00 ZZZ $282.43

60522 2 00 00 00 00 ZZZ $1,578.51

60522 8 00 00 00 00 ZZZ $315.70

60540 2 00 00 00 00 ZZZ $1,125.30

60540 8 00 00 00 00 ZZZ $225.06

60545 2 00 00 00 00 ZZZ $1,125.30

60545 8 00 00 00 00 ZZZ $225.06

60600 2 00 00 00 00 ZZZ $880.15

60600 8 00 00 00 00 ZZZ $176.03

60605 2 00 00 00 00 ZZZ $1,721.36

60605 8 00 00 00 00 ZZZ $344.27

60650 2 00 00 00 00 ZZZ $1,256.20

60650 8 00 00 00 00 ZZZ $251.24

60659 2 00 00 00 00 ZZZ $0.00

60659 8 00 00 00 00 ZZZ $0.00

60699 2 00 00 00 00 ZZZ $0.00

60699 8 00 00 00 00 ZZZ $0.00

61000 2 00 00 00 00 ZZZ $83.60

61000 8 00 00 00 00 ZZZ $16.72

61001 2 00 00 00 00 ZZZ $83.60

61001 8 00 00 00 00 ZZZ $16.72

61020 2 00 00 00 00 ZZZ $97.90

61020 8 00 00 00 00 ZZZ $19.58

61026 2 00 00 00 00 ZZZ $108.90

61026 8 00 00 00 00 ZZZ $21.78

61050 2 00 00 00 00 ZZZ $83.60

61050 8 00 00 00 00 ZZZ $16.72

61055 2 00 00 00 00 ZZZ $170.50

61055 8 00 00 00 00 ZZZ $34.10

61070 2 00 00 00 00 ZZZ $117.23

61070 8 00 00 00 00 ZZZ $23.45

61105 2 00 00 00 00 ZZZ $381.70

61105 8 00 00 00 00 ZZZ $76.34

61107 2 00 00 00 00 ZZZ $381.70

61107 8 00 00 00 00 ZZZ $76.34

61108 2 00 00 00 00 ZZZ $571.46

Page 244: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61108 8 00 00 00 00 ZZZ $114.29

61120 2 00 00 00 00 ZZZ $436.92

61120 8 00 00 00 00 ZZZ $87.38

61140 2 00 00 00 00 ZZZ $926.20

61140 8 00 00 00 00 ZZZ $185.24

61150 2 00 00 00 00 ZZZ $1,071.40

61150 8 00 00 00 00 ZZZ $214.28

61151 2 00 00 00 00 ZZZ $530.03

61151 8 00 00 00 00 ZZZ $106.01

61154 2 00 00 00 00 ZZZ $1,144.00

61154 8 00 00 00 00 ZZZ $228.80

61156 2 00 00 00 00 ZZZ $1,197.90

61156 8 00 00 00 00 ZZZ $239.58

61210 2 00 00 00 00 ZZZ $468.60

61210 8 00 00 00 00 ZZZ $93.72

61215 2 00 00 00 00 ZZZ $548.91

61215 8 00 00 00 00 ZZZ $109.78

61250 2 00 00 00 00 ZZZ $834.90

61250 8 00 00 00 00 ZZZ $166.98

61253 2 00 00 00 00 ZZZ $1,104.06

61253 8 00 00 00 00 ZZZ $220.81

61304 2 00 00 00 00 ZZZ $1,851.30

61304 8 00 00 00 00 ZZZ $370.26

61305 2 00 00 00 00 ZZZ $2,214.30

61305 8 00 00 00 00 ZZZ $442.86

61312 2 00 00 00 00 ZZZ $2,286.90

61312 8 00 00 00 00 ZZZ $457.38

61313 2 00 00 00 00 ZZZ $1,315.49

61313 8 00 00 00 00 ZZZ $263.10

61314 2 00 00 00 00 ZZZ $1,311.30

61314 8 00 00 00 00 ZZZ $262.26

61315 2 00 00 00 00 ZZZ $1,492.70

61315 8 00 00 00 00 ZZZ $298.54

61316 2 00 00 00 00 ZZZ $98.59

61316 8 00 00 00 00 ZZZ $19.72

61320 2 00 00 00 00 ZZZ $1,633.50

61320 8 00 00 00 00 ZZZ $326.70

61321 2 00 00 00 00 ZZZ $1,633.50

61321 8 00 00 00 00 ZZZ $326.70

61322 2 00 00 00 00 ZZZ $1,995.42

Page 245: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61322 8 00 00 00 00 ZZZ $399.08

61323 2 00 00 00 00 ZZZ $2,065.56

61323 8 00 00 00 00 ZZZ $413.11

61330 2 00 00 00 00 ZZZ $1,325.50

61330 8 00 00 00 00 ZZZ $265.10

61332 2 00 00 00 00 ZZZ $1,452.00

61332 8 00 00 00 00 ZZZ $290.40

61333 2 00 00 00 00 ZZZ $2,178.00

61333 8 00 00 00 00 ZZZ $435.60

61340 2 00 00 00 00 ZZZ $980.10

61340 8 00 00 00 00 ZZZ $196.02

61343 2 00 00 00 00 ZZZ $1,592.97

61343 8 00 00 00 00 ZZZ $318.59

61345 2 00 00 00 00 ZZZ $1,346.18

61345 8 00 00 00 00 ZZZ $269.24

61450 2 00 00 00 00 ZZZ $1,524.60

61450 8 00 00 00 00 ZZZ $304.92

61458 2 00 00 00 00 ZZZ $1,906.30

61458 8 00 00 00 00 ZZZ $381.26

61460 2 00 00 00 00 ZZZ $1,942.60

61460 8 00 00 00 00 ZZZ $388.52

61480 2 00 00 00 00 ZZZ $1,887.60

61480 8 00 00 00 00 ZZZ $377.52

61500 2 00 00 00 00 ZZZ $1,180.30

61500 8 00 00 00 00 ZZZ $236.06

61501 2 00 00 00 00 ZZZ $806.71

61501 8 00 00 00 00 ZZZ $161.34

61510 2 00 00 00 00 ZZZ $2,613.60

61510 8 00 00 00 00 ZZZ $522.72

61512 2 00 00 00 00 ZZZ $2,214.30

61512 8 00 00 00 00 ZZZ $442.86

61514 2 00 00 00 00 ZZZ $1,923.90

61514 8 00 00 00 00 ZZZ $384.78

61516 2 00 00 00 00 ZZZ $1,923.90

61516 8 00 00 00 00 ZZZ $384.78

61517 2 00 00 00 00 ZZZ $83.34

61517 8 00 00 00 00 ZZZ $16.67

61518 2 00 00 00 00 ZZZ $2,414.50

61518 8 00 00 00 00 ZZZ $482.90

61519 2 00 00 00 00 ZZZ $2,305.60

Page 246: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61519 8 00 00 00 00 ZZZ $461.12

61520 2 00 00 00 00 ZZZ $2,591.91

61520 8 00 00 00 00 ZZZ $518.38

61521 2 00 00 00 00 ZZZ $2,185.94

61521 8 00 00 00 00 ZZZ $437.19

61522 2 00 00 00 00 ZZZ $1,923.90

61522 8 00 00 00 00 ZZZ $384.78

61524 2 00 00 00 00 ZZZ $1,923.90

61524 8 00 00 00 00 ZZZ $384.78

61526 2 00 00 00 00 ZZZ $2,426.95

61526 8 00 00 00 00 ZZZ $485.39

61530 2 00 00 00 00 ZZZ $2,152.11

61530 8 00 00 00 00 ZZZ $430.42

61531 2 00 00 00 00 ZZZ $1,224.59

61531 8 00 00 00 00 ZZZ $244.92

61533 2 00 00 00 00 ZZZ $1,585.58

61533 8 00 00 00 00 ZZZ $317.12

61534 2 00 00 00 00 ZZZ $1,626.25

61534 8 00 00 00 00 ZZZ $325.25

61535 2 00 00 00 00 ZZZ $789.25

61535 8 00 00 00 00 ZZZ $157.85

61536 2 00 00 00 00 ZZZ $2,359.50

61536 8 00 00 00 00 ZZZ $471.90

61537 2 00 00 00 00 ZZZ $1,893.53

61537 8 00 00 00 00 ZZZ $378.71

61538 2 00 00 00 00 ZZZ $2,015.20

61538 8 00 00 00 00 ZZZ $403.04

61539 2 00 00 00 00 ZZZ $2,015.20

61539 8 00 00 00 00 ZZZ $403.04

61540 2 00 00 00 00 ZZZ $2,286.27

61540 8 00 00 00 00 ZZZ $457.25

61541 2 00 00 00 00 ZZZ $1,408.34

61541 8 00 00 00 00 ZZZ $281.67

61543 2 00 00 00 00 ZZZ $1,939.51

61543 8 00 00 00 00 ZZZ $387.90

61544 2 00 00 00 00 ZZZ $1,724.80

61544 8 00 00 00 00 ZZZ $344.96

61545 2 00 00 00 00 ZZZ $2,070.54

61545 8 00 00 00 00 ZZZ $414.11

61546 2 00 00 00 00 ZZZ $1,870.00

Page 247: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61546 8 00 00 00 00 ZZZ $374.00

61548 2 00 00 00 00 ZZZ $2,032.80

61548 8 00 00 00 00 ZZZ $406.56

61550 2 00 00 00 00 ZZZ $1,197.90

61550 8 00 00 00 00 ZZZ $239.58

61552 2 00 00 00 00 ZZZ $1,549.78

61552 8 00 00 00 00 ZZZ $309.96

61556 2 00 00 00 00 ZZZ $1,271.60

61556 8 00 00 00 00 ZZZ $254.32

61557 2 00 00 00 00 ZZZ $1,271.60

61557 8 00 00 00 00 ZZZ $254.32

61558 2 00 00 00 00 ZZZ $1,271.60

61558 8 00 00 00 00 ZZZ $254.32

61559 2 00 00 00 00 ZZZ $1,609.23

61559 8 00 00 00 00 ZZZ $321.85

61563 2 00 00 00 00 ZZZ $1,296.61

61563 8 00 00 00 00 ZZZ $259.32

61564 2 00 00 00 00 ZZZ $1,548.12

61564 8 00 00 00 00 ZZZ $309.62

61566 2 00 00 00 00 ZZZ $2,263.16

61566 8 00 00 00 00 ZZZ $452.63

61567 2 00 00 00 00 ZZZ $2,585.36

61567 8 00 00 00 00 ZZZ $517.07

61570 2 00 00 00 00 ZZZ $1,851.30

61570 8 00 00 00 00 ZZZ $370.26

61571 2 00 00 00 00 ZZZ $1,870.00

61571 8 00 00 00 00 ZZZ $374.00

61575 2 00 00 00 00 ZZZ $1,783.11

61575 8 00 00 00 00 ZZZ $356.62

61576 2 00 00 00 00 ZZZ $2,375.29

61576 8 00 00 00 00 ZZZ $475.06

61580 2 00 00 00 00 ZZZ $2,487.10

61580 8 00 00 00 00 ZZZ $497.42

61581 2 00 00 00 00 ZZZ $2,813.80

61581 8 00 00 00 00 ZZZ $562.76

61582 2 00 00 00 00 ZZZ $2,559.70

61582 8 00 00 00 00 ZZZ $511.94

61583 2 00 00 00 00 ZZZ $2,922.70

61583 8 00 00 00 00 ZZZ $584.54

61584 2 00 00 00 00 ZZZ $2,831.40

Page 248: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61584 8 00 00 00 00 ZZZ $566.28

61585 2 00 00 00 00 ZZZ $3,158.10

61585 8 00 00 00 00 ZZZ $631.62

61586 2 00 00 00 00 ZZZ $1,950.12

61586 8 00 00 00 00 ZZZ $390.02

61590 2 00 00 00 00 ZZZ $3,430.90

61590 8 00 00 00 00 ZZZ $686.18

61591 2 00 00 00 00 ZZZ $3,593.70

61591 8 00 00 00 00 ZZZ $718.74

61592 2 00 00 00 00 ZZZ $3,267.00

61592 8 00 00 00 00 ZZZ $653.40

61595 2 00 00 00 00 ZZZ $2,414.50

61595 8 00 00 00 00 ZZZ $482.90

61596 2 00 00 00 00 ZZZ $2,940.30

61596 8 00 00 00 00 ZZZ $588.06

61597 2 00 00 00 00 ZZZ $3,104.20

61597 8 00 00 00 00 ZZZ $620.84

61598 2 00 00 00 00 ZZZ $2,722.50

61598 8 00 00 00 00 ZZZ $544.50

61600 2 00 00 00 00 ZZZ $2,087.80

61600 8 00 00 00 00 ZZZ $417.56

61601 2 00 00 00 00 ZZZ $2,250.60

61601 8 00 00 00 00 ZZZ $450.12

61605 2 00 00 00 00 ZZZ $2,359.50

61605 8 00 00 00 00 ZZZ $471.90

61606 2 00 00 00 00 ZZZ $3,176.80

61606 8 00 00 00 00 ZZZ $635.36

61607 2 00 00 00 00 ZZZ $2,959.00

61607 8 00 00 00 00 ZZZ $591.80

61608 2 00 00 00 00 ZZZ $3,448.50

61608 8 00 00 00 00 ZZZ $689.70

61610 2 00 00 00 00 ZZZ $2,015.20

61610 8 00 00 00 00 ZZZ $403.04

61611 2 00 00 00 00 ZZZ $500.50

61611 8 00 00 00 00 ZZZ $100.10

61612 2 00 00 00 00 ZZZ $1,322.58

61612 8 00 00 00 00 ZZZ $264.52

61613 2 00 00 00 00 ZZZ $3,375.90

61613 8 00 00 00 00 ZZZ $675.18

61615 2 00 00 00 00 ZZZ $2,613.60

Page 249: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61615 8 00 00 00 00 ZZZ $522.72

61616 2 00 00 00 00 ZZZ $3,539.80

61616 8 00 00 00 00 ZZZ $707.96

61618 2 00 00 00 00 ZZZ $1,343.10

61618 8 00 00 00 00 ZZZ $268.62

61619 2 00 00 00 00 ZZZ $1,669.80

61619 8 00 00 00 00 ZZZ $333.96

61623 2 00 00 00 00 ZZZ $606.01

61623 8 00 00 00 00 ZZZ $121.20

61624 2 00 00 00 00 ZZZ $1,550.84

61624 8 00 00 00 00 ZZZ $310.17

61626 2 00 00 00 00 ZZZ $1,290.22

61626 8 00 00 00 00 ZZZ $258.04

61630 2 00 00 00 00 ZZZ $1,725.68

61630 8 00 00 00 00 ZZZ $345.14

61635 2 00 00 00 00 ZZZ $1,836.79

61635 8 00 00 00 00 ZZZ $367.36

61640 2 00 00 00 00 ZZZ $0.00

61640 8 00 00 00 00 ZZZ $0.00

61641 2 00 00 00 00 ZZZ $276.63

61641 8 00 00 00 00 ZZZ $55.33

61642 2 00 00 00 00 ZZZ $0.00

61642 8 00 00 00 00 ZZZ $0.00

61680 2 00 00 00 00 ZZZ $1,644.11

61680 8 00 00 00 00 ZZZ $328.82

61682 2 00 00 00 00 ZZZ $4,172.77

61682 8 00 00 00 00 ZZZ $834.55

61684 2 00 00 00 00 ZZZ $1,991.60

61684 8 00 00 00 00 ZZZ $398.32

61686 2 00 00 00 00 ZZZ $3,015.73

61686 8 00 00 00 00 ZZZ $603.15

61690 2 00 00 00 00 ZZZ $1,523.47

61690 8 00 00 00 00 ZZZ $304.69

61692 2 00 00 00 00 ZZZ $2,388.40

61692 8 00 00 00 00 ZZZ $477.68

61697 2 00 00 00 00 ZZZ $3,624.13

61697 8 00 00 00 00 ZZZ $724.83

61698 2 00 00 00 00 ZZZ $3,488.40

61698 8 00 00 00 00 ZZZ $697.68

61700 2 00 00 00 00 ZZZ $3,049.20

Page 250: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61700 8 00 00 00 00 ZZZ $609.84

61702 2 00 00 00 00 ZZZ $2,395.22

61702 8 00 00 00 00 ZZZ $479.04

61703 2 00 00 00 00 ZZZ $1,180.30

61703 8 00 00 00 00 ZZZ $236.06

61705 2 00 00 00 00 ZZZ $1,813.79

61705 8 00 00 00 00 ZZZ $362.76

61708 2 00 00 00 00 ZZZ $2,141.70

61708 8 00 00 00 00 ZZZ $428.34

61710 2 00 00 00 00 ZZZ $1,268.82

61710 8 00 00 00 00 ZZZ $253.76

61711 2 00 00 00 00 ZZZ $1,877.52

61711 8 00 00 00 00 ZZZ $375.50

61720 2 00 00 00 00 ZZZ $1,650.95

61720 8 00 00 00 00 ZZZ $330.19

61735 2 00 00 00 00 ZZZ $1,762.86

61735 8 00 00 00 00 ZZZ $352.57

61750 2 00 00 00 00 ZZZ $906.37

61750 8 00 00 00 00 ZZZ $181.27

61751 2 00 00 00 00 ZZZ $1,670.53

61751 8 00 00 00 00 ZZZ $334.11

61760 2 00 00 00 00 ZZZ $1,271.60

61760 8 00 00 00 00 ZZZ $254.32

61770 2 00 00 00 00 ZZZ $1,200.10

61770 8 00 00 00 00 ZZZ $240.02

61781 2 00 00 00 00 ZZZ $307.42

61781 8 00 00 00 00 ZZZ $61.48

61782 2 00 00 00 00 ZZZ $253.87

61782 8 00 00 00 00 ZZZ $50.77

61783 2 00 00 00 00 ZZZ $269.01

61783 8 00 00 00 00 ZZZ $53.80

61790 2 00 00 00 00 ZZZ $744.70

61790 8 00 00 00 00 ZZZ $148.94

61791 2 00 00 00 00 ZZZ $718.33

61791 8 00 00 00 00 ZZZ $143.67

61796 2 00 00 00 00 ZZZ $961.76

61796 8 00 00 00 00 ZZZ $192.35

61797 2 00 00 00 00 ZZZ $262.73

61797 8 00 00 00 00 ZZZ $52.55

61798 2 00 00 00 00 ZZZ $961.76

Page 251: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

61798 8 00 00 00 00 ZZZ $192.35

61799 2 00 00 00 00 ZZZ $363.27

61799 8 00 00 00 00 ZZZ $72.65

61800 2 00 00 00 00 ZZZ $186.38

61800 8 00 00 00 00 ZZZ $37.28

61850 2 00 00 00 00 ZZZ $737.00

61850 8 00 00 00 00 ZZZ $147.40

61860 2 00 00 00 00 ZZZ $945.71

61860 8 00 00 00 00 ZZZ $189.14

61863 2 00 00 00 00 ZZZ $1,360.13

61863 8 00 00 00 00 ZZZ $272.03

61864 2 00 00 00 00 ZZZ $326.32

61864 8 00 00 00 00 ZZZ $65.26

61867 2 00 00 00 00 ZZZ $2,058.13

61867 8 00 00 00 00 ZZZ $411.63

61868 2 00 00 00 00 ZZZ $542.49

61868 8 00 00 00 00 ZZZ $108.50

61870 2 00 00 00 00 ZZZ $851.40

61870 8 00 00 00 00 ZZZ $170.28

61880 2 00 00 00 00 ZZZ $670.00

61880 8 00 00 00 00 ZZZ $134.00

61885 2 00 00 00 00 ZZZ $432.30

61885 8 00 00 00 00 ZZZ $86.46

61886 2 00 00 00 00 ZZZ $635.71

61886 8 00 00 00 00 ZZZ $127.14

61888 2 00 00 00 00 ZZZ $430.81

61888 8 00 00 00 00 ZZZ $86.16

62000 2 00 00 00 00 ZZZ $898.45

62000 8 00 00 00 00 ZZZ $179.69

62005 2 00 00 00 00 ZZZ $1,107.70

62005 8 00 00 00 00 ZZZ $221.54

62010 2 00 00 00 00 ZZZ $1,306.80

62010 8 00 00 00 00 ZZZ $261.36

62100 2 00 00 00 00 ZZZ $1,379.40

62100 8 00 00 00 00 ZZZ $275.88

62115 2 00 00 00 00 ZZZ $1,175.90

62115 8 00 00 00 00 ZZZ $235.18

62117 2 00 00 00 00 ZZZ $1,317.86

62117 8 00 00 00 00 ZZZ $263.57

62120 2 00 00 00 00 ZZZ $1,325.50

Page 252: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

62120 8 00 00 00 00 ZZZ $265.10

62121 2 00 00 00 00 ZZZ $1,281.50

62121 8 00 00 00 00 ZZZ $256.30

62140 2 00 00 00 00 ZZZ $962.50

62140 8 00 00 00 00 ZZZ $192.50

62141 2 00 00 00 00 ZZZ $1,107.70

62141 8 00 00 00 00 ZZZ $221.54

62142 2 00 00 00 00 ZZZ $629.20

62142 8 00 00 00 00 ZZZ $125.84

62143 2 00 00 00 00 ZZZ $653.03

62143 8 00 00 00 00 ZZZ $130.61

62145 2 00 00 00 00 ZZZ $1,366.16

62145 8 00 00 00 00 ZZZ $273.23

62146 2 00 00 00 00 ZZZ $1,271.60

62146 8 00 00 00 00 ZZZ $254.32

62147 2 00 00 00 00 ZZZ $1,463.00

62147 8 00 00 00 00 ZZZ $292.60

62148 2 00 00 00 00 ZZZ $134.07

62148 8 00 00 00 00 ZZZ $26.81

62160 2 00 00 00 00 ZZZ $193.07

62160 8 00 00 00 00 ZZZ $38.61

62161 2 00 00 00 00 ZZZ $1,378.28

62161 8 00 00 00 00 ZZZ $275.66

62162 2 00 00 00 00 ZZZ $1,770.19

62162 8 00 00 00 00 ZZZ $354.04

62163 2 00 00 00 00 ZZZ $1,120.86

62163 8 00 00 00 00 ZZZ $224.17

62164 2 00 00 00 00 ZZZ $1,913.75

62164 8 00 00 00 00 ZZZ $382.75

62165 2 00 00 00 00 ZZZ $1,497.91

62165 8 00 00 00 00 ZZZ $299.58

62180 2 00 00 00 00 ZZZ $1,361.80

62180 8 00 00 00 00 ZZZ $272.36

62190 2 00 00 00 00 ZZZ $1,096.13

62190 8 00 00 00 00 ZZZ $219.23

62192 2 00 00 00 00 ZZZ $1,052.70

62192 8 00 00 00 00 ZZZ $210.54

62194 2 00 00 00 00 ZZZ $265.10

62194 8 00 00 00 00 ZZZ $53.02

62200 2 00 00 00 00 ZZZ $1,434.40

Page 253: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

62200 8 00 00 00 00 ZZZ $286.88

62201 2 00 00 00 00 ZZZ $1,089.00

62201 8 00 00 00 00 ZZZ $217.80

62220 2 00 00 00 00 ZZZ $1,197.90

62220 8 00 00 00 00 ZZZ $239.58

62223 2 00 00 00 00 ZZZ $1,107.70

62223 8 00 00 00 00 ZZZ $221.54

62225 2 00 00 00 00 ZZZ $291.11

62225 8 00 00 00 00 ZZZ $58.22

62230 2 00 00 00 00 ZZZ $557.30

62230 8 00 00 00 00 ZZZ $111.46

62252 2 00 00 00 00 ZZZ $89.94

62252 8 00 00 00 00 ZZZ $17.99

62256 2 00 00 00 00 ZZZ $421.30

62256 8 00 00 00 00 ZZZ $84.26

62258 2 00 00 00 00 ZZZ $980.10

62258 8 00 00 00 00 ZZZ $196.02

62263 2 00 00 00 00 ZZZ $474.83

62263 8 00 00 00 00 ZZZ $94.97

62264 2 00 00 00 00 ZZZ $0.00

62264 8 00 00 00 00 ZZZ $0.00

62267 2 00 00 00 00 ZZZ $313.47

62267 8 00 00 00 00 ZZZ $62.69

62268 2 00 00 00 00 ZZZ $204.83

62268 8 00 00 00 00 ZZZ $40.97

62269 2 00 00 00 00 ZZZ $192.24

62269 8 00 00 00 00 ZZZ $38.45

62270 2 00 00 00 00 ZZZ $108.90

62270 8 00 00 00 00 ZZZ $21.78

62272 2 00 00 00 00 ZZZ $108.90

62272 8 00 00 00 00 ZZZ $21.78

62273 2 00 00 00 00 ZZZ $163.65

62273 8 00 00 00 00 ZZZ $32.73

62280 2 00 00 00 00 ZZZ $141.90

62280 8 00 00 00 00 ZZZ $28.38

62281 2 00 00 00 00 ZZZ $141.90

62281 8 00 00 00 00 ZZZ $28.38

62282 2 00 00 00 00 ZZZ $158.67

62282 8 00 00 00 00 ZZZ $31.73

62284 2 00 00 00 00 ZZZ $192.50

Page 254: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

62284 8 00 00 00 00 ZZZ $38.50

62287 2 00 00 00 00 ZZZ $869.54

62287 8 00 00 00 00 ZZZ $173.91

62290 2 00 00 00 00 ZZZ $261.80

62290 8 00 00 00 00 ZZZ $52.36

62291 2 00 00 00 00 ZZZ $236.50

62291 8 00 00 00 00 ZZZ $47.30

62292 2 00 00 00 00 ZZZ $885.27

62292 8 00 00 00 00 ZZZ $177.05

62294 2 00 00 00 00 ZZZ $489.11

62294 8 00 00 00 00 ZZZ $97.82

62302 2 00 00 00 00 ZZZ $259.23

62302 8 00 00 00 00 ZZZ $51.85

62303 2 00 00 00 00 ZZZ $267.79

62303 8 00 00 00 00 ZZZ $53.56

62304 2 00 00 00 00 ZZZ $255.34

62304 8 00 00 00 00 ZZZ $51.07

62305 2 00 00 00 00 ZZZ $276.79

62305 8 00 00 00 00 ZZZ $55.36

62320 2 00 00 00 00 ZZZ $190.63

62320 8 00 00 00 00 ZZZ $38.13

62321 2 00 00 00 00 ZZZ $280.37

62321 8 00 00 00 00 ZZZ $56.07

62322 2 00 00 00 00 ZZZ $177.39

62322 8 00 00 00 00 ZZZ $35.48

62323 2 00 00 00 00 ZZZ $275.04

62323 8 00 00 00 00 ZZZ $55.01

62324 2 00 00 00 00 ZZZ $167.71

62324 8 00 00 00 00 ZZZ $33.54

62325 2 00 00 00 00 ZZZ $250.38

62325 8 00 00 00 00 ZZZ $50.08

62326 2 00 00 00 00 ZZZ $175.60

62326 8 00 00 00 00 ZZZ $35.12

62327 2 00 00 00 00 ZZZ $253.98

62327 8 00 00 00 00 ZZZ $50.80

62350 2 00 00 00 00 ZZZ $399.94

62350 8 00 00 00 00 ZZZ $79.99

62351 2 00 00 00 00 ZZZ $591.05

62351 8 00 00 00 00 ZZZ $118.21

62355 2 00 00 00 00 ZZZ $333.40

Page 255: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

62355 8 00 00 00 00 ZZZ $66.68

62360 2 00 00 00 00 ZZZ $128.12

62360 8 00 00 00 00 ZZZ $25.62

62361 2 00 00 00 00 ZZZ $307.21

62361 8 00 00 00 00 ZZZ $61.44

62362 2 00 00 00 00 ZZZ $402.06

62362 8 00 00 00 00 ZZZ $80.41

62365 2 00 00 00 00 ZZZ $331.28

62365 8 00 00 00 00 ZZZ $66.26

62367 2 00 00 00 00 ZZZ $36.83

62367 8 00 00 00 00 ZZZ $27.00

62368 2 00 00 00 00 ZZZ $56.42

62368 8 00 00 00 00 ZZZ $42.30

62369 2 00 00 00 00 ZZZ $110.27

62369 8 00 00 00 00 ZZZ $22.54

62370 2 00 00 00 00 ZZZ $116.05

62370 8 00 00 00 00 ZZZ $23.21

63001 2 00 00 00 00 ZZZ $1,567.97

63001 8 00 00 00 00 ZZZ $313.59

63003 2 00 00 00 00 ZZZ $1,585.22

63003 8 00 00 00 00 ZZZ $317.04

63005 2 00 00 00 00 ZZZ $1,473.32

63005 8 00 00 00 00 ZZZ $294.66

63011 2 00 00 00 00 ZZZ $1,524.60

63011 8 00 00 00 00 ZZZ $304.92

63012 2 00 00 00 00 ZZZ $1,634.00

63012 8 00 00 00 00 ZZZ $327.00

63015 2 00 00 00 00 ZZZ $1,870.00

63015 8 00 00 00 00 ZZZ $374.00

63016 2 00 00 00 00 ZZZ $1,870.00

63016 8 00 00 00 00 ZZZ $374.00

63017 2 00 00 00 00 ZZZ $1,700.00

63017 8 00 00 00 00 ZZZ $340.00

63020 2 00 00 00 00 ZZZ $1,478.45

63020 8 00 00 00 00 ZZZ $295.69

63030 2 00 00 00 00 ZZZ $1,511.78

63030 8 00 00 00 00 ZZZ $302.36

63035 2 00 00 00 00 ZZZ $296.99

63035 8 00 00 00 00 ZZZ $59.40

63040 2 00 00 00 00 ZZZ $1,597.20

Page 256: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

63040 8 00 00 00 00 ZZZ $319.44

63042 2 00 00 00 00 ZZZ $1,848.00

63042 8 00 00 00 00 ZZZ $370.00

63043 2 00 00 00 00 ZZZ $298.10

63043 8 00 00 00 00 ZZZ $59.62

63044 2 00 00 00 00 ZZZ $298.10

63044 8 00 00 00 00 ZZZ $59.62

63045 2 00 00 00 00 ZZZ $1,914.00

63045 8 00 00 00 00 ZZZ $383.00

63046 2 00 00 00 00 ZZZ $1,086.80

63046 8 00 00 00 00 ZZZ $217.36

63047 2 00 00 00 00 ZZZ $1,807.85

63047 8 00 00 00 00 ZZZ $361.57

63048 2 00 00 00 00 ZZZ $383.48

63048 8 00 00 00 00 ZZZ $76.70

63050 2 00 00 00 00 ZZZ $1,735.81

63050 8 00 00 00 00 ZZZ $347.16

63051 2 00 00 00 00 ZZZ $1,974.99

63051 8 00 00 00 00 ZZZ $395.00

63055 2 00 00 00 00 ZZZ $1,417.90

63055 8 00 00 00 00 ZZZ $283.58

63056 2 00 00 00 00 ZZZ $1,418.00

63056 8 00 00 00 00 ZZZ $283.60

63057 2 00 00 00 00 ZZZ $557.16

63057 8 00 00 00 00 ZZZ $111.43

63064 2 00 00 00 00 ZZZ $1,870.00

63064 8 00 00 00 00 ZZZ $374.00

63066 2 00 00 00 00 ZZZ $347.93

63066 8 00 00 00 00 ZZZ $69.59

63075 2 00 00 00 00 ZZZ $1,822.06

63075 8 00 00 00 00 ZZZ $364.41

63076 2 00 00 00 00 ZZZ $326.70

63076 8 00 00 00 00 ZZZ $65.34

63077 2 00 00 00 00 ZZZ $1,298.00

63077 8 00 00 00 00 ZZZ $259.60

63078 2 00 00 00 00 ZZZ $346.18

63078 8 00 00 00 00 ZZZ $69.24

63081 2 00 00 00 00 ZZZ $1,313.14

63081 8 00 00 00 00 ZZZ $262.63

63082 2 00 00 00 00 ZZZ $517.53

Page 257: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

63082 8 00 00 00 00 ZZZ $103.51

63085 2 00 00 00 00 ZZZ $1,439.81

63085 8 00 00 00 00 ZZZ $287.96

63086 2 00 00 00 00 ZZZ $374.16

63086 8 00 00 00 00 ZZZ $74.83

63087 2 00 00 00 00 ZZZ $1,746.39

63087 8 00 00 00 00 ZZZ $349.28

63088 2 00 00 00 00 ZZZ $504.70

63088 8 00 00 00 00 ZZZ $100.94

63090 2 00 00 00 00 ZZZ $1,484.13

63090 8 00 00 00 00 ZZZ $296.83

63091 2 00 00 00 00 ZZZ $329.86

63091 8 00 00 00 00 ZZZ $65.97

63101 2 00 00 00 00 ZZZ $2,350.62

63101 8 00 00 00 00 ZZZ $470.12

63102 2 00 00 00 00 ZZZ $2,350.62

63102 8 00 00 00 00 ZZZ $470.12

63103 2 00 00 00 00 ZZZ $274.75

63103 8 00 00 00 00 ZZZ $54.95

63170 2 00 00 00 00 ZZZ $1,065.83

63170 8 00 00 00 00 ZZZ $213.17

63172 2 00 00 00 00 ZZZ $1,200.10

63172 8 00 00 00 00 ZZZ $240.02

63173 2 00 00 00 00 ZZZ $1,380.50

63173 8 00 00 00 00 ZZZ $276.10

63180 2 00 00 00 00 ZZZ $1,667.00

63180 8 00 00 00 00 ZZZ $333.00

63182 2 00 00 00 00 ZZZ $1,813.21

63182 8 00 00 00 00 ZZZ $362.64

63185 2 00 00 00 00 ZZZ $926.20

63185 8 00 00 00 00 ZZZ $185.24

63190 2 00 00 00 00 ZZZ $2,023.00

63190 8 00 00 00 00 ZZZ $405.00

63191 2 00 00 00 00 ZZZ $1,086.80

63191 8 00 00 00 00 ZZZ $217.36

63194 2 00 00 00 00 ZZZ $1,524.60

63194 8 00 00 00 00 ZZZ $304.92

63195 2 00 00 00 00 ZZZ $1,524.60

63195 8 00 00 00 00 ZZZ $304.92

63196 2 00 00 00 00 ZZZ $1,579.60

Page 258: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

63196 8 00 00 00 00 ZZZ $315.92

63197 2 00 00 00 00 ZZZ $1,579.60

63197 8 00 00 00 00 ZZZ $315.92

63198 2 00 00 00 00 ZZZ $1,815.00

63198 8 00 00 00 00 ZZZ $363.00

63199 2 00 00 00 00 ZZZ $1,870.00

63199 8 00 00 00 00 ZZZ $374.00

63200 2 00 00 00 00 ZZZ $953.70

63200 8 00 00 00 00 ZZZ $190.74

63225 8 00 00 00 00 ZZZ $127.00

63250 2 00 00 00 00 ZZZ $1,978.90

63250 8 00 00 00 00 ZZZ $395.78

63251 2 00 00 00 00 ZZZ $1,978.90

63251 8 00 00 00 00 ZZZ $395.78

63252 2 00 00 00 00 ZZZ $1,978.49

63252 8 00 00 00 00 ZZZ $395.70

63265 2 00 00 00 00 ZZZ $1,313.40

63265 8 00 00 00 00 ZZZ $262.68

63266 2 00 00 00 00 ZZZ $1,313.40

63266 8 00 00 00 00 ZZZ $262.68

63267 2 00 00 00 00 ZZZ $1,182.50

63267 8 00 00 00 00 ZZZ $236.50

63268 2 00 00 00 00 ZZZ $1,182.50

63268 8 00 00 00 00 ZZZ $236.50

63270 2 00 00 00 00 ZZZ $1,313.40

63270 8 00 00 00 00 ZZZ $262.68

63271 2 00 00 00 00 ZZZ $1,431.15

63271 8 00 00 00 00 ZZZ $286.23

63272 2 00 00 00 00 ZZZ $1,314.97

63272 8 00 00 00 00 ZZZ $262.99

63273 2 00 00 00 00 ZZZ $1,199.31

63273 8 00 00 00 00 ZZZ $239.86

63275 2 00 00 00 00 ZZZ $1,313.40

63275 8 00 00 00 00 ZZZ $262.68

63276 2 00 00 00 00 ZZZ $1,313.40

63276 8 00 00 00 00 ZZZ $262.68

63277 2 00 00 00 00 ZZZ $1,182.50

63277 8 00 00 00 00 ZZZ $236.50

63278 2 00 00 00 00 ZZZ $1,182.50

63278 8 00 00 00 00 ZZZ $236.50

Page 259: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

63280 2 00 00 00 00 ZZZ $1,507.47

63280 8 00 00 00 00 ZZZ $301.49

63281 2 00 00 00 00 ZZZ $1,487.80

63281 8 00 00 00 00 ZZZ $297.56

63282 2 00 00 00 00 ZZZ $1,373.72

63282 8 00 00 00 00 ZZZ $274.74

63283 2 00 00 00 00 ZZZ $1,216.36

63283 8 00 00 00 00 ZZZ $243.27

63285 2 00 00 00 00 ZZZ $1,748.75

63285 8 00 00 00 00 ZZZ $349.75

63286 2 00 00 00 00 ZZZ $1,790.19

63286 8 00 00 00 00 ZZZ $358.04

63287 2 00 00 00 00 ZZZ $1,795.43

63287 8 00 00 00 00 ZZZ $359.09

63290 2 00 00 00 00 ZZZ $1,831.63

63290 8 00 00 00 00 ZZZ $366.33

63295 2 00 00 00 00 ZZZ $392.58

63295 8 00 00 00 00 ZZZ $78.52

63300 2 00 00 00 00 ZZZ $1,195.38

63300 8 00 00 00 00 ZZZ $239.08

63301 2 00 00 00 00 ZZZ $1,316.55

63301 8 00 00 00 00 ZZZ $263.31

63302 2 00 00 00 00 ZZZ $1,365.06

63302 8 00 00 00 00 ZZZ $273.01

63303 2 00 00 00 00 ZZZ $1,404.67

63303 8 00 00 00 00 ZZZ $280.93

63304 2 00 00 00 00 ZZZ $1,497.77

63304 8 00 00 00 00 ZZZ $299.55

63305 2 00 00 00 00 ZZZ $1,534.48

63305 8 00 00 00 00 ZZZ $306.90

63306 2 00 00 00 00 ZZZ $1,547.60

63306 8 00 00 00 00 ZZZ $309.52

63307 2 00 00 00 00 ZZZ $1,503.01

63307 8 00 00 00 00 ZZZ $300.60

63308 2 00 00 00 00 ZZZ $414.10

63308 8 00 00 00 00 ZZZ $82.82

63600 2 00 00 00 00 ZZZ $633.10

63600 8 00 00 00 00 ZZZ $126.62

63610 2 00 00 00 00 ZZZ $530.20

63610 8 00 00 00 00 ZZZ $106.04

Page 260: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

63615 2 00 00 00 00 ZZZ $803.57

63615 8 00 00 00 00 ZZZ $160.71

63620 2 00 00 00 00 ZZZ $961.76

63620 8 00 00 00 00 ZZZ $192.35

63621 2 00 00 00 00 ZZZ $302.09

63621 8 00 00 00 00 ZZZ $60.42

63650 2 00 00 00 00 ZZZ $736.66

63650 8 00 00 00 00 ZZZ $147.33

63655 2 00 00 00 00 ZZZ $1,265.26

63655 8 00 00 00 00 ZZZ $253.05

63661 2 00 00 00 00 ZZZ $702.82

63661 8 00 00 00 00 ZZZ $140.56

63662 2 00 00 00 00 ZZZ $902.95

63662 8 00 00 00 00 ZZZ $180.59

63663 2 00 00 00 00 ZZZ $1,041.43

63663 8 00 00 00 00 ZZZ $208.29

63664 2 00 00 00 00 ZZZ $939.94

63664 8 00 00 00 00 ZZZ $187.99

63685 2 00 00 00 00 ZZZ $814.17

63685 8 00 00 00 00 ZZZ $162.83

63688 2 00 00 00 00 ZZZ $639.33

63688 8 00 00 00 00 ZZZ $127.87

63700 2 00 00 00 00 ZZZ $834.90

63700 8 00 00 00 00 ZZZ $166.98

63702 2 00 00 00 00 ZZZ $1,107.70

63702 8 00 00 00 00 ZZZ $221.54

63704 2 00 00 00 00 ZZZ $1,107.70

63704 8 00 00 00 00 ZZZ $221.54

63706 2 00 00 00 00 ZZZ $1,633.50

63706 8 00 00 00 00 ZZZ $326.70

63707 2 00 00 00 00 ZZZ $730.40

63707 8 00 00 00 00 ZZZ $146.08

63709 2 00 00 00 00 ZZZ $953.70

63709 8 00 00 00 00 ZZZ $190.74

63710 2 00 00 00 00 ZZZ $1,234.60

63710 8 00 00 00 00 ZZZ $246.92

63740 2 00 00 00 00 ZZZ $1,125.04

63740 8 00 00 00 00 ZZZ $225.01

63741 2 00 00 00 00 ZZZ $784.68

63741 8 00 00 00 00 ZZZ $156.94

Page 261: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

63744 2 00 00 00 00 ZZZ $468.60

63744 8 00 00 00 00 ZZZ $93.72

63746 2 00 00 00 00 ZZZ $468.60

63746 8 00 00 00 00 ZZZ $93.72

64400 2 00 00 00 00 ZZZ $65.83

64400 8 00 00 00 00 ZZZ $13.17

64402 2 00 00 00 00 ZZZ $94.94

64402 8 00 00 00 00 ZZZ $18.99

64405 2 00 00 00 00 ZZZ $76.05

64405 8 00 00 00 00 ZZZ $15.21

64408 2 00 00 00 00 ZZZ $94.60

64408 8 00 00 00 00 ZZZ $18.92

64410 2 00 00 00 00 ZZZ $83.60

64410 8 00 00 00 00 ZZZ $16.72

64413 2 00 00 00 00 ZZZ $82.61

64413 8 00 00 00 00 ZZZ $16.52

64415 2 00 00 00 00 ZZZ $79.73

64415 8 00 00 00 00 ZZZ $15.95

64416 2 00 00 00 00 ZZZ $178.63

64416 8 00 00 00 00 ZZZ $35.73

64417 2 00 00 00 00 ZZZ $80.30

64417 8 00 00 00 00 ZZZ $16.06

64418 2 00 00 00 00 ZZZ $80.30

64418 8 00 00 00 00 ZZZ $16.06

64420 2 00 00 00 00 ZZZ $71.50

64420 8 00 00 00 00 ZZZ $14.30

64421 2 00 00 00 00 ZZZ $101.20

64421 8 00 00 00 00 ZZZ $20.24

64425 2 00 00 00 00 ZZZ $85.76

64425 8 00 00 00 00 ZZZ $17.15

64430 2 00 00 00 00 ZZZ $86.90

64430 8 00 00 00 00 ZZZ $17.38

64435 2 00 00 00 00 ZZZ $82.87

64435 8 00 00 00 00 ZZZ $16.57

64445 2 00 00 00 00 ZZZ $87.33

64445 8 00 00 00 00 ZZZ $17.47

64446 2 00 00 00 00 ZZZ $184.81

64446 8 00 00 00 00 ZZZ $36.96

64447 2 00 00 00 00 ZZZ $86.64

64447 8 00 00 00 00 ZZZ $17.33

Page 262: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64448 2 00 00 00 00 ZZZ $169.96

64448 8 00 00 00 00 ZZZ $33.99

64449 2 00 00 00 00 ZZZ $167.90

64449 8 00 00 00 00 ZZZ $33.58

64450 2 00 00 00 00 ZZZ $72.60

64450 8 00 00 00 00 ZZZ $14.52

64455 2 00 00 00 00 ZZZ $64.50

64455 8 00 00 00 00 ZZZ $12.90

64461 2 00 00 00 00 ZZZ $148.39

64461 8 00 00 00 00 ZZZ $29.68

64462 2 00 00 00 00 ZZZ $84.24

64462 8 00 00 00 00 ZZZ $16.85

64463 2 00 00 00 00 ZZZ $163.60

64463 8 00 00 00 00 ZZZ $32.72

64479 2 00 00 00 00 ZZZ $249.58

64479 8 00 00 00 00 ZZZ $49.92

64480 2 00 00 00 00 ZZZ $224.83

64480 8 00 00 00 00 ZZZ $44.97

64483 2 00 00 00 00 ZZZ $230.20

64483 8 00 00 00 00 ZZZ $46.04

64484 2 00 00 00 00 ZZZ $212.45

64484 8 00 00 00 00 ZZZ $42.49

64486 2 00 00 00 00 ZZZ $133.65

64486 8 00 00 00 00 ZZZ $26.73

64487 2 00 00 00 00 ZZZ $162.16

64487 8 00 00 00 00 ZZZ $32.43

64488 2 00 00 00 00 ZZZ $164.93

64488 8 00 00 00 00 ZZZ $32.99

64489 2 00 00 00 00 ZZZ $271.78

64489 8 00 00 00 00 ZZZ $44.36

64490 2 00 00 00 00 ZZZ $175.19

64490 8 00 00 00 00 ZZZ $35.04

64491 2 00 00 00 00 ZZZ $90.64

64491 8 00 00 00 00 ZZZ $18.13

64492 2 00 00 00 00 ZZZ $91.60

64492 8 00 00 00 00 ZZZ $18.32

64493 2 00 00 00 00 ZZZ $156.34

64493 8 00 00 00 00 ZZZ $31.27

64494 2 00 00 00 00 ZZZ $80.50

64494 8 00 00 00 00 ZZZ $16.10

Page 263: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64495 2 00 00 00 00 ZZZ $81.46

64495 8 00 00 00 00 ZZZ $16.29

64505 2 00 00 00 00 ZZZ $74.22

64505 8 00 00 00 00 ZZZ $14.84

64508 2 00 00 00 00 ZZZ $83.60

64508 8 00 00 00 00 ZZZ $16.72

64510 2 00 00 00 00 ZZZ $123.20

64510 8 00 00 00 00 ZZZ $24.64

64517 2 00 00 00 00 ZZZ $207.50

64517 8 00 00 00 00 ZZZ $41.50

64520 2 00 00 00 00 ZZZ $92.84

64520 8 00 00 00 00 ZZZ $18.57

64530 2 00 00 00 00 ZZZ $96.51

64530 8 00 00 00 00 ZZZ $19.30

64550 2 00 00 00 00 ZZZ $26.40

64550 8 00 00 00 00 ZZZ $5.28

64553 2 00 00 00 00 ZZZ $217.97

64553 8 00 00 00 00 ZZZ $43.59

64555 2 00 00 00 00 ZZZ $218.55

64555 8 00 00 00 00 ZZZ $43.71

64561 2 00 00 00 00 ZZZ $912.95

64561 8 00 00 00 00 ZZZ $182.59

64565 2 00 00 00 00 ZZZ $198.15

64565 8 00 00 00 00 ZZZ $39.63

64568 2 00 00 00 00 ZZZ $818.62

64568 8 00 00 00 00 ZZZ $163.72

64569 2 00 00 00 00 ZZZ $812.37

64569 8 00 00 00 00 ZZZ $162.47

64570 2 00 00 00 00 ZZZ $0.00

64570 8 00 00 00 00 ZZZ $0.00

64575 2 00 00 00 00 ZZZ $485.47

64575 8 00 00 00 00 ZZZ $97.09

64580 2 00 00 00 00 ZZZ $454.58

64580 8 00 00 00 00 ZZZ $90.92

64581 2 00 00 00 00 ZZZ $849.42

64581 8 00 00 00 00 ZZZ $169.88

64585 2 00 00 00 00 ZZZ $280.91

64585 8 00 00 00 00 ZZZ $56.18

64590 2 00 00 00 00 ZZZ $287.32

64590 8 00 00 00 00 ZZZ $57.46

Page 264: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64595 2 00 00 00 00 ZZZ $202.23

64595 8 00 00 00 00 ZZZ $40.45

64600 2 00 00 00 00 ZZZ $170.50

64600 8 00 00 00 00 ZZZ $34.10

64605 2 00 00 00 00 ZZZ $374.00

64605 8 00 00 00 00 ZZZ $74.80

64610 2 00 00 00 00 ZZZ $544.50

64610 8 00 00 00 00 ZZZ $108.90

64611 2 00 00 00 00 ZZZ $124.83

64611 8 00 00 00 00 ZZZ $24.97

64612 2 00 00 00 00 ZZZ $112.25

64612 8 00 00 00 00 ZZZ $22.45

64615 2 00 00 00 00 ZZZ $160.83

64615 8 00 00 00 00 ZZZ $32.17

64616 2 00 00 00 00 ZZZ $138.61

64616 8 00 00 00 00 ZZZ $27.72

64617 2 00 00 00 00 ZZZ $205.73

64617 8 00 00 00 00 ZZZ $41.15

64620 2 00 00 00 00 ZZZ $141.90

64620 8 00 00 00 00 ZZZ $28.38

64630 2 00 00 00 00 ZZZ $143.98

64630 8 00 00 00 00 ZZZ $28.80

64632 2 00 00 00 00 ZZZ $104.33

64632 8 00 00 00 00 ZZZ $20.87

64633 2 00 00 00 00 ZZZ $1,040.00

64633 8 00 00 00 00 ZZZ $208.00

64634 2 00 00 00 00 ZZZ $1,040.00

64634 8 00 00 00 00 ZZZ $208.00

64635 2 00 00 00 00 ZZZ $1,040.00

64635 8 00 00 00 00 ZZZ $208.00

64636 2 00 00 00 00 ZZZ $1,040.00

64636 8 00 00 00 00 ZZZ $208.00

64640 2 00 00 00 00 ZZZ $147.92

64640 8 00 00 00 00 ZZZ $29.58

64642 2 00 00 00 00 ZZZ $155.43

64642 8 00 00 00 00 ZZZ $31.09

64643 2 00 00 00 00 ZZZ $104.75

64643 8 00 00 00 00 ZZZ $20.95

64644 2 00 00 00 00 ZZZ $176.28

64644 8 00 00 00 00 ZZZ $35.26

Page 265: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64645 2 00 00 00 00 ZZZ $126.26

64645 8 00 00 00 00 ZZZ $25.25

64646 2 00 00 00 00 ZZZ $167.68

64646 8 00 00 00 00 ZZZ $33.54

64647 2 00 00 00 00 ZZZ $194.58

64647 8 00 00 00 00 ZZZ $38.92

64650 2 00 00 00 00 ZZZ $77.30

64650 8 00 00 00 00 ZZZ $15.46

64653 2 00 00 00 00 ZZZ $89.16

64653 8 00 00 00 00 ZZZ $17.83

64680 2 00 00 00 00 ZZZ $163.90

64680 8 00 00 00 00 ZZZ $32.78

64681 2 00 00 00 00 ZZZ $512.78

64681 8 00 00 00 00 ZZZ $102.56

64702 2 00 00 00 00 ZZZ $279.40

64702 8 00 00 00 00 ZZZ $55.88

64704 2 00 00 00 00 ZZZ $385.00

64704 8 00 00 00 00 ZZZ $77.00

64708 2 00 00 00 00 ZZZ $544.50

64708 8 00 00 00 00 ZZZ $108.90

64712 2 00 00 00 00 ZZZ $635.80

64712 8 00 00 00 00 ZZZ $127.16

64713 2 00 00 00 00 ZZZ $635.80

64713 8 00 00 00 00 ZZZ $127.16

64714 2 00 00 00 00 ZZZ $635.80

64714 8 00 00 00 00 ZZZ $127.16

64716 2 00 00 00 00 ZZZ $578.00

64716 8 00 00 00 00 ZZZ $116.00

64718 2 00 00 00 00 ZZZ $738.99

64718 8 00 00 00 00 ZZZ $147.80

64719 2 00 00 00 00 ZZZ $385.00

64719 8 00 00 00 00 ZZZ $77.00

64721 2 00 00 00 00 ZZZ $581.63

64721 8 00 00 00 00 ZZZ $116.33

64722 2 00 00 00 00 ZZZ $317.90

64722 8 00 00 00 00 ZZZ $63.58

64726 2 00 00 00 00 ZZZ $221.10

64726 8 00 00 00 00 ZZZ $44.22

64727 2 00 00 00 00 ZZZ $289.00

64727 8 00 00 00 00 ZZZ $58.00

Page 266: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64732 2 00 00 00 00 ZZZ $427.90

64732 8 00 00 00 00 ZZZ $85.58

64734 2 00 00 00 00 ZZZ $427.90

64734 8 00 00 00 00 ZZZ $85.58

64736 2 00 00 00 00 ZZZ $410.76

64736 8 00 00 00 00 ZZZ $82.15

64738 2 00 00 00 00 ZZZ $443.30

64738 8 00 00 00 00 ZZZ $88.66

64740 2 00 00 00 00 ZZZ $610.77

64740 8 00 00 00 00 ZZZ $122.15

64742 2 00 00 00 00 ZZZ $684.79

64742 8 00 00 00 00 ZZZ $136.96

64744 2 00 00 00 00 ZZZ $443.30

64744 8 00 00 00 00 ZZZ $88.66

64746 2 00 00 00 00 ZZZ $294.26

64746 8 00 00 00 00 ZZZ $58.85

64755 2 00 00 00 00 ZZZ $1,298.00

64755 8 00 00 00 00 ZZZ $259.00

64760 2 00 00 00 00 ZZZ $612.18

64760 8 00 00 00 00 ZZZ $122.44

64763 2 00 00 00 00 ZZZ $385.00

64763 8 00 00 00 00 ZZZ $77.00

64766 2 00 00 00 00 ZZZ $490.60

64766 8 00 00 00 00 ZZZ $98.12

64771 2 00 00 00 00 ZZZ $583.26

64771 8 00 00 00 00 ZZZ $116.65

64772 2 00 00 00 00 ZZZ $508.20

64772 8 00 00 00 00 ZZZ $101.64

64774 2 00 00 00 00 ZZZ $261.80

64774 8 00 00 00 00 ZZZ $52.36

64776 2 00 00 00 00 ZZZ $261.80

64776 8 00 00 00 00 ZZZ $52.36

64778 2 00 00 00 00 ZZZ $167.20

64778 8 00 00 00 00 ZZZ $33.44

64782 2 00 00 00 00 ZZZ $287.18

64782 8 00 00 00 00 ZZZ $57.44

64783 2 00 00 00 00 ZZZ $177.81

64783 8 00 00 00 00 ZZZ $35.56

64784 2 00 00 00 00 ZZZ $544.50

64784 8 00 00 00 00 ZZZ $108.90

Page 267: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64786 2 00 00 00 00 ZZZ $834.90

64786 8 00 00 00 00 ZZZ $166.98

64787 2 00 00 00 00 ZZZ $359.47

64787 8 00 00 00 00 ZZZ $71.89

64788 2 00 00 00 00 ZZZ $272.80

64788 8 00 00 00 00 ZZZ $54.56

64790 2 00 00 00 00 ZZZ $834.90

64790 8 00 00 00 00 ZZZ $166.98

64792 2 00 00 00 00 ZZZ $763.40

64792 8 00 00 00 00 ZZZ $152.68

64795 2 00 00 00 00 ZZZ $261.56

64795 8 00 00 00 00 ZZZ $52.31

64802 2 00 00 00 00 ZZZ $675.40

64802 8 00 00 00 00 ZZZ $135.08

64804 2 00 00 00 00 ZZZ $962.50

64804 8 00 00 00 00 ZZZ $192.50

64809 2 00 00 00 00 ZZZ $980.10

64809 8 00 00 00 00 ZZZ $196.02

64818 2 00 00 00 00 ZZZ $661.10

64818 8 00 00 00 00 ZZZ $132.22

64820 2 00 00 00 00 ZZZ $771.56

64820 8 00 00 00 00 ZZZ $154.31

64821 2 00 00 00 00 ZZZ $694.30

64821 8 00 00 00 00 ZZZ $138.86

64822 2 00 00 00 00 ZZZ $694.30

64822 8 00 00 00 00 ZZZ $138.86

64823 2 00 00 00 00 ZZZ $801.56

64823 8 00 00 00 00 ZZZ $160.31

64831 2 00 00 00 00 ZZZ $421.30

64831 8 00 00 00 00 ZZZ $84.26

64832 2 00 00 00 00 ZZZ $246.40

64832 8 00 00 00 00 ZZZ $49.28

64834 2 00 00 00 00 ZZZ $431.94

64834 8 00 00 00 00 ZZZ $86.39

64835 2 00 00 00 00 ZZZ $497.25

64835 8 00 00 00 00 ZZZ $99.45

64836 2 00 00 00 00 ZZZ $907.30

64836 8 00 00 00 00 ZZZ $181.46

64837 2 00 00 00 00 ZZZ $477.09

64837 8 00 00 00 00 ZZZ $95.42

Page 268: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64840 2 00 00 00 00 ZZZ $635.80

64840 8 00 00 00 00 ZZZ $127.16

64856 2 00 00 00 00 ZZZ $762.30

64856 8 00 00 00 00 ZZZ $152.46

64857 2 00 00 00 00 ZZZ $762.30

64857 8 00 00 00 00 ZZZ $152.46

64858 2 00 00 00 00 ZZZ $782.59

64858 8 00 00 00 00 ZZZ $156.52

64859 2 00 00 00 00 ZZZ $344.01

64859 8 00 00 00 00 ZZZ $68.80

64861 2 00 00 00 00 ZZZ $908.47

64861 8 00 00 00 00 ZZZ $181.69

64862 2 00 00 00 00 ZZZ $1,071.86

64862 8 00 00 00 00 ZZZ $214.37

64864 2 00 00 00 00 ZZZ $953.70

64864 8 00 00 00 00 ZZZ $190.74

64865 2 00 00 00 00 ZZZ $834.90

64865 8 00 00 00 00 ZZZ $166.98

64866 2 00 00 00 00 ZZZ $834.90

64866 8 00 00 00 00 ZZZ $166.98

64868 2 00 00 00 00 ZZZ $834.90

64868 8 00 00 00 00 ZZZ $166.98

64872 2 00 00 00 00 ZZZ $127.60

64872 8 00 00 00 00 ZZZ $25.52

64874 2 00 00 00 00 ZZZ $191.40

64874 8 00 00 00 00 ZZZ $38.28

64876 2 00 00 00 00 ZZZ $260.49

64876 8 00 00 00 00 ZZZ $52.10

64885 2 00 00 00 00 ZZZ $1,169.30

64885 8 00 00 00 00 ZZZ $233.86

64886 2 00 00 00 00 ZZZ $1,287.00

64886 8 00 00 00 00 ZZZ $257.40

64890 2 00 00 00 00 ZZZ $1,017.50

64890 8 00 00 00 00 ZZZ $203.50

64891 2 00 00 00 00 ZZZ $1,017.50

64891 8 00 00 00 00 ZZZ $203.50

64892 2 00 00 00 00 ZZZ $1,017.50

64892 8 00 00 00 00 ZZZ $203.50

64893 2 00 00 00 00 ZZZ $1,017.50

64893 8 00 00 00 00 ZZZ $203.50

Page 269: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

64895 2 00 00 00 00 ZZZ $1,017.50

64895 8 00 00 00 00 ZZZ $203.50

64896 2 00 00 00 00 ZZZ $1,017.50

64896 8 00 00 00 00 ZZZ $203.50

64897 2 00 00 00 00 ZZZ $1,017.50

64897 8 00 00 00 00 ZZZ $203.50

64898 2 00 00 00 00 ZZZ $1,017.50

64898 8 00 00 00 00 ZZZ $203.50

64901 2 00 00 00 00 ZZZ $925.00

64901 8 00 00 00 00 ZZZ $185.00

64902 2 00 00 00 00 ZZZ $1,017.50

64902 8 00 00 00 00 ZZZ $203.50

64905 2 00 00 00 00 ZZZ $1,017.50

64905 8 00 00 00 00 ZZZ $203.50

64907 2 00 00 00 00 ZZZ $1,017.50

64907 8 00 00 00 00 ZZZ $203.50

64910 2 00 00 00 00 ZZZ $780.86

64910 8 00 00 00 00 ZZZ $156.17

64911 2 00 00 00 00 ZZZ $955.51

64911 8 00 00 00 00 ZZZ $191.10

64999 2 00 00 00 00 ZZZ $0.00

64999 8 00 00 00 00 ZZZ $0.00

65091 2 00 00 00 00 ZZZ $404.41

65091 8 00 00 00 00 ZZZ $80.88

65093 2 00 00 00 00 ZZZ $424.34

65093 8 00 00 00 00 ZZZ $84.87

65101 2 00 00 00 00 ZZZ $536.80

65101 8 00 00 00 00 ZZZ $107.36

65103 2 00 00 00 00 ZZZ $536.80

65103 8 00 00 00 00 ZZZ $107.36

65105 2 00 00 00 00 ZZZ $536.80

65105 8 00 00 00 00 ZZZ $107.36

65110 2 00 00 00 00 ZZZ $777.86

65110 8 00 00 00 00 ZZZ $155.57

65112 2 00 00 00 00 ZZZ $826.12

65112 8 00 00 00 00 ZZZ $165.22

65114 2 00 00 00 00 ZZZ $867.56

65114 8 00 00 00 00 ZZZ $173.51

65130 2 00 00 00 00 ZZZ $434.83

65130 8 00 00 00 00 ZZZ $86.97

Page 270: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

65135 2 00 00 00 00 ZZZ $443.30

65135 8 00 00 00 00 ZZZ $88.66

65140 2 00 00 00 00 ZZZ $490.60

65140 8 00 00 00 00 ZZZ $98.12

65150 2 00 00 00 00 ZZZ $584.68

65150 8 00 00 00 00 ZZZ $116.94

65155 2 00 00 00 00 ZZZ $810.49

65155 8 00 00 00 00 ZZZ $162.10

65175 2 00 00 00 00 ZZZ $389.98

65175 8 00 00 00 00 ZZZ $78.00

65205 2 00 00 00 00 ZZZ $97.82

65205 8 00 00 00 00 ZZZ $19.56

65210 2 00 00 00 00 ZZZ $105.17

65210 8 00 00 00 00 ZZZ $21.03

65220 2 00 00 00 00 ZZZ $124.05

65220 8 00 00 00 00 ZZZ $24.81

65222 2 00 00 00 00 ZZZ $108.32

65222 8 00 00 00 00 ZZZ $21.66

65235 2 00 00 00 00 ZZZ $635.80

65235 8 00 00 00 00 ZZZ $127.16

65260 2 00 00 00 00 ZZZ $569.89

65260 8 00 00 00 00 ZZZ $113.98

65265 2 00 00 00 00 ZZZ $657.75

65265 8 00 00 00 00 ZZZ $131.55

65270 2 00 00 00 00 ZZZ $113.04

65270 8 00 00 00 00 ZZZ $22.61

65272 2 00 00 00 00 ZZZ $430.69

65272 8 00 00 00 00 ZZZ $86.14

65273 2 00 00 00 00 ZZZ $223.97

65273 8 00 00 00 00 ZZZ $44.79

65275 2 00 00 00 00 ZZZ $381.70

65275 8 00 00 00 00 ZZZ $76.34

65280 2 00 00 00 00 ZZZ $508.20

65280 8 00 00 00 00 ZZZ $101.64

65285 2 00 00 00 00 ZZZ $826.10

65285 8 00 00 00 00 ZZZ $165.22

65286 2 00 00 00 00 ZZZ $508.20

65286 8 00 00 00 00 ZZZ $101.64

65290 2 00 00 00 00 ZZZ $377.30

65290 8 00 00 00 00 ZZZ $75.46

Page 271: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

65400 2 00 00 00 00 ZZZ $388.30

65400 8 00 00 00 00 ZZZ $77.66

65410 2 00 00 00 00 ZZZ $91.30

65410 8 00 00 00 00 ZZZ $18.26

65420 2 00 00 00 00 ZZZ $366.30

65420 8 00 00 00 00 ZZZ $73.26

65426 2 00 00 00 00 ZZZ $318.38

65426 8 00 00 00 00 ZZZ $63.68

65430 2 00 00 00 00 ZZZ $130.87

65430 8 00 00 00 00 ZZZ $26.17

65435 2 00 00 00 00 ZZZ $55.00

65435 8 00 00 00 00 ZZZ $11.00

65436 2 00 00 00 00 ZZZ $204.30

65436 8 00 00 00 00 ZZZ $40.86

65450 2 00 00 00 00 ZZZ $223.97

65450 8 00 00 00 00 ZZZ $44.79

65600 2 00 00 00 00 ZZZ $260.70

65600 8 00 00 00 00 ZZZ $52.14

65710 2 00 00 00 00 ZZZ $1,144.00

65710 8 00 00 00 00 ZZZ $228.80

65730 2 00 00 00 00 ZZZ $1,392.66

65730 8 00 00 00 00 ZZZ $278.53

65750 2 00 00 00 00 ZZZ $1,398.10

65750 8 00 00 00 00 ZZZ $279.62

65755 2 00 00 00 00 ZZZ $818.51

65755 8 00 00 00 00 ZZZ $163.70

65756 2 00 00 00 00 ZZZ $1,303.21

65756 8 00 00 00 00 ZZZ $260.64

65765 2 00 00 00 00 ZZZ $990.00

65765 8 00 00 00 00 ZZZ $198.00

65767 2 00 00 00 00 ZZZ $0.00

65767 8 00 00 00 00 ZZZ $0.00

65770 2 00 00 00 00 ZZZ $1,197.90

65770 8 00 00 00 00 ZZZ $239.58

65772 2 00 00 00 00 ZZZ $551.00

65772 8 00 00 00 00 ZZZ $110.00

65775 2 00 00 00 00 ZZZ $649.00

65775 8 00 00 00 00 ZZZ $130.00

65778 2 00 00 00 00 ZZZ $1,496.69

65778 8 00 00 00 00 ZZZ $299.34

Page 272: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

65779 2 00 00 00 00 ZZZ $1,371.98

65779 8 00 00 00 00 ZZZ $274.40

65800 2 00 00 00 00 ZZZ $105.17

65800 8 00 00 00 00 ZZZ $21.03

65810 2 00 00 00 00 ZZZ $307.37

65810 8 00 00 00 00 ZZZ $61.47

65815 2 00 00 00 00 ZZZ $309.10

65815 8 00 00 00 00 ZZZ $61.82

65820 2 00 00 00 00 ZZZ $484.39

65820 8 00 00 00 00 ZZZ $96.88

65850 2 00 00 00 00 ZZZ $1,025.73

65850 8 00 00 00 00 ZZZ $205.15

65855 2 00 00 00 00 ZZZ $583.97

65855 8 00 00 00 00 ZZZ $116.79

65860 2 00 00 00 00 ZZZ $315.70

65860 8 00 00 00 00 ZZZ $63.14

65865 2 00 00 00 00 ZZZ $443.30

65865 8 00 00 00 00 ZZZ $88.66

65870 2 00 00 00 00 ZZZ $352.00

65870 8 00 00 00 00 ZZZ $70.40

65875 2 00 00 00 00 ZZZ $355.89

65875 8 00 00 00 00 ZZZ $71.18

65880 2 00 00 00 00 ZZZ $381.85

65880 8 00 00 00 00 ZZZ $76.37

65900 2 00 00 00 00 ZZZ $635.80

65900 8 00 00 00 00 ZZZ $127.16

65920 2 00 00 00 00 ZZZ $796.34

65920 8 00 00 00 00 ZZZ $159.27

65930 2 00 00 00 00 ZZZ $751.00

65930 8 00 00 00 00 ZZZ $150.00

66020 2 00 00 00 00 ZZZ $134.20

66020 8 00 00 00 00 ZZZ $26.84

66030 2 00 00 00 00 ZZZ $83.60

66030 8 00 00 00 00 ZZZ $16.72

66130 2 00 00 00 00 ZZZ $381.70

66130 8 00 00 00 00 ZZZ $76.34

66150 2 00 00 00 00 ZZZ $490.60

66150 8 00 00 00 00 ZZZ $98.12

66155 2 00 00 00 00 ZZZ $490.60

66155 8 00 00 00 00 ZZZ $98.12

Page 273: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

66160 2 00 00 00 00 ZZZ $561.24

66160 8 00 00 00 00 ZZZ $112.25

66170 2 00 00 00 00 ZZZ $962.50

66170 8 00 00 00 00 ZZZ $192.50

66172 2 00 00 00 00 ZZZ $1,180.30

66172 8 00 00 00 00 ZZZ $236.06

66174 2 00 00 00 00 ZZZ $1,244.42

66174 8 00 00 00 00 ZZZ $248.88

66175 2 00 00 00 00 ZZZ $1,391.73

66175 8 00 00 00 00 ZZZ $278.35

66179 2 00 00 00 00 ZZZ $1,161.82

66179 8 00 00 00 00 ZZZ $232.36

66180 2 00 00 00 00 ZZZ $782.59

66180 8 00 00 00 00 ZZZ $156.52

66183 2 00 00 00 00 ZZZ $1,350.97

66183 8 00 00 00 00 ZZZ $270.19

66184 2 00 00 00 00 ZZZ $808.48

66184 8 00 00 00 00 ZZZ $161.70

66185 2 00 00 00 00 ZZZ $731.50

66185 8 00 00 00 00 ZZZ $146.30

66220 2 00 00 00 00 ZZZ $672.10

66220 8 00 00 00 00 ZZZ $134.42

66225 2 00 00 00 00 ZZZ $853.60

66225 8 00 00 00 00 ZZZ $170.72

66250 2 00 00 00 00 ZZZ $635.80

66250 8 00 00 00 00 ZZZ $127.16

66298 2 00 00 00 00 ZZZ $146.00

66500 2 00 00 00 00 ZZZ $261.80

66500 8 00 00 00 00 ZZZ $52.36

66505 2 00 00 00 00 ZZZ $279.40

66505 8 00 00 00 00 ZZZ $55.88

66600 2 00 00 00 00 ZZZ $491.74

66600 8 00 00 00 00 ZZZ $98.35

66605 2 00 00 00 00 ZZZ $677.16

66605 8 00 00 00 00 ZZZ $135.43

66625 2 00 00 00 00 ZZZ $574.87

66625 8 00 00 00 00 ZZZ $114.97

66630 2 00 00 00 00 ZZZ $536.80

66630 8 00 00 00 00 ZZZ $107.36

66635 2 00 00 00 00 ZZZ $536.80

Page 274: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

66635 8 00 00 00 00 ZZZ $107.36

66680 2 00 00 00 00 ZZZ $475.20

66680 8 00 00 00 00 ZZZ $95.04

66682 2 00 00 00 00 ZZZ $559.81

66682 8 00 00 00 00 ZZZ $111.96

66700 2 00 00 00 00 ZZZ $301.86

66700 8 00 00 00 00 ZZZ $60.37

66710 2 00 00 00 00 ZZZ $305.53

66710 8 00 00 00 00 ZZZ $61.11

66711 2 00 00 00 00 ZZZ $623.36

66711 8 00 00 00 00 ZZZ $124.67

66720 2 00 00 00 00 ZZZ $301.60

66720 8 00 00 00 00 ZZZ $60.32

66721 2 00 00 00 00 ZZZ $90.00

66740 2 00 00 00 00 ZZZ $281.67

66740 8 00 00 00 00 ZZZ $56.33

66761 2 00 00 00 00 ZZZ $512.00

66761 8 00 00 00 00 ZZZ $102.00

66762 2 00 00 00 00 ZZZ $459.25

66762 8 00 00 00 00 ZZZ $91.85

66770 2 00 00 00 00 ZZZ $449.90

66770 8 00 00 00 00 ZZZ $89.98

66820 2 00 00 00 00 ZZZ $315.70

66820 8 00 00 00 00 ZZZ $63.14

66821 2 00 00 00 00 ZZZ $287.00

66821 8 00 00 00 00 ZZZ $57.00

66825 2 00 00 00 00 ZZZ $792.00

66825 8 00 00 00 00 ZZZ $158.40

66830 2 00 00 00 00 ZZZ $726.00

66830 8 00 00 00 00 ZZZ $145.00

66840 2 00 00 00 00 ZZZ $776.00

66840 8 00 00 00 00 ZZZ $155.00

66850 2 00 00 00 00 ZZZ $853.22

66850 8 00 00 00 00 ZZZ $170.64

66852 2 00 00 00 00 ZZZ $625.90

66852 8 00 00 00 00 ZZZ $125.18

66920 2 00 00 00 00 ZZZ $831.78

66920 8 00 00 00 00 ZZZ $166.36

66930 2 00 00 00 00 ZZZ $871.20

66930 8 00 00 00 00 ZZZ $174.24

Page 275: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

66940 2 00 00 00 00 ZZZ $867.67

66940 8 00 00 00 00 ZZZ $173.53

66982 2 00 00 00 00 ZZZ $954.80

66982 8 00 00 00 00 ZZZ $190.96

66983 2 00 00 00 00 ZZZ $1,011.16

66983 8 00 00 00 00 ZZZ $202.23

66984 2 00 00 00 00 ZZZ $1,122.00

66984 8 00 00 00 00 ZZZ $224.00

66985 2 00 00 00 00 ZZZ $792.00

66985 8 00 00 00 00 ZZZ $158.00

66986 2 00 00 00 00 ZZZ $871.20

66986 8 00 00 00 00 ZZZ $174.24

66990 2 00 00 00 00 ZZZ $93.65

66990 8 00 00 00 00 ZZZ $18.73

66999 2 00 00 00 00 ZZZ $0.00

66999 8 00 00 00 00 ZZZ $0.00

67005 2 00 00 00 00 ZZZ $627.09

67005 8 00 00 00 00 ZZZ $125.42

67010 2 00 00 00 00 ZZZ $757.06

67010 8 00 00 00 00 ZZZ $151.41

67015 2 00 00 00 00 ZZZ $443.30

67015 8 00 00 00 00 ZZZ $88.66

67025 2 00 00 00 00 ZZZ $482.04

67025 8 00 00 00 00 ZZZ $96.41

67027 2 00 00 00 00 ZZZ $839.92

67027 8 00 00 00 00 ZZZ $167.98

67028 2 00 00 00 00 ZZZ $244.21

67028 8 00 00 00 00 ZZZ $48.84

67030 2 00 00 00 00 ZZZ $508.20

67030 8 00 00 00 00 ZZZ $101.64

67031 2 00 00 00 00 ZZZ $386.74

67031 8 00 00 00 00 ZZZ $77.35

67036 2 00 00 00 00 ZZZ $1,350.00

67036 8 00 00 00 00 ZZZ $270.00

67039 2 00 00 00 00 ZZZ $1,553.00

67039 8 00 00 00 00 ZZZ $310.00

67040 2 00 00 00 00 ZZZ $1,599.74

67040 8 00 00 00 00 ZZZ $319.95

67041 2 00 00 00 00 ZZZ $1,433.62

67041 8 00 00 00 00 ZZZ $286.72

Page 276: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

67042 2 00 00 00 00 ZZZ $1,641.82

67042 8 00 00 00 00 ZZZ $328.36

67043 2 00 00 00 00 ZZZ $1,722.91

67043 8 00 00 00 00 ZZZ $344.58

67101 2 00 00 00 00 ZZZ $825.00

67101 8 00 00 00 00 ZZZ $165.00

67105 2 00 00 00 00 ZZZ $891.00

67105 8 00 00 00 00 ZZZ $178.00

67107 2 00 00 00 00 ZZZ $1,430.89

67107 8 00 00 00 00 ZZZ $286.18

67108 2 00 00 00 00 ZZZ $1,989.91

67108 8 00 00 00 00 ZZZ $397.98

67110 2 00 00 00 00 ZZZ $700.70

67110 8 00 00 00 00 ZZZ $140.14

67113 2 00 00 00 00 ZZZ $1,725.76

67113 8 00 00 00 00 ZZZ $345.15

67115 2 00 00 00 00 ZZZ $454.44

67115 8 00 00 00 00 ZZZ $90.89

67120 2 00 00 00 00 ZZZ $508.20

67120 8 00 00 00 00 ZZZ $101.64

67121 2 00 00 00 00 ZZZ $573.56

67121 8 00 00 00 00 ZZZ $114.71

67141 2 00 00 00 00 ZZZ $627.00

67141 8 00 00 00 00 ZZZ $125.00

67145 2 00 00 00 00 ZZZ $627.00

67145 8 00 00 00 00 ZZZ $125.00

67208 2 00 00 00 00 ZZZ $443.30

67208 8 00 00 00 00 ZZZ $88.66

67210 2 00 00 00 00 ZZZ $464.20

67210 8 00 00 00 00 ZZZ $92.84

67218 2 00 00 00 00 ZZZ $725.67

67218 8 00 00 00 00 ZZZ $145.13

67220 2 00 00 00 00 ZZZ $829.61

67220 8 00 00 00 00 ZZZ $165.92

67221 2 00 00 00 00 ZZZ $367.57

67221 8 00 00 00 00 ZZZ $73.51

67225 2 00 00 00 00 ZZZ $49.92

67225 8 00 00 00 00 ZZZ $9.98

67227 2 00 00 00 00 ZZZ $497.20

67227 8 00 00 00 00 ZZZ $99.44

Page 277: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

67228 2 00 00 00 00 ZZZ $871.20

67228 8 00 00 00 00 ZZZ $174.24

67229 2 00 00 00 00 ZZZ $1,243.93

67229 8 00 00 00 00 ZZZ $248.79

67250 2 00 00 00 00 ZZZ $693.00

67250 8 00 00 00 00 ZZZ $138.60

67255 2 00 00 00 00 ZZZ $853.60

67255 8 00 00 00 00 ZZZ $170.72

67299 2 00 00 00 00 ZZZ $0.00

67299 8 00 00 00 00 ZZZ $0.00

67311 2 00 00 00 00 ZZZ $652.74

67311 8 00 00 00 00 ZZZ $130.55

67312 2 00 00 00 00 ZZZ $667.70

67312 8 00 00 00 00 ZZZ $133.54

67314 2 00 00 00 00 ZZZ $444.40

67314 8 00 00 00 00 ZZZ $88.88

67316 2 00 00 00 00 ZZZ $510.88

67316 8 00 00 00 00 ZZZ $102.18

67318 2 00 00 00 00 ZZZ $576.40

67318 8 00 00 00 00 ZZZ $115.28

67320 2 00 00 00 00 ZZZ $600.98

67320 8 00 00 00 00 ZZZ $120.20

67331 2 00 00 00 00 ZZZ $537.58

67331 8 00 00 00 00 ZZZ $107.52

67332 2 00 00 00 00 ZZZ $598.66

67332 8 00 00 00 00 ZZZ $119.73

67334 2 00 00 00 00 ZZZ $380.60

67334 8 00 00 00 00 ZZZ $76.12

67335 2 00 00 00 00 ZZZ $273.92

67335 8 00 00 00 00 ZZZ $54.78

67340 2 00 00 00 00 ZZZ $666.02

67340 8 00 00 00 00 ZZZ $133.20

67343 2 00 00 00 00 ZZZ $541.51

67343 8 00 00 00 00 ZZZ $108.30

67345 2 00 00 00 00 ZZZ $292.00

67345 8 00 00 00 00 ZZZ $58.00

67346 2 00 00 00 00 ZZZ $232.38

67346 8 00 00 00 00 ZZZ $46.48

67399 2 00 00 00 00 ZZZ $0.00

67399 8 00 00 00 00 ZZZ $0.00

Page 278: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

67400 2 00 00 00 00 ZZZ $572.25

67400 8 00 00 00 00 ZZZ $114.45

67405 2 00 00 00 00 ZZZ $584.10

67405 8 00 00 00 00 ZZZ $116.82

67412 2 00 00 00 00 ZZZ $1,041.00

67412 8 00 00 00 00 ZZZ $208.00

67413 2 00 00 00 00 ZZZ $763.40

67413 8 00 00 00 00 ZZZ $152.68

67414 2 00 00 00 00 ZZZ $877.80

67414 8 00 00 00 00 ZZZ $175.56

67415 2 00 00 00 00 ZZZ $127.60

67415 8 00 00 00 00 ZZZ $25.52

67420 2 00 00 00 00 ZZZ $1,030.68

67420 8 00 00 00 00 ZZZ $206.14

67430 2 00 00 00 00 ZZZ $798.60

67430 8 00 00 00 00 ZZZ $159.72

67440 2 00 00 00 00 ZZZ $749.02

67440 8 00 00 00 00 ZZZ $149.80

67445 2 00 00 00 00 ZZZ $756.09

67445 8 00 00 00 00 ZZZ $151.22

67450 2 00 00 00 00 ZZZ $798.60

67450 8 00 00 00 00 ZZZ $159.72

67500 2 00 00 00 00 ZZZ $131.92

67500 8 00 00 00 00 ZZZ $26.38

67505 2 00 00 00 00 ZZZ $115.65

67505 8 00 00 00 00 ZZZ $23.13

67515 2 00 00 00 00 ZZZ $100.97

67515 8 00 00 00 00 ZZZ $20.19

67550 2 00 00 00 00 ZZZ $564.12

67550 8 00 00 00 00 ZZZ $112.82

67560 2 00 00 00 00 ZZZ $557.83

67560 8 00 00 00 00 ZZZ $111.57

67570 2 00 00 00 00 ZZZ $1,215.95

67570 8 00 00 00 00 ZZZ $243.19

67599 2 00 00 00 00 ZZZ $0.00

67599 8 00 00 00 00 ZZZ $0.00

67700 2 00 00 00 00 ZZZ $118.80

67700 8 00 00 00 00 ZZZ $23.76

67710 2 00 00 00 00 ZZZ $119.33

67710 8 00 00 00 00 ZZZ $23.87

Page 279: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

67715 2 00 00 00 00 ZZZ $75.90

67715 8 00 00 00 00 ZZZ $15.18

67800 2 00 00 00 00 ZZZ $128.77

67800 8 00 00 00 00 ZZZ $25.75

67801 2 00 00 00 00 ZZZ $152.64

67801 8 00 00 00 00 ZZZ $30.53

67805 2 00 00 00 00 ZZZ $164.17

67805 8 00 00 00 00 ZZZ $32.83

67808 2 00 00 00 00 ZZZ $195.80

67808 8 00 00 00 00 ZZZ $39.16

67810 2 00 00 00 00 ZZZ $113.04

67810 8 00 00 00 00 ZZZ $22.61

67820 2 00 00 00 00 ZZZ $50.09

67820 8 00 00 00 00 ZZZ $10.02

67825 2 00 00 00 00 ZZZ $148.18

67825 8 00 00 00 00 ZZZ $29.64

67830 2 00 00 00 00 ZZZ $188.56

67830 8 00 00 00 00 ZZZ $37.71

67835 2 00 00 00 00 ZZZ $297.93

67835 8 00 00 00 00 ZZZ $59.59

67840 2 00 00 00 00 ZZZ $154.73

67840 8 00 00 00 00 ZZZ $30.95

67850 2 00 00 00 00 ZZZ $150.27

67850 8 00 00 00 00 ZZZ $30.05

67875 2 00 00 00 00 ZZZ $347.00

67875 8 00 00 00 00 ZZZ $70.00

67880 2 00 00 00 00 ZZZ $288.23

67880 8 00 00 00 00 ZZZ $57.65

67882 2 00 00 00 00 ZZZ $383.95

67882 8 00 00 00 00 ZZZ $76.79

67900 2 00 00 00 00 ZZZ $351.80

67900 8 00 00 00 00 ZZZ $70.36

67901 2 00 00 00 00 ZZZ $427.90

67901 8 00 00 00 00 ZZZ $85.58

67902 2 00 00 00 00 ZZZ $573.10

67902 8 00 00 00 00 ZZZ $114.62

67903 2 00 00 00 00 ZZZ $759.00

67903 8 00 00 00 00 ZZZ $152.00

67904 2 00 00 00 00 ZZZ $763.23

67904 8 00 00 00 00 ZZZ $152.65

Page 280: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

67906 2 00 00 00 00 ZZZ $573.10

67906 8 00 00 00 00 ZZZ $114.62

67908 2 00 00 00 00 ZZZ $427.90

67908 8 00 00 00 00 ZZZ $85.58

67909 2 00 00 00 00 ZZZ $343.82

67909 8 00 00 00 00 ZZZ $68.76

67911 2 00 00 00 00 ZZZ $427.90

67911 8 00 00 00 00 ZZZ $85.58

67912 2 00 00 00 00 ZZZ $822.50

67912 8 00 00 00 00 ZZZ $164.50

67914 2 00 00 00 00 ZZZ $566.00

67914 8 00 00 00 00 ZZZ $114.00

67915 2 00 00 00 00 ZZZ $221.61

67915 8 00 00 00 00 ZZZ $44.32

67916 2 00 00 00 00 ZZZ $566.50

67916 8 00 00 00 00 ZZZ $113.30

67917 2 00 00 00 00 ZZZ $584.10

67917 8 00 00 00 00 ZZZ $116.82

67921 2 00 00 00 00 ZZZ $276.16

67921 8 00 00 00 00 ZZZ $55.23

67922 2 00 00 00 00 ZZZ $216.36

67922 8 00 00 00 00 ZZZ $43.27

67923 2 00 00 00 00 ZZZ $427.75

67923 8 00 00 00 00 ZZZ $85.55

67924 2 00 00 00 00 ZZZ $360.35

67924 8 00 00 00 00 ZZZ $72.07

67930 2 00 00 00 00 ZZZ $381.70

67930 8 00 00 00 00 ZZZ $76.34

67935 2 00 00 00 00 ZZZ $635.80

67935 8 00 00 00 00 ZZZ $127.16

67938 2 00 00 00 00 ZZZ $135.32

67938 8 00 00 00 00 ZZZ $27.06

67950 2 00 00 00 00 ZZZ $549.30

67950 8 00 00 00 00 ZZZ $109.86

67961 2 00 00 00 00 ZZZ $385.00

67961 8 00 00 00 00 ZZZ $77.00

67966 2 00 00 00 00 ZZZ $454.30

67966 8 00 00 00 00 ZZZ $90.86

67971 2 00 00 00 00 ZZZ $678.70

67971 8 00 00 00 00 ZZZ $135.74

Page 281: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

67973 2 00 00 00 00 ZZZ $871.20

67973 8 00 00 00 00 ZZZ $174.24

67974 2 00 00 00 00 ZZZ $889.90

67974 8 00 00 00 00 ZZZ $177.98

67975 2 00 00 00 00 ZZZ $405.72

67975 8 00 00 00 00 ZZZ $81.14

67999 2 00 00 00 00 ZZZ $0.00

67999 8 00 00 00 00 ZZZ $0.00

68020 2 00 00 00 00 ZZZ $120.90

68020 8 00 00 00 00 ZZZ $24.18

68040 2 00 00 00 00 ZZZ $103.59

68040 8 00 00 00 00 ZZZ $20.72

68100 2 00 00 00 00 ZZZ $129.56

68100 8 00 00 00 00 ZZZ $25.91

68110 2 00 00 00 00 ZZZ $154.21

68110 8 00 00 00 00 ZZZ $30.84

68115 2 00 00 00 00 ZZZ $177.03

68115 8 00 00 00 00 ZZZ $35.41

68130 2 00 00 00 00 ZZZ $225.28

68130 8 00 00 00 00 ZZZ $45.06

68135 2 00 00 00 00 ZZZ $141.88

68135 8 00 00 00 00 ZZZ $28.38

68200 2 00 00 00 00 ZZZ $95.72

68200 8 00 00 00 00 ZZZ $19.14

68320 2 00 00 00 00 ZZZ $427.90

68320 8 00 00 00 00 ZZZ $85.58

68325 2 00 00 00 00 ZZZ $490.60

68325 8 00 00 00 00 ZZZ $98.12

68326 2 00 00 00 00 ZZZ $635.80

68326 8 00 00 00 00 ZZZ $127.16

68328 2 00 00 00 00 ZZZ $763.40

68328 8 00 00 00 00 ZZZ $152.68

68330 2 00 00 00 00 ZZZ $290.85

68330 8 00 00 00 00 ZZZ $58.17

68335 2 00 00 00 00 ZZZ $635.80

68335 8 00 00 00 00 ZZZ $127.16

68360 2 00 00 00 00 ZZZ $334.40

68360 8 00 00 00 00 ZZZ $66.88

68362 2 00 00 00 00 ZZZ $412.01

68362 8 00 00 00 00 ZZZ $82.40

Page 282: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

68371 2 00 00 00 00 ZZZ $400.98

68371 8 00 00 00 00 ZZZ $80.20

68399 2 00 00 00 00 ZZZ $0.00

68399 8 00 00 00 00 ZZZ $0.00

68400 2 00 00 00 00 ZZZ $173.35

68400 8 00 00 00 00 ZZZ $34.67

68420 2 00 00 00 00 ZZZ $195.91

68420 8 00 00 00 00 ZZZ $39.18

68440 2 00 00 00 00 ZZZ $112.25

68440 8 00 00 00 00 ZZZ $22.45

68500 2 00 00 00 00 ZZZ $635.80

68500 8 00 00 00 00 ZZZ $127.16

68505 2 00 00 00 00 ZZZ $635.80

68505 8 00 00 00 00 ZZZ $127.16

68510 2 00 00 00 00 ZZZ $316.55

68510 8 00 00 00 00 ZZZ $63.31

68520 2 00 00 00 00 ZZZ $635.80

68520 8 00 00 00 00 ZZZ $127.16

68525 2 00 00 00 00 ZZZ $202.46

68525 8 00 00 00 00 ZZZ $40.49

68530 2 00 00 00 00 ZZZ $290.06

68530 8 00 00 00 00 ZZZ $58.01

68540 2 00 00 00 00 ZZZ $763.40

68540 8 00 00 00 00 ZZZ $152.68

68550 2 00 00 00 00 ZZZ $763.40

68550 8 00 00 00 00 ZZZ $152.68

68700 2 00 00 00 00 ZZZ $531.51

68700 8 00 00 00 00 ZZZ $106.30

68705 2 00 00 00 00 ZZZ $155.26

68705 8 00 00 00 00 ZZZ $31.05

68720 2 00 00 00 00 ZZZ $834.90

68720 8 00 00 00 00 ZZZ $166.98

68745 2 00 00 00 00 ZZZ $530.20

68745 8 00 00 00 00 ZZZ $106.04

68750 2 00 00 00 00 ZZZ $530.20

68750 8 00 00 00 00 ZZZ $106.04

68760 2 00 00 00 00 ZZZ $139.78

68760 8 00 00 00 00 ZZZ $27.96

68761 2 00 00 00 00 ZZZ $125.88

68761 8 00 00 00 00 ZZZ $25.18

Page 283: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

68770 2 00 00 00 00 ZZZ $428.80

68770 8 00 00 00 00 ZZZ $85.76

68801 2 00 00 00 00 ZZZ $120.38

68801 8 00 00 00 00 ZZZ $24.08

68810 2 00 00 00 00 ZZZ $172.57

68810 8 00 00 00 00 ZZZ $34.51

68811 2 00 00 00 00 ZZZ $157.85

68811 8 00 00 00 00 ZZZ $31.57

68815 2 00 00 00 00 ZZZ $237.61

68815 8 00 00 00 00 ZZZ $47.52

68816 2 00 00 00 00 ZZZ $268.90

68816 8 00 00 00 00 ZZZ $53.78

68840 2 00 00 00 00 ZZZ $139.52

68840 8 00 00 00 00 ZZZ $27.90

68850 2 00 00 00 00 ZZZ $197.22

68850 8 00 00 00 00 ZZZ $39.44

68899 2 00 00 00 00 ZZZ $0.00

68899 8 00 00 00 00 ZZZ $0.00

69000 2 00 00 00 00 ZZZ $68.98

69000 8 00 00 00 00 ZZZ $13.80

69005 2 00 00 00 00 ZZZ $104.38

69005 8 00 00 00 00 ZZZ $20.88

69020 2 00 00 00 00 ZZZ $72.65

69020 8 00 00 00 00 ZZZ $14.53

69100 2 00 00 00 00 ZZZ $51.40

69100 8 00 00 00 00 ZZZ $10.28

69105 2 00 00 00 00 ZZZ $51.66

69105 8 00 00 00 00 ZZZ $10.33

69110 2 00 00 00 00 ZZZ $175.45

69110 8 00 00 00 00 ZZZ $35.09

69120 2 00 00 00 00 ZZZ $254.10

69120 8 00 00 00 00 ZZZ $50.82

69140 2 00 00 00 00 ZZZ $595.10

69140 8 00 00 00 00 ZZZ $119.02

69145 2 00 00 00 00 ZZZ $147.65

69145 8 00 00 00 00 ZZZ $29.53

69150 2 00 00 00 00 ZZZ $1,017.50

69150 8 00 00 00 00 ZZZ $203.50

69155 2 00 00 00 00 ZZZ $1,399.20

69155 8 00 00 00 00 ZZZ $279.84

Page 284: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

69200 2 00 00 00 00 ZZZ $43.53

69200 8 00 00 00 00 ZZZ $8.71

69205 2 00 00 00 00 ZZZ $145.70

69205 8 00 00 00 00 ZZZ $29.14

69209 2 00 00 00 00 ZZZ $13.27

69209 8 00 00 00 00 ZZZ $2.65

69210 2 00 00 00 00 ZZZ $35.15

69210 8 00 00 00 00 ZZZ $7.03

69220 2 00 00 00 00 ZZZ $46.68

69220 8 00 00 00 00 ZZZ $9.34

69222 2 00 00 00 00 ZZZ $89.19

69222 8 00 00 00 00 ZZZ $17.84

69300 2 00 00 00 00 ZZZ $460.90

69300 8 00 00 00 00 ZZZ $92.18

69310 2 00 00 00 00 ZZZ $1,203.35

69310 8 00 00 00 00 ZZZ $240.67

69320 2 00 00 00 00 ZZZ $1,271.60

69320 8 00 00 00 00 ZZZ $254.32

69399 2 00 00 00 00 ZZZ $0.00

69399 8 00 00 00 00 ZZZ $0.00

69420 2 00 00 00 00 ZZZ $83.60

69420 8 00 00 00 00 ZZZ $16.72

69421 2 00 00 00 00 ZZZ $92.58

69421 8 00 00 00 00 ZZZ $18.52

69424 2 00 00 00 00 ZZZ $88.58

69424 8 00 00 00 00 ZZZ $17.72

69433 2 00 00 00 00 ZZZ $116.60

69433 8 00 00 00 00 ZZZ $23.32

69436 2 00 00 00 00 ZZZ $211.00

69436 8 00 00 00 00 ZZZ $42.00

69440 2 00 00 00 00 ZZZ $635.80

69440 8 00 00 00 00 ZZZ $127.16

69450 2 00 00 00 00 ZZZ $556.69

69450 8 00 00 00 00 ZZZ $111.34

69501 2 00 00 00 00 ZZZ $544.50

69501 8 00 00 00 00 ZZZ $108.90

69502 2 00 00 00 00 ZZZ $943.80

69502 8 00 00 00 00 ZZZ $188.76

69505 2 00 00 00 00 ZZZ $1,016.40

69505 8 00 00 00 00 ZZZ $203.28

Page 285: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

69511 2 00 00 00 00 ZZZ $1,016.40

69511 8 00 00 00 00 ZZZ $203.28

69530 2 00 00 00 00 ZZZ $1,504.18

69530 8 00 00 00 00 ZZZ $300.84

69535 2 00 00 00 00 ZZZ $2,583.66

69535 8 00 00 00 00 ZZZ $516.73

69540 2 00 00 00 00 ZZZ $83.60

69540 8 00 00 00 00 ZZZ $16.72

69550 2 00 00 00 00 ZZZ $1,057.43

69550 8 00 00 00 00 ZZZ $211.49

69552 2 00 00 00 00 ZZZ $1,361.80

69552 8 00 00 00 00 ZZZ $272.36

69554 2 00 00 00 00 ZZZ $1,549.70

69554 8 00 00 00 00 ZZZ $309.94

69601 2 00 00 00 00 ZZZ $871.20

69601 8 00 00 00 00 ZZZ $174.24

69602 2 00 00 00 00 ZZZ $1,107.70

69602 8 00 00 00 00 ZZZ $221.54

69603 2 00 00 00 00 ZZZ $1,107.70

69603 8 00 00 00 00 ZZZ $221.54

69604 2 00 00 00 00 ZZZ $1,197.90

69604 8 00 00 00 00 ZZZ $239.58

69605 2 00 00 00 00 ZZZ $1,271.60

69605 8 00 00 00 00 ZZZ $254.32

69610 2 00 00 00 00 ZZZ $186.47

69610 8 00 00 00 00 ZZZ $37.29

69620 2 00 00 00 00 ZZZ $693.00

69620 8 00 00 00 00 ZZZ $139.00

69631 2 00 00 00 00 ZZZ $990.00

69631 8 00 00 00 00 ZZZ $198.00

69632 2 00 00 00 00 ZZZ $1,234.20

69632 8 00 00 00 00 ZZZ $246.84

69633 2 00 00 00 00 ZZZ $1,387.00

69633 8 00 00 00 00 ZZZ $278.00

69635 2 00 00 00 00 ZZZ $1,278.90

69635 8 00 00 00 00 ZZZ $255.78

69636 2 00 00 00 00 ZZZ $1,452.00

69636 8 00 00 00 00 ZZZ $290.40

69637 2 00 00 00 00 ZZZ $1,451.87

69637 8 00 00 00 00 ZZZ $290.37

Page 286: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

69641 2 00 00 00 00 ZZZ $1,304.00

69641 8 00 00 00 00 ZZZ $261.00

69642 2 00 00 00 00 ZZZ $1,452.00

69642 8 00 00 00 00 ZZZ $290.40

69643 2 00 00 00 00 ZZZ $1,452.00

69643 8 00 00 00 00 ZZZ $290.40

69644 2 00 00 00 00 ZZZ $1,470.70

69644 8 00 00 00 00 ZZZ $294.14

69645 2 00 00 00 00 ZZZ $1,415.70

69645 8 00 00 00 00 ZZZ $283.14

69646 2 00 00 00 00 ZZZ $1,415.70

69646 8 00 00 00 00 ZZZ $283.14

69650 2 00 00 00 00 ZZZ $682.00

69650 8 00 00 00 00 ZZZ $136.40

69660 2 00 00 00 00 ZZZ $1,125.30

69660 8 00 00 00 00 ZZZ $225.06

69661 2 00 00 00 00 ZZZ $1,472.33

69661 8 00 00 00 00 ZZZ $294.47

69662 2 00 00 00 00 ZZZ $825.86

69662 8 00 00 00 00 ZZZ $165.17

69666 2 00 00 00 00 ZZZ $939.94

69666 8 00 00 00 00 ZZZ $187.99

69667 2 00 00 00 00 ZZZ $940.41

69667 8 00 00 00 00 ZZZ $188.08

69670 2 00 00 00 00 ZZZ $1,017.50

69670 8 00 00 00 00 ZZZ $203.50

69676 2 00 00 00 00 ZZZ $768.02

69676 8 00 00 00 00 ZZZ $153.60

69700 2 00 00 00 00 ZZZ $418.31

69700 8 00 00 00 00 ZZZ $83.66

69714 2 00 00 00 00 ZZZ $976.89

69714 8 00 00 00 00 ZZZ $195.38

69715 2 00 00 00 00 ZZZ $1,237.19

69715 8 00 00 00 00 ZZZ $247.44

69717 2 00 00 00 00 ZZZ $1,006.17

69717 8 00 00 00 00 ZZZ $201.23

69718 2 00 00 00 00 ZZZ $1,252.04

69718 8 00 00 00 00 ZZZ $250.41

69720 2 00 00 00 00 ZZZ $1,361.80

69720 8 00 00 00 00 ZZZ $272.36

Page 287: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

69725 2 00 00 00 00 ZZZ $1,525.70

69725 8 00 00 00 00 ZZZ $305.14

69740 2 00 00 00 00 ZZZ $1,353.00

69740 8 00 00 00 00 ZZZ $271.00

69745 2 00 00 00 00 ZZZ $1,175.90

69745 8 00 00 00 00 ZZZ $235.18

69799 2 00 00 00 00 ZZZ $0.00

69799 8 00 00 00 00 ZZZ $0.00

69801 2 00 00 00 00 ZZZ $832.24

69801 8 00 00 00 00 ZZZ $166.45

69805 2 00 00 00 00 ZZZ $1,386.00

69805 8 00 00 00 00 ZZZ $277.00

69806 2 00 00 00 00 ZZZ $1,485.00

69806 8 00 00 00 00 ZZZ $297.00

69820 2 00 00 00 00 ZZZ $1,156.00

69820 8 00 00 00 00 ZZZ $231.00

69840 2 00 00 00 00 ZZZ $785.72

69840 8 00 00 00 00 ZZZ $157.14

69905 2 00 00 00 00 ZZZ $1,016.40

69905 8 00 00 00 00 ZZZ $203.28

69910 2 00 00 00 00 ZZZ $1,197.90

69910 8 00 00 00 00 ZZZ $239.58

69915 2 00 00 00 00 ZZZ $1,633.50

69915 8 00 00 00 00 ZZZ $326.70

69930 2 00 00 00 00 ZZZ $1,421.20

69930 8 00 00 00 00 ZZZ $284.24

69949 2 00 00 00 00 ZZZ $0.00

69949 8 00 00 00 00 ZZZ $0.00

69950 2 00 00 00 00 ZZZ $1,271.60

69950 8 00 00 00 00 ZZZ $254.32

69955 2 00 00 00 00 ZZZ $1,302.12

69955 8 00 00 00 00 ZZZ $260.42

69960 2 00 00 00 00 ZZZ $1,868.72

69960 8 00 00 00 00 ZZZ $373.74

69970 2 00 00 00 00 ZZZ $1,590.60

69970 8 00 00 00 00 ZZZ $318.12

69979 2 00 00 00 00 ZZZ $0.00

69979 8 00 00 00 00 ZZZ $0.00

69990 2 00 00 00 00 ZZZ $248.35

69990 8 00 00 00 00 ZZZ $49.67

Page 288: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

70010 C 00 00 00 00 ZZZ $83.60

70010 P 00 00 00 00 ZZZ $78.33

70015 C 00 00 00 00 ZZZ $83.60

70015 P 00 00 00 00 ZZZ $78.79

70030 C 00 00 00 00 ZZZ $28.60

70030 P 00 00 00 00 ZZZ $11.66

70030 T 00 00 00 00 ZZZ $16.94

70100 C 00 00 00 00 ZZZ $35.20

70100 P 00 00 00 00 ZZZ $16.00

70100 T 00 00 00 00 ZZZ $19.20

70110 C 00 00 00 00 ZZZ $47.56

70110 P 00 00 00 00 ZZZ $19.00

70110 T 00 00 00 00 ZZZ $28.56

70120 C 00 00 00 00 ZZZ $36.30

70120 P 00 00 00 00 ZZZ $11.00

70120 T 00 00 00 00 ZZZ $25.30

70130 C 00 00 00 00 ZZZ $61.54

70130 P 00 00 00 00 ZZZ $22.38

70130 T 00 00 00 00 ZZZ $39.16

70134 C 00 00 00 00 ZZZ $51.70

70134 P 00 00 00 00 ZZZ $22.38

70134 T 00 00 00 00 ZZZ $29.32

70140 C 00 00 00 00 ZZZ $40.70

70140 P 00 00 00 00 ZZZ $17.00

70140 T 00 00 00 00 ZZZ $23.70

70150 C 00 00 00 00 ZZZ $39.60

70150 P 00 00 00 00 ZZZ $18.00

70150 T 00 00 00 00 ZZZ $21.60

70160 C 00 00 00 00 ZZZ $37.30

70160 P 00 00 00 00 ZZZ $13.00

70160 T 00 00 00 00 ZZZ $24.30

70170 C 00 00 00 00 ZZZ $38.03

70170 P 00 00 00 00 ZZZ $20.05

70190 C 00 00 00 00 ZZZ $27.50

70190 P 00 00 00 00 ZZZ $13.20

70190 T 00 00 00 00 ZZZ $14.30

70200 C 00 00 00 00 ZZZ $32.52

70200 P 00 00 00 00 ZZZ $16.82

70200 T 00 00 00 00 ZZZ $15.70

70210 C 00 00 00 00 ZZZ $35.20

Page 289: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

70210 P 00 00 00 00 ZZZ $18.00

70210 T 00 00 00 00 ZZZ $17.20

70220 C 00 00 00 00 ZZZ $49.50

70220 P 00 00 00 00 ZZZ $16.50

70220 T 00 00 00 00 ZZZ $33.00

70240 C 00 00 00 00 ZZZ $30.80

70240 P 00 00 00 00 ZZZ $12.10

70240 T 00 00 00 00 ZZZ $18.70

70250 C 00 00 00 00 ZZZ $45.10

70250 P 00 00 00 00 ZZZ $19.00

70250 T 00 00 00 00 ZZZ $26.10

70260 C 00 00 00 00 ZZZ $58.30

70260 P 00 00 00 00 ZZZ $22.38

70260 T 00 00 00 00 ZZZ $35.92

70300 C 00 00 00 00 ZZZ $20.90

70300 P 00 00 00 00 ZZZ $7.38

70300 T 00 00 00 00 ZZZ $13.52

70310 C 00 00 00 00 ZZZ $24.20

70310 P 00 00 00 00 ZZZ $7.70

70310 T 00 00 00 00 ZZZ $16.50

70320 C 00 00 00 00 ZZZ $34.10

70320 P 00 00 00 00 ZZZ $13.20

70320 T 00 00 00 00 ZZZ $20.90

70328 C 00 00 00 00 ZZZ $30.80

70328 P 00 00 00 00 ZZZ $15.00

70328 T 00 00 00 00 ZZZ $15.80

70330 C 00 00 00 00 ZZZ $44.00

70330 P 00 00 00 00 ZZZ $16.32

70330 T 00 00 00 00 ZZZ $27.68

70332 C 00 00 00 00 ZZZ $79.20

70332 P 00 00 00 00 ZZZ $36.37

70336 C 00 00 00 00 ZZZ $462.00

70336 P 00 00 00 00 ZZZ $119.00

70336 T 00 00 00 00 ZZZ $343.00

70350 C 00 00 00 00 ZZZ $31.00

70350 P 00 00 00 00 ZZZ $9.00

70350 T 00 00 00 00 ZZZ $22.00

70355 C 00 00 00 00 ZZZ $35.20

70355 P 00 00 00 00 ZZZ $10.45

70355 T 00 00 00 00 ZZZ $24.20

Page 290: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

70360 C 00 00 00 00 ZZZ $20.90

70360 P 00 00 00 00 ZZZ $11.00

70360 T 00 00 00 00 ZZZ $10.45

70370 C 00 00 00 00 ZZZ $55.00

70370 P 00 00 00 00 ZZZ $15.40

70370 T 00 00 00 00 ZZZ $39.60

70371 C 00 00 00 00 ZZZ $140.67

70371 P 00 00 00 00 ZZZ $52.80

70371 T 00 00 00 00 ZZZ $87.87

70380 C 00 00 00 00 ZZZ $27.50

70380 P 00 00 00 00 ZZZ $11.00

70380 T 00 00 00 00 ZZZ $16.50

70390 C 00 00 00 00 ZZZ $64.26

70390 P 00 00 00 00 ZZZ $25.18

70450 C 00 00 00 00 ZZZ $276.10

70450 P 00 00 00 00 ZZZ $86.00

70450 T 00 00 00 00 ZZZ $190.10

70460 C 00 00 00 00 ZZZ $341.00

70460 P 00 00 00 00 ZZZ $102.00

70460 T 00 00 00 00 ZZZ $239.00

70470 C 00 00 00 00 ZZZ $413.60

70470 P 00 00 00 00 ZZZ $125.00

70470 T 00 00 00 00 ZZZ $288.60

70480 C 00 00 00 00 ZZZ $304.70

70480 P 00 00 00 00 ZZZ $96.00

70480 T 00 00 00 00 ZZZ $208.70

70481 C 00 00 00 00 ZZZ $359.70

70481 P 00 00 00 00 ZZZ $106.00

70481 T 00 00 00 00 ZZZ $253.70

70482 C 00 00 00 00 ZZZ $424.60

70482 P 00 00 00 00 ZZZ $129.00

70482 T 00 00 00 00 ZZZ $295.60

70486 C 00 00 00 00 ZZZ $298.10

70486 P 00 00 00 00 ZZZ $92.00

70486 T 00 00 00 00 ZZZ $206.10

70487 C 00 00 00 00 ZZZ $298.10

70487 P 00 00 00 00 ZZZ $85.79

70487 T 00 00 00 00 ZZZ $212.31

70488 C 00 00 00 00 ZZZ $556.57

70488 P 00 00 00 00 ZZZ $278.56

Page 291: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

70488 T 00 00 00 00 ZZZ $278.00

70490 C 00 00 00 00 ZZZ $298.10

70490 P 00 00 00 00 ZZZ $84.86

70490 T 00 00 00 00 ZZZ $213.24

70491 C 00 00 00 00 ZZZ $355.30

70491 P 00 00 00 00 ZZZ $96.00

70491 T 00 00 00 00 ZZZ $259.30

70492 C 00 00 00 00 ZZZ $558.32

70492 P 00 00 00 00 ZZZ $416.32

70492 T 00 00 00 00 ZZZ $142.00

70496 C 00 00 00 00 ZZZ $375.03

70496 P 00 00 00 00 ZZZ $94.13

70496 T 00 00 00 00 ZZZ $280.90

70498 C 00 00 00 00 ZZZ $375.03

70498 P 00 00 00 00 ZZZ $94.13

70498 T 00 00 00 00 ZZZ $280.90

70540 C 00 00 00 00 ZZZ $564.00

70540 P 00 00 00 00 ZZZ $162.00

70540 T 00 00 00 00 ZZZ $403.00

70542 C 00 00 00 00 ZZZ $576.05

70542 P 00 00 00 00 ZZZ $61.13

70542 T 00 00 00 00 ZZZ $514.92

70543 C 00 00 00 00 ZZZ $1,035.46

70543 P 00 00 00 00 ZZZ $82.51

70543 T 00 00 00 00 ZZZ $952.95

70544 C 00 00 00 00 ZZZ $499.54

70544 P 00 00 00 00 ZZZ $63.76

70544 T 00 00 00 00 ZZZ $435.78

70545 C 00 00 00 00 ZZZ $499.54

70545 P 00 00 00 00 ZZZ $63.76

70545 T 00 00 00 00 ZZZ $435.78

70546 C 00 00 00 00 ZZZ $946.96

70546 P 00 00 00 00 ZZZ $94.13

70546 T 00 00 00 00 ZZZ $852.82

70547 C 00 00 00 00 ZZZ $499.54

70547 P 00 00 00 00 ZZZ $63.76

70547 T 00 00 00 00 ZZZ $435.78

70548 C 00 00 00 00 ZZZ $499.54

70548 P 00 00 00 00 ZZZ $63.76

70548 T 00 00 00 00 ZZZ $435.78

Page 292: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

70549 C 00 00 00 00 ZZZ $946.96

70549 P 00 00 00 00 ZZZ $94.13

70549 T 00 00 00 00 ZZZ $852.82

70551 C 00 00 00 00 ZZZ $564.00

70551 P 00 00 00 00 ZZZ $162.00

70551 T 00 00 00 00 ZZZ $403.00

70552 C 00 00 00 00 ZZZ $677.00

70552 P 00 00 00 00 ZZZ $182.00

70552 T 00 00 00 00 ZZZ $495.00

70553 C 00 00 00 00 ZZZ $834.90

70553 P 00 00 00 00 ZZZ $182.00

70553 T 00 00 00 00 ZZZ $652.90

70557 C 00 00 00 00 ZZZ $0.00

70557 P 00 00 00 00 ZZZ $184.63

70558 C 00 00 00 00 ZZZ $0.00

70558 P 00 00 00 00 ZZZ $204.22

70559 C 00 00 00 00 ZZZ $0.00

70559 P 00 00 00 00 ZZZ $205.14

71010 C 00 00 00 00 ZZZ $28.60

71010 P 00 00 00 00 ZZZ $17.00

71010 T 00 00 00 00 ZZZ $11.60

71015 C 00 00 00 00 ZZZ $30.80

71015 P 00 00 00 00 ZZZ $15.00

71015 T 00 00 00 00 ZZZ $15.80

71020 C 00 00 00 00 ZZZ $37.40

71020 P 00 00 00 00 ZZZ $18.00

71020 T 00 00 00 00 ZZZ $19.40

71021 C 00 00 00 00 ZZZ $30.69

71021 P 00 00 00 00 ZZZ $12.98

71021 T 00 00 00 00 ZZZ $17.71

71022 C 00 00 00 00 ZZZ $35.20

71022 P 00 00 00 00 ZZZ $18.12

71022 T 00 00 00 00 ZZZ $17.08

71023 C 00 00 00 00 ZZZ $37.40

71023 P 00 00 00 00 ZZZ $11.59

71023 T 00 00 00 00 ZZZ $25.81

71030 C 00 00 00 00 ZZZ $39.60

71030 P 00 00 00 00 ZZZ $16.04

71030 T 00 00 00 00 ZZZ $23.56

71034 C 00 00 00 00 ZZZ $57.96

Page 293: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

71034 P 00 00 00 00 ZZZ $21.57

71034 T 00 00 00 00 ZZZ $36.39

71035 C 00 00 00 00 ZZZ $42.00

71035 P 00 00 00 00 ZZZ $13.00

71035 T 00 00 00 00 ZZZ $29.00

71100 C 00 00 00 00 ZZZ $39.60

71100 P 00 00 00 00 ZZZ $18.00

71100 T 00 00 00 00 ZZZ $21.60

71101 C 00 00 00 00 ZZZ $46.20

71101 P 00 00 00 00 ZZZ $24.00

71101 T 00 00 00 00 ZZZ $22.20

71110 C 00 00 00 00 ZZZ $52.80

71110 P 00 00 00 00 ZZZ $22.00

71110 T 00 00 00 00 ZZZ $30.80

71111 C 00 00 00 00 ZZZ $59.40

71111 P 00 00 00 00 ZZZ $22.00

71111 T 00 00 00 00 ZZZ $37.40

71120 C 00 00 00 00 ZZZ $26.40

71120 P 00 00 00 00 ZZZ $11.00

71120 T 00 00 00 00 ZZZ $15.40

71130 C 00 00 00 00 ZZZ $35.20

71130 P 00 00 00 00 ZZZ $14.92

71130 T 00 00 00 00 ZZZ $20.28

71250 C 00 00 00 00 ZZZ $352.00

71250 P 00 00 00 00 ZZZ $106.00

71250 T 00 00 00 00 ZZZ $246.00

71260 C 00 00 00 00 ZZZ $413.60

71260 P 00 00 00 00 ZZZ $112.00

71260 T 00 00 00 00 ZZZ $301.60

71270 C 00 00 00 00 ZZZ $504.90

71270 P 00 00 00 00 ZZZ $129.00

71270 T 00 00 00 00 ZZZ $375.90

71275 C 00 00 00 00 ZZZ $406.16

71275 P 00 00 00 00 ZZZ $64.88

71275 T 00 00 00 00 ZZZ $341.28

71550 C 00 00 00 00 ZZZ $571.00

71550 P 00 00 00 00 ZZZ $165.00

71550 T 00 00 00 00 ZZZ $406.00

71551 C 00 00 00 00 ZZZ $584.30

71551 P 00 00 00 00 ZZZ $67.88

Page 294: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

71551 T 00 00 00 00 ZZZ $516.42

71552 C 00 00 00 00 ZZZ $1,036.59

71552 P 00 00 00 00 ZZZ $88.88

71552 T 00 00 00 00 ZZZ $947.71

71555 C 00 00 00 00 ZZZ $542.30

71555 P 00 00 00 00 ZZZ $94.88

71555 T 00 00 00 00 ZZZ $447.41

72020 C 00 00 00 00 ZZZ $39.05

72020 P 00 00 00 00 ZZZ $12.00

72020 T 00 00 00 00 ZZZ $27.04

72040 C 00 00 00 00 ZZZ $46.00

72040 P 00 00 00 00 ZZZ $18.00

72040 T 00 00 00 00 ZZZ $28.00

72050 C 00 00 00 00 ZZZ $58.30

72050 P 00 00 00 00 ZZZ $21.00

72050 T 00 00 00 00 ZZZ $37.30

72052 C 00 00 00 00 ZZZ $83.00

72052 P 00 00 00 00 ZZZ $27.00

72052 T 00 00 00 00 ZZZ $55.00

72070 C 00 00 00 00 ZZZ $47.09

72070 P 00 00 00 00 ZZZ $19.00

72070 T 00 00 00 00 ZZZ $28.09

72072 C 00 00 00 00 ZZZ $50.60

72072 P 00 00 00 00 ZZZ $18.00

72072 T 00 00 00 00 ZZZ $32.60

72074 C 00 00 00 00 ZZZ $57.20

72074 P 00 00 00 00 ZZZ $20.00

72074 T 00 00 00 00 ZZZ $37.20

72080 C 00 00 00 00 ZZZ $48.02

72080 P 00 00 00 00 ZZZ $18.00

72080 T 00 00 00 00 ZZZ $30.02

72081 C 00 00 00 00 ZZZ $37.23

72081 P 00 00 00 00 ZZZ $13.72

72081 T 00 00 00 00 ZZZ $23.51

72082 C 00 00 00 00 ZZZ $59.46

72082 P 00 00 00 00 ZZZ $16.64

72082 T 00 00 00 00 ZZZ $42.82

72083 C 00 00 00 00 ZZZ $64.66

72083 P 00 00 00 00 ZZZ $18.18

72083 T 00 00 00 00 ZZZ $46.48

Page 295: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

72084 C 00 00 00 00 ZZZ $76.95

72084 P 00 00 00 00 ZZZ $21.15

72084 T 00 00 00 00 ZZZ $55.80

72100 C 00 00 00 00 ZZZ $46.20

72100 P 00 00 00 00 ZZZ $14.92

72100 T 00 00 00 00 ZZZ $31.28

72110 C 00 00 00 00 ZZZ $66.00

72110 P 00 00 00 00 ZZZ $20.51

72110 T 00 00 00 00 ZZZ $45.49

72114 C 00 00 00 00 ZZZ $71.50

72114 P 00 00 00 00 ZZZ $22.00

72114 T 00 00 00 00 ZZZ $49.50

72120 C 00 00 00 00 ZZZ $58.30

72120 P 00 00 00 00 ZZZ $20.00

72120 T 00 00 00 00 ZZZ $38.30

72125 C 00 00 00 00 ZZZ $352.00

72125 P 00 00 00 00 ZZZ $106.00

72125 T 00 00 00 00 ZZZ $246.00

72126 C 00 00 00 00 ZZZ $410.30

72126 P 00 00 00 00 ZZZ $112.00

72126 T 00 00 00 00 ZZZ $298.30

72127 C 00 00 00 00 ZZZ $497.20

72127 P 00 00 00 00 ZZZ $129.00

72127 T 00 00 00 00 ZZZ $368.20

72128 C 00 00 00 00 ZZZ $352.00

72128 P 00 00 00 00 ZZZ $106.00

72128 T 00 00 00 00 ZZZ $246.00

72129 C 00 00 00 00 ZZZ $410.30

72129 P 00 00 00 00 ZZZ $112.00

72129 T 00 00 00 00 ZZZ $298.30

72130 C 00 00 00 00 ZZZ $497.20

72130 P 00 00 00 00 ZZZ $129.00

72130 T 00 00 00 00 ZZZ $368.20

72131 C 00 00 00 00 ZZZ $352.00

72131 P 00 00 00 00 ZZZ $106.00

72131 T 00 00 00 00 ZZZ $246.00

72132 C 00 00 00 00 ZZZ $410.30

72132 P 00 00 00 00 ZZZ $112.00

72132 T 00 00 00 00 ZZZ $298.30

72133 C 00 00 00 00 ZZZ $497.20

Page 296: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

72133 P 00 00 00 00 ZZZ $129.00

72133 T 00 00 00 00 ZZZ $368.20

72141 C 00 00 00 00 ZZZ $571.00

72141 P 00 00 00 00 ZZZ $165.00

72141 T 00 00 00 00 ZZZ $406.00

72142 C 00 00 00 00 ZZZ $693.00

72142 P 00 00 00 00 ZZZ $182.00

72142 T 00 00 00 00 ZZZ $512.00

72146 C 00 00 00 00 ZZZ $627.00

72146 P 00 00 00 00 ZZZ $182.00

72146 T 00 00 00 00 ZZZ $446.00

72147 C 00 00 00 00 ZZZ $693.00

72147 P 00 00 00 00 ZZZ $182.00

72147 T 00 00 00 00 ZZZ $512.00

72148 C 00 00 00 00 ZZZ $614.00

72148 P 00 00 00 00 ZZZ $182.00

72148 T 00 00 00 00 ZZZ $432.00

72149 C 00 00 00 00 ZZZ $677.00

72149 P 00 00 00 00 ZZZ $182.00

72149 T 00 00 00 00 ZZZ $495.00

72156 C 00 00 00 00 ZZZ $834.90

72156 P 00 00 00 00 ZZZ $182.00

72156 T 00 00 00 00 ZZZ $652.90

72157 C 00 00 00 00 ZZZ $834.90

72157 P 00 00 00 00 ZZZ $182.00

72157 T 00 00 00 00 ZZZ $652.90

72158 C 00 00 00 00 ZZZ $834.90

72158 P 00 00 00 00 ZZZ $182.00

72158 T 00 00 00 00 ZZZ $652.90

72159 C 00 00 00 00 ZZZ $447.06

72159 P 00 00 00 00 ZZZ $243.85

72159 T 00 00 00 00 ZZZ $203.21

72170 C 00 00 00 00 ZZZ $35.20

72170 P 00 00 00 00 ZZZ $11.66

72170 T 00 00 00 00 ZZZ $23.54

72190 A FP 00 00 00 ZZZ $46.20

72190 C 00 00 00 00 ZZZ $46.20

72190 J 00 00 00 00 ZZZ $13.20

72190 P 00 00 00 00 ZZZ $13.20

72190 T 00 00 00 00 ZZZ $33.00

Page 297: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

72191 C 00 00 00 00 ZZZ $393.03

72191 P 00 00 00 00 ZZZ $64.88

72191 T 00 00 00 00 ZZZ $328.15

72192 C 00 00 00 00 ZZZ $348.70

72192 P 00 00 00 00 ZZZ $89.00

72192 T 00 00 00 00 ZZZ $259.70

72193 C 00 00 00 00 ZZZ $396.00

72193 P 00 00 00 00 ZZZ $106.00

72193 T 00 00 00 00 ZZZ $290.00

72194 C 00 00 00 00 ZZZ $479.60

72194 P 00 00 00 00 ZZZ $128.00

72194 T 00 00 00 00 ZZZ $351.60

72195 C 00 00 00 00 ZZZ $488.67

72195 P 00 00 00 00 ZZZ $57.38

72195 T 00 00 00 00 ZZZ $431.29

72196 C 00 00 00 00 ZZZ $502.00

72196 P 00 00 00 00 ZZZ $132.00

72196 T 00 00 00 00 ZZZ $370.00

72197 C 00 00 00 00 ZZZ $1,044.84

72197 P 00 00 00 00 ZZZ $89.63

72197 T 00 00 00 00 ZZZ $955.20

72198 C 00 00 00 00 ZZZ $545.30

72198 P 00 00 00 00 ZZZ $97.88

72198 T 00 00 00 00 ZZZ $447.41

72200 C 00 00 00 00 ZZZ $30.80

72200 P 00 00 00 00 ZZZ $15.00

72200 T 00 00 00 00 ZZZ $15.80

72202 C 00 00 00 00 ZZZ $35.20

72202 P 00 00 00 00 ZZZ $12.10

72202 T 00 00 00 00 ZZZ $23.10

72220 C 00 00 00 00 ZZZ $35.20

72220 P 00 00 00 00 ZZZ $15.00

72220 T 00 00 00 00 ZZZ $20.20

72240 C 00 00 00 00 ZZZ $166.54

72240 P 00 00 00 00 ZZZ $60.14

72255 C 00 00 00 00 ZZZ $154.60

72255 P 00 00 00 00 ZZZ $60.14

72265 C 00 00 00 00 ZZZ $144.77

72265 P 00 00 00 00 ZZZ $55.02

72270 C 00 00 00 00 ZZZ $220.04

Page 298: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

72270 P 00 00 00 00 ZZZ $88.12

72275 C 00 00 00 00 ZZZ $125.00

72275 P 00 00 00 00 ZZZ $113.64

72285 C 00 00 00 00 ZZZ $275.37

72285 P 00 00 00 00 ZZZ $58.30

72295 C 00 00 00 00 ZZZ $250.72

72295 P 00 00 00 00 ZZZ $58.30

73000 C 00 00 00 00 ZZZ $27.50

73000 P 00 00 00 00 ZZZ $10.72

73000 T 00 00 00 00 ZZZ $16.78

73010 C 00 00 00 00 ZZZ $33.00

73010 P 00 00 00 00 ZZZ $12.00

73010 T 00 00 00 00 ZZZ $21.00

73020 C 00 00 00 00 ZZZ $27.50

73020 P 00 00 00 00 ZZZ $12.00

73020 T 00 00 00 00 ZZZ $15.50

73030 C 00 00 00 00 ZZZ $38.50

73030 P 00 00 00 00 ZZZ $15.00

73030 T 00 00 00 00 ZZZ $23.50

73040 C 00 00 00 00 ZZZ $78.94

73040 P 00 00 00 00 ZZZ $36.00

73050 C 00 00 00 00 ZZZ $45.10

73050 P 00 00 00 00 ZZZ $15.00

73050 T 00 00 00 00 ZZZ $30.10

73060 C 00 00 00 00 ZZZ $37.40

73060 P 00 00 00 00 ZZZ $12.00

73060 T 00 00 00 00 ZZZ $25.40

73070 C 00 00 00 00 ZZZ $33.00

73070 P 00 00 00 00 ZZZ $12.00

73070 T 00 00 00 00 ZZZ $21.00

73080 C 00 00 00 00 ZZZ $35.20

73080 P 00 00 00 00 ZZZ $12.00

73080 T 00 00 00 00 ZZZ $23.20

73085 C 00 00 00 00 ZZZ $79.20

73085 P 00 00 00 00 ZZZ $36.37

73090 C 00 00 00 00 ZZZ $33.00

73090 P 00 00 00 00 ZZZ $12.00

73090 T 00 00 00 00 ZZZ $21.00

73092 C 00 00 00 00 ZZZ $44.29

73092 P 00 00 00 00 ZZZ $13.40

Page 299: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

73092 T 00 00 00 00 ZZZ $30.89

73100 C 00 00 00 00 ZZZ $33.00

73100 P 00 00 00 00 ZZZ $12.00

73100 T 00 00 00 00 ZZZ $21.00

73110 C 00 00 00 00 ZZZ $37.77

73110 P 00 00 00 00 ZZZ $12.00

73110 T 00 00 00 00 ZZZ $25.77

73115 C 00 00 00 00 ZZZ $64.78

73115 P 00 00 00 00 ZZZ $36.37

73120 C 00 00 00 00 ZZZ $30.80

73120 P 00 00 00 00 ZZZ $12.00

73120 T 00 00 00 00 ZZZ $18.80

73130 C 00 00 00 00 ZZZ $40.00

73130 P 00 00 00 00 ZZZ $15.00

73130 T 00 00 00 00 ZZZ $25.00

73140 C 00 00 00 00 ZZZ $27.50

73140 P 00 00 00 00 ZZZ $9.33

73140 T 00 00 00 00 ZZZ $18.17

73200 C 00 00 00 00 ZZZ $301.40

73200 P 00 00 00 00 ZZZ $89.00

73200 T 00 00 00 00 ZZZ $212.40

73201 C 00 00 00 00 ZZZ $370.66

73201 P 00 00 00 00 ZZZ $204.00

73201 T 00 00 00 00 ZZZ $166.66

73202 C 00 00 00 00 ZZZ $443.30

73202 P 00 00 00 00 ZZZ $242.00

73202 T 00 00 00 00 ZZZ $201.30

73206 C 00 00 00 00 ZZZ $353.28

73206 P 00 00 00 00 ZZZ $64.88

73206 T 00 00 00 00 ZZZ $288.40

73218 C 00 00 00 00 ZZZ $480.79

73218 P 00 00 00 00 ZZZ $51.38

73218 T 00 00 00 00 ZZZ $429.41

73219 C 00 00 00 00 ZZZ $576.05

73219 P 00 00 00 00 ZZZ $61.13

73219 T 00 00 00 00 ZZZ $514.92

73220 C 00 00 00 00 ZZZ $564.00

73220 P 00 00 00 00 ZZZ $162.00

73220 T 00 00 00 00 ZZZ $403.00

73221 C 00 00 00 00 ZZZ $577.19

Page 300: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

73221 P 00 00 00 00 ZZZ $98.20

73221 T 00 00 00 00 ZZZ $380.00

73222 C 00 00 00 00 ZZZ $576.05

73222 P 00 00 00 00 ZZZ $61.13

73222 T 00 00 00 00 ZZZ $514.92

73223 C 00 00 00 00 ZZZ $1,035.46

73223 P 00 00 00 00 ZZZ $82.51

73223 T 00 00 00 00 ZZZ $952.95

73225 C 00 00 00 00 ZZZ $426.39

73225 P 00 00 00 00 ZZZ $93.39

73225 T 00 00 00 00 ZZZ $333.00

73501 C 00 00 00 00 ZZZ $28.63

73501 P 00 00 00 00 ZZZ $9.78

73501 T 00 00 00 00 ZZZ $18.85

73502 C 00 00 00 00 ZZZ $39.49

73502 P 00 00 00 00 ZZZ $11.65

73502 T 00 00 00 00 ZZZ $27.84

73503 C 00 00 00 00 ZZZ $55.16

73503 P 00 00 00 00 ZZZ $16.54

73503 T 00 00 00 00 ZZZ $38.63

73521 C 00 00 00 00 ZZZ $38.16

73521 P 00 00 00 00 ZZZ $11.98

73521 T 00 00 00 00 ZZZ $26.17

73522 C 00 00 00 00 ZZZ $46.71

73522 P 00 00 00 00 ZZZ $15.54

73522 T 00 00 00 00 ZZZ $31.17

73523 C 00 00 00 00 ZZZ $54.14

73523 P 00 00 00 00 ZZZ $16.64

73523 T 00 00 00 00 ZZZ $37.49

73525 C 00 00 00 00 ZZZ $78.94

73525 P 00 00 00 00 ZZZ $36.00

73551 C 00 00 00 00 ZZZ $26.53

73551 P 00 00 00 00 ZZZ $8.68

73551 T 00 00 00 00 ZZZ $17.85

73552 C 00 00 00 00 ZZZ $30.96

73552 P 00 00 00 00 ZZZ $9.78

73552 T 00 00 00 00 ZZZ $21.18

73560 C 00 00 00 00 ZZZ $37.30

73560 P 00 00 00 00 ZZZ $12.00

73560 T 00 00 00 00 ZZZ $32.81

Page 301: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

73562 C 00 00 00 00 ZZZ $48.00

73562 P 00 00 00 00 ZZZ $12.00

73562 T 00 00 00 00 ZZZ $35.00

73564 C 00 00 00 00 ZZZ $51.00

73564 P 00 00 00 00 ZZZ $14.00

73564 T 00 00 00 00 ZZZ $37.00

73565 C 00 00 00 00 ZZZ $35.20

73565 P 00 00 00 00 ZZZ $10.49

73565 T 00 00 00 00 ZZZ $24.71

73580 C 00 00 00 00 ZZZ $93.37

73580 P 00 00 00 00 ZZZ $36.00

73590 C 00 00 00 00 ZZZ $37.30

73590 P 00 00 00 00 ZZZ $12.00

73590 T 00 00 00 00 ZZZ $25.30

73592 C 00 00 00 00 ZZZ $40.00

73592 P 00 00 00 00 ZZZ $13.00

73592 T 00 00 00 00 ZZZ $27.00

73600 C 00 00 00 00 ZZZ $33.00

73600 P 00 00 00 00 ZZZ $11.19

73600 T 00 00 00 00 ZZZ $21.81

73610 C 00 00 00 00 ZZZ $37.40

73610 P 00 00 00 00 ZZZ $16.00

73610 T 00 00 00 00 ZZZ $21.40

73615 C 00 00 00 00 ZZZ $137.50

73615 P 00 00 00 00 ZZZ $38.00

73615 T 00 00 00 00 ZZZ $99.50

73620 C 00 00 00 00 ZZZ $35.90

73620 P 00 00 00 00 ZZZ $12.00

73620 T 00 00 00 00 ZZZ $23.90

73630 C 00 00 00 00 ZZZ $44.00

73630 P 00 00 00 00 ZZZ $16.00

73630 T 00 00 00 00 ZZZ $28.00

73650 C 00 00 00 00 ZZZ $25.30

73650 P 00 00 00 00 ZZZ $11.00

73650 T 00 00 00 00 ZZZ $14.30

73660 C 00 00 00 00 ZZZ $28.60

73660 P 00 00 00 00 ZZZ $13.00

73660 T 00 00 00 00 ZZZ $15.60

73700 C 00 00 00 00 ZZZ $293.70

73700 P 00 00 00 00 ZZZ $86.00

Page 302: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

73700 T 00 00 00 00 ZZZ $207.70

73701 C 00 00 00 00 ZZZ $370.66

73701 P 00 00 00 00 ZZZ $204.00

73701 T 00 00 00 00 ZZZ $166.66

73702 C 00 00 00 00 ZZZ $443.30

73702 P 00 00 00 00 ZZZ $242.00

73702 T 00 00 00 00 ZZZ $201.30

73706 C 00 00 00 00 ZZZ $353.28

73706 P 00 00 00 00 ZZZ $64.88

73706 T 00 00 00 00 ZZZ $288.40

73718 C 00 00 00 00 ZZZ $521.34

73718 P 00 00 00 00 ZZZ $115.32

73718 T 00 00 00 00 ZZZ $403.00

73719 C 00 00 00 00 ZZZ $576.05

73719 P 00 00 00 00 ZZZ $61.13

73719 T 00 00 00 00 ZZZ $514.92

73720 C 00 00 00 00 ZZZ $564.00

73720 P 00 00 00 00 ZZZ $162.00

73720 T 00 00 00 00 ZZZ $403.00

73721 C 00 00 00 00 ZZZ $531.00

73721 P 00 00 00 00 ZZZ $152.00

73721 T 00 00 00 00 ZZZ $380.00

73722 C 00 00 00 00 ZZZ $576.05

73722 P 00 00 00 00 ZZZ $61.13

73722 T 00 00 00 00 ZZZ $514.92

73723 C 00 00 00 00 ZZZ $1,035.46

73723 P 00 00 00 00 ZZZ $82.51

73723 T 00 00 00 00 ZZZ $952.95

73725 C 00 00 00 00 ZZZ $541.17

73725 P 00 00 00 00 ZZZ $93.76

73725 T 00 00 00 00 ZZZ $447.41

74000 C 00 00 00 00 ZZZ $37.77

74000 P 00 00 00 00 ZZZ $15.00

74000 T 00 00 00 00 ZZZ $22.77

74010 C 00 00 00 00 ZZZ $43.82

74010 P 00 00 00 00 ZZZ $15.38

74010 T 00 00 00 00 ZZZ $28.44

74020 C 00 00 00 00 ZZZ $46.20

74020 P 00 00 00 00 ZZZ $18.18

74020 T 00 00 00 00 ZZZ $28.02

Page 303: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

74022 C 00 00 00 00 ZZZ $57.20

74022 P 00 00 00 00 ZZZ $21.45

74022 T 00 00 00 00 ZZZ $35.75

74150 C 00 00 00 00 ZZZ $345.40

74150 P 00 00 00 00 ZZZ $96.00

74150 T 00 00 00 00 ZZZ $249.40

74160 C 00 00 00 00 ZZZ $402.60

74160 P 00 00 00 00 ZZZ $106.00

74160 T 00 00 00 00 ZZZ $296.60

74170 C 00 00 00 00 ZZZ $490.60

74170 P 00 00 00 00 ZZZ $129.00

74170 T 00 00 00 00 ZZZ $361.60

74174 C 00 00 00 00 ZZZ $566.11

74174 P 00 00 00 00 ZZZ $136.95

74174 T 00 00 00 00 ZZZ $429.16

74175 C 00 00 00 00 ZZZ $393.03

74175 P 00 00 00 00 ZZZ $64.88

74175 T 00 00 00 00 ZZZ $328.15

74176 C 00 00 00 00 ZZZ $212.36

74176 P 00 00 00 00 ZZZ $112.11

74176 T 00 00 00 00 ZZZ $108.30

74177 C 00 00 00 00 ZZZ $315.22

74177 P 00 00 00 00 ZZZ $117.51

74177 T 00 00 00 00 ZZZ $206.27

74178 C 00 00 00 00 ZZZ $393.56

74178 P 00 00 00 00 ZZZ $130.03

74178 T 00 00 00 00 ZZZ $272.95

74181 C 00 00 00 00 ZZZ $571.00

74181 P 00 00 00 00 ZZZ $162.00

74181 T 00 00 00 00 ZZZ $409.00

74182 C 00 00 00 00 ZZZ $584.30

74182 P 00 00 00 00 ZZZ $67.88

74182 T 00 00 00 00 ZZZ $516.42

74183 C 00 00 00 00 ZZZ $1,044.84

74183 P 00 00 00 00 ZZZ $89.53

74183 T 00 00 00 00 ZZZ $955.20

74185 C 00 00 00 00 ZZZ $541.54

74185 P 00 00 00 00 ZZZ $94.13

74185 T 00 00 00 00 ZZZ $447.41

74190 C 00 00 00 00 ZZZ $70.40

Page 304: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

74190 P 00 00 00 00 ZZZ $64.00

74210 C 00 00 00 00 ZZZ $66.00

74210 P 00 00 00 00 ZZZ $25.00

74210 T 00 00 00 00 ZZZ $41.00

74220 C 00 00 00 00 ZZZ $80.30

74220 P 00 00 00 00 ZZZ $37.00

74220 T 00 00 00 00 ZZZ $43.30

74230 C 00 00 00 00 ZZZ $62.70

74230 P 00 00 00 00 ZZZ $30.80

74230 T 00 00 00 00 ZZZ $31.90

74235 C 00 00 00 00 ZZZ $208.87

74235 P 00 00 00 00 ZZZ $78.79

74240 C 00 00 00 00 ZZZ $80.30

74240 P 00 00 00 00 ZZZ $46.16

74240 T 00 00 00 00 ZZZ $34.14

74241 C 00 00 00 00 ZZZ $94.60

74241 P 00 00 00 00 ZZZ $46.16

74241 T 00 00 00 00 ZZZ $48.44

74245 C 00 00 00 00 ZZZ $101.20

74245 P 00 00 00 00 ZZZ $57.67

74245 T 00 00 00 00 ZZZ $43.53

74246 C 00 00 00 00 ZZZ $94.60

74246 P 00 00 00 00 ZZZ $46.16

74246 T 00 00 00 00 ZZZ $48.44

74247 C 00 00 00 00 ZZZ $94.60

74247 P 00 00 00 00 ZZZ $50.00

74247 T 00 00 00 00 ZZZ $44.60

74249 C 00 00 00 00 ZZZ $105.95

74249 P 00 00 00 00 ZZZ $56.84

74249 T 00 00 00 00 ZZZ $49.11

74250 C 00 00 00 00 ZZZ $70.40

74250 P 00 00 00 00 ZZZ $31.24

74250 T 00 00 00 00 ZZZ $39.16

74251 C 00 00 00 00 ZZZ $70.40

74251 P 00 00 00 00 ZZZ $31.90

74251 T 00 00 00 00 ZZZ $38.50

74260 C 00 00 00 00 ZZZ $94.60

74260 P 00 00 00 00 ZZZ $40.00

74260 T 00 00 00 00 ZZZ $54.60

74261 C 00 00 00 00 ZZZ $409.91

Page 305: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

74261 P 00 00 00 00 ZZZ $145.12

74261 T 00 00 00 00 ZZZ $264.79

74262 C 00 00 00 00 ZZZ $459.34

74262 P 00 00 00 00 ZZZ $159.34

74262 T 00 00 00 00 ZZZ $299.99

74263 C 00 00 00 00 ZZZ $675.11

74263 P 00 00 00 00 ZZZ $151.76

74263 T 00 00 00 00 ZZZ $523.35

74270 C 00 00 00 00 ZZZ $94.60

74270 P 00 00 00 00 ZZZ $40.70

74270 T 00 00 00 00 ZZZ $53.90

74280 C 00 00 00 00 ZZZ $112.20

74280 P 00 00 00 00 ZZZ $62.70

74280 T 00 00 00 00 ZZZ $49.50

74283 C 00 00 00 00 ZZZ $146.87

74283 P 00 00 00 00 ZZZ $88.32

74283 T 00 00 00 00 ZZZ $58.55

74290 C 00 00 00 00 ZZZ $58.28

74290 P 00 00 00 00 ZZZ $24.00

74290 T 00 00 00 00 ZZZ $34.28

74300 C 00 00 00 00 ZZZ $29.72

74300 P 00 00 00 00 ZZZ $29.72

74300 T 00 00 00 00 ZZZ $24.00

74301 C 00 00 00 00 ZZZ $18.07

74301 P 00 00 00 00 ZZZ $18.07

74301 T 00 00 00 00 ZZZ $18.07

74328 C 00 00 00 00 ZZZ $254.10

74328 P 00 00 00 00 ZZZ $58.28

74329 C 00 00 00 00 ZZZ $254.10

74329 P 00 00 00 00 ZZZ $58.28

74330 C 00 00 00 00 ZZZ $120.64

74330 P 00 00 00 00 ZZZ $56.10

74340 C 00 00 00 00 ZZZ $93.37

74340 P 00 00 00 00 ZZZ $24.00

74340 T 00 00 00 00 ZZZ $72.00

74355 C 00 00 00 00 ZZZ $101.76

74355 P 00 00 00 00 ZZZ $50.82

74360 C 00 00 00 00 ZZZ $108.84

74360 P 00 00 00 00 ZZZ $36.83

74363 C 00 00 00 00 ZZZ $310.23

Page 306: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

74363 P 00 00 00 00 ZZZ $55.29

74363 T 00 00 00 00 ZZZ $254.94

74400 C 00 00 00 00 ZZZ $97.90

74400 P 00 00 00 00 ZZZ $34.00

74400 T 00 00 00 00 ZZZ $63.90

74410 C 00 00 00 00 ZZZ $94.60

74410 P 00 00 00 00 ZZZ $41.00

74410 T 00 00 00 00 ZZZ $53.60

74415 C 00 00 00 00 ZZZ $119.90

74415 P 00 00 00 00 ZZZ $45.00

74415 T 00 00 00 00 ZZZ $74.90

74420 C 00 00 00 00 ZZZ $97.90

74420 P 00 00 00 00 ZZZ $16.50

74420 T 00 00 00 00 ZZZ $81.40

74425 C 00 00 00 00 ZZZ $49.83

74425 P 00 00 00 00 ZZZ $23.78

74430 C 00 00 00 00 ZZZ $41.70

74430 P 00 00 00 00 ZZZ $21.45

74440 C 00 00 00 00 ZZZ $46.16

74440 P 00 00 00 00 ZZZ $25.64

74445 C 00 00 00 00 ZZZ $80.30

74445 P 00 00 00 00 ZZZ $76.46

74450 C 00 00 00 00 ZZZ $53.24

74450 P 00 00 00 00 ZZZ $21.91

74455 C 00 00 00 00 ZZZ $80.30

74455 P 00 00 00 00 ZZZ $73.00

74470 C 00 00 00 00 ZZZ $55.08

74470 P 00 00 00 00 ZZZ $36.00

74485 C 00 00 00 00 ZZZ $108.32

74485 P 00 00 00 00 ZZZ $35.90

74710 C 00 00 00 00 ZZZ $45.10

74710 P 00 00 00 00 ZZZ $24.00

74710 T 00 00 00 00 ZZZ $21.10

74712 C 00 00 00 00 ZZZ $463.34

74712 P 00 00 00 00 ZZZ $155.97

74712 T 00 00 00 00 ZZZ $307.37

74713 C 00 00 00 00 ZZZ $224.09

74713 P 00 00 00 00 ZZZ $92.38

74713 T 00 00 00 00 ZZZ $131.71

74740 A FP 00 00 00 ZZZ $50.88

Page 307: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

74740 C 00 00 00 00 ZZZ $50.88

74740 J 00 00 00 00 ZZZ $25.64

74740 P 00 00 00 00 ZZZ $25.64

74742 A FP 00 00 00 ZZZ $110.41

74742 C 00 00 00 00 ZZZ $110.41

74742 J 00 00 00 00 ZZZ $39.63

74742 P 00 00 00 00 ZZZ $39.63

74775 C 00 00 00 00 ZZZ $100.24

74775 P 00 00 00 00 ZZZ $39.19

74775 T 00 00 00 00 ZZZ $61.05

75557 C 00 00 00 00 ZZZ $435.58

75557 P 00 00 00 00 ZZZ $160.77

75557 T 00 00 00 00 ZZZ $274.82

75559 C 00 00 00 00 ZZZ $479.69

75559 P 00 00 00 00 ZZZ $204.87

75559 T 00 00 00 00 ZZZ $274.82

75561 C 00 00 00 00 ZZZ $598.03

75561 P 00 00 00 00 ZZZ $177.84

75561 T 00 00 00 00 ZZZ $420.19

75563 C 00 00 00 00 ZZZ $633.13

75563 P 00 00 00 00 ZZZ $212.94

75563 T 00 00 00 00 ZZZ $420.19

75565 C 00 00 00 00 ZZZ $86.83

75565 P 00 00 00 00 ZZZ $16.60

75565 T 00 00 00 00 ZZZ $70.23

75571 C 00 00 00 00 ZZZ $79.35

75571 P 00 00 00 00 ZZZ $24.48

75571 T 00 00 00 00 ZZZ $54.87

75572 C 00 00 00 00 ZZZ $247.55

75572 P 00 00 00 00 ZZZ $89.63

75572 T 00 00 00 00 ZZZ $157.91

75573 C 00 00 00 00 ZZZ $313.15

75573 P 00 00 00 00 ZZZ $89.63

75573 T 00 00 00 00 ZZZ $223.51

75574 C 00 00 00 00 ZZZ $501.31

75574 P 00 00 00 00 ZZZ $89.63

75574 T 00 00 00 00 ZZZ $411.67

75600 C 00 00 00 00 ZZZ $370.84

75600 P 00 00 00 00 ZZZ $34.03

75605 C 00 00 00 00 ZZZ $394.70

Page 308: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

75605 P 00 00 00 00 ZZZ $76.46

75625 C 00 00 00 00 ZZZ $394.44

75625 P 00 00 00 00 ZZZ $76.00

75630 C 00 00 00 00 ZZZ $430.89

75630 P 00 00 00 00 ZZZ $91.30

75635 C 00 00 00 00 ZZZ $429.41

75635 P 00 00 00 00 ZZZ $101.26

75635 T 00 00 00 00 ZZZ $328.15

75658 C 00 00 00 00 ZZZ $401.78

75658 P 00 00 00 00 ZZZ $89.05

75705 C 00 00 00 00 ZZZ $433.26

75705 P 00 00 00 00 ZZZ $145.00

75710 C 00 00 00 00 ZZZ $394.70

75710 P 00 00 00 00 ZZZ $76.46

75716 C 00 00 00 00 ZZZ $400.47

75716 P 00 00 00 00 ZZZ $86.72

75726 C 00 00 00 00 ZZZ $394.18

75726 P 00 00 00 00 ZZZ $75.53

75731 C 00 00 00 00 ZZZ $394.18

75731 P 00 00 00 00 ZZZ $75.53

75733 C 00 00 00 00 ZZZ $400.73

75733 P 00 00 00 00 ZZZ $87.18

75736 C 00 00 00 00 ZZZ $394.18

75736 P 00 00 00 00 ZZZ $75.53

75741 C 00 00 00 00 ZZZ $400.47

75741 P 00 00 00 00 ZZZ $86.72

75743 C 00 00 00 00 ZZZ $413.59

75743 P 00 00 00 00 ZZZ $110.03

75746 C 00 00 00 00 ZZZ $393.92

75746 P 00 00 00 00 ZZZ $75.06

75756 C 00 00 00 00 ZZZ $396.01

75756 P 00 00 00 00 ZZZ $78.79

75774 C 00 00 00 00 ZZZ $365.07

75774 P 00 00 00 00 ZZZ $23.78

75801 C 00 00 00 00 ZZZ $182.01

75801 P 00 00 00 00 ZZZ $54.55

75803 C 00 00 00 00 ZZZ $194.86

75803 P 00 00 00 00 ZZZ $77.39

75805 C 00 00 00 00 ZZZ $200.89

75805 P 00 00 00 00 ZZZ $54.08

Page 309: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

75807 C 00 00 00 00 ZZZ $214.00

75807 P 00 00 00 00 ZZZ $77.39

75809 C 00 00 00 00 ZZZ $69.94

75809 P 00 00 00 00 ZZZ $65.00

75810 C 00 00 00 00 ZZZ $394.18

75810 P 00 00 00 00 ZZZ $75.53

75820 C 00 00 00 00 ZZZ $52.98

75820 P 00 00 00 00 ZZZ $35.20

75822 C 00 00 00 00 ZZZ $80.78

75822 P 00 00 00 00 ZZZ $69.94

75825 C 00 00 00 00 ZZZ $394.18

75825 P 00 00 00 00 ZZZ $75.53

75827 C 00 00 00 00 ZZZ $394.18

75827 P 00 00 00 00 ZZZ $75.53

75831 C 00 00 00 00 ZZZ $394.18

75831 P 00 00 00 00 ZZZ $75.53

75833 C 00 00 00 00 ZZZ $407.29

75833 P 00 00 00 00 ZZZ $98.84

75840 C 00 00 00 00 ZZZ $394.18

75840 P 00 00 00 00 ZZZ $75.53

75842 C 00 00 00 00 ZZZ $407.29

75842 P 00 00 00 00 ZZZ $98.84

75860 C 00 00 00 00 ZZZ $394.44

75860 P 00 00 00 00 ZZZ $76.00

75870 C 00 00 00 00 ZZZ $394.18

75870 P 00 00 00 00 ZZZ $75.53

75872 C 00 00 00 00 ZZZ $394.18

75872 P 00 00 00 00 ZZZ $75.53

75880 C 00 00 00 00 ZZZ $52.98

75880 P 00 00 00 00 ZZZ $46.62

75885 C 00 00 00 00 ZZZ $697.40

75885 P 00 00 00 00 ZZZ $95.11

75885 T 00 00 00 00 ZZZ $602.29

75887 C 00 00 00 00 ZZZ $697.40

75887 P 00 00 00 00 ZZZ $95.11

75887 T 00 00 00 00 ZZZ $602.29

75889 C 00 00 00 00 ZZZ $672.10

75889 P 00 00 00 00 ZZZ $76.00

75889 T 00 00 00 00 ZZZ $596.10

75891 C 00 00 00 00 ZZZ $394.18

Page 310: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

75891 P 00 00 00 00 ZZZ $75.53

75893 C 00 00 00 00 ZZZ $371.88

75893 P 00 00 00 00 ZZZ $104.00

75894 C 00 00 00 00 ZZZ $722.52

75894 P 00 00 00 00 ZZZ $86.72

75898 C 00 00 00 00 ZZZ $203.40

75898 P 00 00 00 00 ZZZ $120.44

75898 T 00 00 00 00 ZZZ $79.96

75901 C 00 00 00 00 ZZZ $110.14

75901 P 00 00 00 00 ZZZ $28.05

75902 C 00 00 00 00 ZZZ $104.37

75902 P 00 00 00 00 ZZZ $22.28

75952 C 00 00 00 00 ZZZ $259.07

75952 P 00 00 00 00 ZZZ $259.07

75953 C 00 00 00 00 ZZZ $106.44

75953 P 00 00 00 00 ZZZ $106.44

75954 C 00 00 00 00 ZZZ $0.00

75954 P 00 00 00 00 ZZZ $103.96

75956 C 00 00 00 00 ZZZ $493.21

75956 P 00 00 00 00 ZZZ $493.21

75957 C 00 00 00 00 ZZZ $422.54

75957 P 00 00 00 00 ZZZ $422.54

75958 C 00 00 00 00 ZZZ $281.70

75958 P 00 00 00 00 ZZZ $281.70

75959 C 00 00 00 00 ZZZ $246.61

75959 P 00 00 00 00 ZZZ $246.61

75964 P 00 00 00 00 ZZZ $24.20

75966 C 00 00 00 00 ZZZ $489.38

75966 P 00 00 00 00 ZZZ $88.58

75968 C 00 00 00 00 ZZZ $247.84

75970 C 00 00 00 00 ZZZ $353.79

75970 P 00 00 00 00 ZZZ $55.95

75984 C 00 00 00 00 ZZZ $141.90

75984 P 00 00 00 00 ZZZ $48.02

75984 T 00 00 00 00 ZZZ $93.88

75989 C 00 00 00 00 ZZZ $232.10

75989 P 00 00 00 00 ZZZ $78.79

75989 T 00 00 00 00 ZZZ $153.31

76000 C 00 00 00 00 ZZZ $43.01

76000 P 00 00 00 00 ZZZ $18.00

Page 311: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

76001 C 00 00 00 00 ZZZ $173.30

76001 P 00 00 00 00 ZZZ $45.22

76010 C 00 00 00 00 ZZZ $21.24

76010 P 00 00 00 00 ZZZ $12.55

76010 T 00 00 00 00 ZZZ $8.69

76080 C 00 00 00 00 ZZZ $49.83

76080 P 00 00 00 00 ZZZ $36.00

76098 C 00 00 00 00 ZZZ $40.21

76098 P 00 00 00 00 ZZZ $26.20

76098 T 00 00 00 00 ZZZ $14.00

76100 C 00 00 00 00 ZZZ $91.30

76100 P 00 00 00 00 ZZZ $37.81

76100 T 00 00 00 00 ZZZ $53.49

76101 C 00 00 00 00 ZZZ $136.96

76101 P 00 00 00 00 ZZZ $66.96

76101 T 00 00 00 00 ZZZ $70.00

76102 C 00 00 00 00 ZZZ $112.20

76102 P 00 00 00 00 ZZZ $49.50

76102 T 00 00 00 00 ZZZ $62.70

76120 C 00 00 00 00 ZZZ $66.00

76120 P 00 00 00 00 ZZZ $24.20

76120 T 00 00 00 00 ZZZ $41.80

76125 C 00 00 00 00 ZZZ $32.26

76125 P 00 00 00 00 ZZZ $18.18

76125 T 00 00 00 00 ZZZ $14.08

76140 C 00 00 00 00 ZZZ $6.60

76140 P 00 00 00 00 ZZZ $6.60

76376 C 00 00 00 00 ZZZ $33.75

76376 P 00 00 00 00 ZZZ $13.75

76376 T 00 00 00 00 ZZZ $20.00

76377 C 00 00 00 00 ZZZ $33.75

76377 P 00 00 00 00 ZZZ $13.75

76377 T 00 00 00 00 ZZZ $20.00

76380 C 00 00 00 00 ZZZ $134.28

76380 P 00 00 00 00 ZZZ $65.27

76380 T 00 00 00 00 ZZZ $69.01

76496 C 00 00 00 00 ZZZ $0.00

76496 P 00 00 00 00 ZZZ $0.00

76496 T 00 00 00 00 ZZZ $0.00

76497 C 00 00 00 00 ZZZ $0.00

Page 312: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

76497 P 00 00 00 00 ZZZ $0.00

76497 T 00 00 00 00 ZZZ $0.00

76498 C 00 00 00 00 ZZZ $0.00

76498 P 00 00 00 00 ZZZ $0.00

76498 T 00 00 00 00 ZZZ $0.00

76499 C 00 00 00 00 ZZZ $0.00

76499 P 00 00 00 00 ZZZ $0.00

76499 T 00 00 00 00 ZZZ $0.00

76506 C 00 00 00 00 ZZZ $63.99

76506 P 00 00 00 00 ZZZ $46.00

76506 T 00 00 00 00 ZZZ $17.99

76510 C 00 00 00 00 ZZZ $210.27

76510 P 00 00 00 00 ZZZ $105.37

76510 T 00 00 00 00 ZZZ $104.90

76511 C 00 00 00 00 ZZZ $105.60

76511 P 00 00 00 00 ZZZ $52.80

76511 T 00 00 00 00 ZZZ $52.80

76512 C 00 00 00 00 ZZZ $105.60

76512 P 00 00 00 00 ZZZ $51.00

76512 T 00 00 00 00 ZZZ $54.60

76513 C 00 00 00 00 ZZZ $74.80

76513 P 00 00 00 00 ZZZ $45.10

76513 T 00 00 00 00 ZZZ $29.70

76514 C 00 00 00 00 ZZZ $13.62

76514 P 00 00 00 00 ZZZ $10.73

76514 T 00 00 00 00 ZZZ $2.96

76516 C 00 00 00 00 ZZZ $102.00

76516 P 00 00 00 00 ZZZ $41.00

76516 T 00 00 00 00 ZZZ $61.00

76519 C 00 00 00 00 ZZZ $109.00

76519 P 00 00 00 00 ZZZ $44.00

76519 T 00 00 00 00 ZZZ $65.00

76529 C 00 00 00 00 ZZZ $116.00

76529 P 00 00 00 00 ZZZ $70.00

76529 T 00 00 00 00 ZZZ $46.00

76536 C 00 00 00 00 ZZZ $94.60

76536 P 00 00 00 00 ZZZ $35.20

76536 T 00 00 00 00 ZZZ $59.40

76604 C 00 00 00 00 ZZZ $57.17

76604 P 00 00 00 00 ZZZ $29.19

Page 313: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

76604 T 00 00 00 00 ZZZ $27.98

76641 C 00 00 00 00 ZZZ $108.89

76641 P 00 00 00 00 ZZZ $45.49

76641 T 00 00 00 00 ZZZ $63.40

76642 C 00 00 00 00 ZZZ $90.88

76642 P 00 00 00 00 ZZZ $42.37

76642 T 00 00 00 00 ZZZ $48.50

76700 C 00 00 00 00 ZZZ $141.90

76700 P 00 00 00 00 ZZZ $73.00

76700 T 00 00 00 00 ZZZ $68.90

76705 C 00 00 00 00 ZZZ $80.30

76705 P 00 00 00 00 ZZZ $53.00

76705 T 00 00 00 00 ZZZ $27.30

76706 C 00 00 00 00 ZZZ $105.27

76706 P 00 00 00 00 ZZZ $33.27

76706 T 00 00 00 00 ZZZ $72.03

76770 C 00 00 00 00 ZZZ $108.90

76770 P 00 00 00 00 ZZZ $55.00

76770 T 00 00 00 00 ZZZ $53.90

76775 C 00 00 00 00 ZZZ $61.63

76775 P 00 00 00 00 ZZZ $41.96

76775 T 00 00 00 00 ZZZ $19.67

76776 C 00 00 00 00 ZZZ $124.63

76776 P 00 00 00 00 ZZZ $48.37

76776 T 00 00 00 00 ZZZ $76.26

76800 C 00 00 00 00 ZZZ $88.00

76800 P 00 00 00 00 ZZZ $52.80

76800 T 00 00 00 00 ZZZ $35.20

76801 C 00 00 00 00 ZZZ $104.37

76801 P 00 00 00 00 ZZZ $57.34

76801 T 00 00 00 00 ZZZ $47.03

76802 C 00 00 00 00 ZZZ $81.68

76802 P 00 00 00 00 ZZZ $48.27

76802 T 00 00 00 00 ZZZ $33.41

76802 W 00 00 00 00 ZZZ $48.27

76802 Y 00 00 00 00 ZZZ $33.41

76805 C 00 00 00 00 ZZZ $145.20

76805 P 00 00 00 00 ZZZ $76.00

76805 T 00 00 00 00 ZZZ $69.20

76805 W 00 00 00 00 ZZZ $76.00

Page 314: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

76805 Y 00 00 00 00 ZZZ $61.60

76810 C 00 00 00 00 ZZZ $191.19

76810 P 00 00 00 00 ZZZ $112.57

76810 T 00 00 00 00 ZZZ $78.62

76810 W 00 00 00 00 ZZZ $114.46

76810 Y 00 00 00 00 ZZZ $76.73

76811 C 00 00 00 00 ZZZ $272.27

76811 P 00 00 00 00 ZZZ $112.62

76811 T 00 00 00 00 ZZZ $159.65

76812 C 00 00 00 00 ZZZ $162.13

76812 P 00 00 00 00 ZZZ $105.20

76812 T 00 00 00 00 ZZZ $56.93

76812 W 00 00 00 00 ZZZ $105.20

76812 Y 00 00 00 00 ZZZ $56.93

76813 C 00 00 00 00 ZZZ $162.66

76813 P 00 00 00 00 ZZZ $73.98

76813 T 00 00 00 00 ZZZ $88.68

76814 C 00 00 00 00 ZZZ $95.64

76814 P 00 00 00 00 ZZZ $62.13

76814 T 00 00 00 00 ZZZ $33.52

76815 C 00 00 00 00 ZZZ $92.40

76815 P 00 00 00 00 ZZZ $58.00

76815 T 00 00 00 00 ZZZ $34.40

76815 W 00 00 00 00 ZZZ $58.00

76815 Y 00 00 00 00 ZZZ $28.60

76816 C 00 00 00 00 ZZZ $92.40

76816 P 00 00 00 00 ZZZ $58.00

76816 T 00 00 00 00 ZZZ $34.40

76816 W 00 00 00 00 ZZZ $58.00

76817 C 00 00 00 00 ZZZ $107.67

76817 P 00 00 00 00 ZZZ $43.32

76817 T 00 00 00 00 ZZZ $64.35

76817 W 00 00 00 00 ZZZ $43.32

76817 Y 00 00 00 00 ZZZ $64.35

76818 C 00 00 00 00 ZZZ $95.37

76818 P 00 00 00 00 ZZZ $52.22

76818 T 00 00 00 00 ZZZ $43.15

76818 W 00 00 00 00 ZZZ $52.22

76818 Y 00 00 00 00 ZZZ $38.15

76819 C 00 00 00 00 ZZZ $106.44

Page 315: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

76819 P 00 00 00 00 ZZZ $37.13

76819 T 00 00 00 00 ZZZ $69.31

76819 W 00 00 00 00 ZZZ $37.13

76819 Y 00 00 00 00 ZZZ $69.31

76820 C 00 00 00 00 ZZZ $87.90

76820 P 00 00 00 00 ZZZ $33.57

76820 T 00 00 00 00 ZZZ $57.11

76821 C 00 00 00 00 ZZZ $99.79

76821 P 00 00 00 00 ZZZ $46.62

76821 T 00 00 00 00 ZZZ $57.11

76825 C 00 00 00 00 ZZZ $166.98

76825 P 00 00 00 00 ZZZ $100.19

76825 T 00 00 00 00 ZZZ $66.79

76825 W 00 00 00 00 ZZZ $100.19

76825 Y 00 00 00 00 ZZZ $66.79

76826 C 00 00 00 00 ZZZ $124.72

76826 P 00 00 00 00 ZZZ $80.43

76826 T 00 00 00 00 ZZZ $44.29

76826 W 00 00 00 00 ZZZ $95.00

76826 Y 00 00 00 00 ZZZ $61.00

76827 C 00 00 00 00 ZZZ $143.00

76827 P 00 00 00 00 ZZZ $85.00

76827 T 00 00 00 00 ZZZ $58.00

76827 W 00 00 00 00 ZZZ $85.00

76827 Y 00 00 00 00 ZZZ $63.80

76828 C 00 00 00 00 ZZZ $119.47

76828 P 00 00 00 00 ZZZ $68.48

76828 T 00 00 00 00 ZZZ $49.00

76828 W 00 00 00 00 ZZZ $72.00

76828 Y 00 00 00 00 ZZZ $49.00

76830 C 00 00 00 00 ZZZ $172.00

76830 P 00 00 00 00 ZZZ $104.00

76830 T 00 00 00 00 ZZZ $74.80

76830 W 00 00 00 00 ZZZ $104.00

76830 Y 00 00 00 00 ZZZ $74.80

76831 C 00 00 00 00 ZZZ $108.91

76831 P 00 00 00 00 ZZZ $44.97

76831 T 00 00 00 00 ZZZ $63.94

76856 C 00 00 00 00 ZZZ $116.60

76856 P 00 00 00 00 ZZZ $62.00

Page 316: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

76856 T 00 00 00 00 ZZZ $54.50

76856 W 00 00 00 00 ZZZ $62.00

76856 Y 00 00 00 00 ZZZ $48.40

76857 C 00 00 00 00 ZZZ $71.50

76857 P 00 00 00 00 ZZZ $39.00

76857 T 00 00 00 00 ZZZ $32.50

76857 W 00 00 00 00 ZZZ $39.00

76857 Y 00 00 00 00 ZZZ $28.60

76870 C 00 00 00 00 ZZZ $101.20

76870 P 00 00 00 00 ZZZ $58.00

76870 T 00 00 00 00 ZZZ $43.20

76872 C 00 00 00 00 ZZZ $122.62

76872 P 00 00 00 00 ZZZ $76.00

76872 T 00 00 00 00 ZZZ $46.62

76873 C 00 00 00 00 ZZZ $169.96

76873 P 00 00 00 00 ZZZ $154.51

76873 T 00 00 00 00 ZZZ $84.01

76881 C 00 00 00 00 ZZZ $140.55

76881 P 00 00 00 00 ZZZ $38.21

76881 T 00 00 00 00 ZZZ $102.34

76882 C 00 00 00 00 ZZZ $38.50

76882 P 00 00 00 00 ZZZ $26.51

76882 T 00 00 00 00 ZZZ $11.99

76885 C 00 00 00 00 ZZZ $109.74

76885 P 00 00 00 00 ZZZ $45.79

76885 T 00 00 00 00 ZZZ $63.95

76886 C 00 00 00 00 ZZZ $97.77

76886 P 00 00 00 00 ZZZ $38.37

76886 T 00 00 00 00 ZZZ $59.40

76930 C 00 00 00 00 ZZZ $68.71

76930 P 00 00 00 00 ZZZ $46.16

76932 C 00 00 00 00 ZZZ $68.98

76932 P 00 00 00 00 ZZZ $46.62

76936 C 00 00 00 00 ZZZ $256.75

76936 P 00 00 00 00 ZZZ $143.60

76936 T 00 00 00 00 ZZZ $113.51

76937 C 00 00 00 00 ZZZ $37.96

76937 P 00 00 00 00 ZZZ $18.57

76937 T 00 00 00 00 ZZZ $19.39

76940 C 00 00 00 00 ZZZ $189.35

Page 317: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

76940 P 00 00 00 00 ZZZ $114.68

76940 T 00 00 00 00 ZZZ $74.67

76941 C 00 00 00 00 ZZZ $94.68

76941 P 00 00 00 00 ZZZ $46.72

76942 C 00 00 00 00 ZZZ $68.19

76942 P 00 00 00 00 ZZZ $45.22

76942 T 00 00 00 00 ZZZ $24.13

76945 P 00 00 00 00 ZZZ $46.72

76946 C 00 00 00 00 ZZZ $57.17

76946 P 00 00 00 00 ZZZ $25.64

76965 C 00 00 00 00 ZZZ $343.31

76965 P 00 00 00 00 ZZZ $121.62

76965 T 00 00 00 00 ZZZ $221.69

76970 C 00 00 00 00 ZZZ $44.85

76970 P 00 00 00 00 ZZZ $32.00

76975 C 00 00 00 00 ZZZ $73.17

76975 P 00 00 00 00 ZZZ $26.40

76977 C 00 00 00 00 ZZZ $45.75

76977 P 00 00 00 00 ZZZ $3.85

76977 T 00 00 00 00 ZZZ $41.90

76998 C 00 00 00 00 ZZZ $135.95

76998 P 00 00 00 00 ZZZ $81.57

76998 T 00 00 00 00 ZZZ $54.38

76999 C 00 00 00 00 ZZZ $0.00

76999 P 00 00 00 00 ZZZ $0.00

76999 T 00 00 00 00 ZZZ $0.00

77001 C 00 00 00 00 ZZZ $91.53

77001 P 00 00 00 00 ZZZ $24.66

77001 T 00 00 00 00 ZZZ $66.86

77002 C 00 00 00 00 ZZZ $100.06

77002 P 00 00 00 00 ZZZ $34.62

77002 T 00 00 00 00 ZZZ $65.45

77003 C 00 00 00 00 ZZZ $102.43

77003 P 00 00 00 00 ZZZ $36.99

77003 T 00 00 00 00 ZZZ $65.45

77011 C 00 00 00 00 ZZZ $354.39

77011 P 00 00 00 00 ZZZ $78.72

77011 T 00 00 00 00 ZZZ $275.67

77012 C 00 00 00 00 ZZZ $75.41

77012 P 00 00 00 00 ZZZ $75.41

Page 318: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

77013 C 00 00 00 00 ZZZ $584.41

77013 P 00 00 00 00 ZZZ $259.41

77013 T 00 00 00 00 ZZZ $324.99

77014 C 00 00 00 00 ZZZ $154.50

77014 P 00 00 00 00 ZZZ $55.49

77014 T 00 00 00 00 ZZZ $99.02

77021 C 00 00 00 00 ZZZ $99.12

77021 P 00 00 00 00 ZZZ $99.12

77022 C 00 00 00 00 ZZZ $699.23

77022 P 00 00 00 00 ZZZ $277.90

77022 T 00 00 00 00 ZZZ $421.33

77053 C 00 00 00 00 ZZZ $23.71

77053 P 00 00 00 00 ZZZ $23.71

77054 C 00 00 00 00 ZZZ $29.40

77054 P 00 00 00 00 ZZZ $29.40

77058 C 00 00 00 00 ZZZ $695.18

77058 P 00 00 00 00 ZZZ $105.75

77058 T 00 00 00 00 ZZZ $589.42

77059 C 00 00 00 00 ZZZ $905.26

77059 P 00 00 00 00 ZZZ $105.75

77059 T 00 00 00 00 ZZZ $799.50

77061 C 00 00 00 00 ZZZ $0.00

77061 P 00 00 00 00 ZZZ $0.00

77061 T 00 00 00 00 ZZZ $0.00

77062 C 00 00 00 00 ZZZ $0.00

77062 P 00 00 00 00 ZZZ $0.00

77062 T 00 00 00 00 ZZZ $0.00

77063 C 00 00 00 00 ZZZ $60.95

77063 P 00 00 00 00 ZZZ $38.12

77063 T 00 00 00 00 ZZZ $22.83

77065 C 00 00 00 00 ZZZ $147.36

77065 P 00 00 00 00 ZZZ $42.92

77065 T 00 00 00 00 ZZZ $104.44

77066 C 00 00 00 00 ZZZ $182.79

77066 P 00 00 00 00 ZZZ $56.31

77066 T 00 00 00 00 ZZZ $126.48

77067 C 00 00 00 00 ZZZ $144.14

77067 P 00 00 00 00 ZZZ $45.30

77067 T 00 00 00 00 ZZZ $98.84

77071 C 00 00 00 00 ZZZ $30.82

Page 319: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

77071 P 00 00 00 00 ZZZ $30.82

77072 C 00 00 00 00 ZZZ $37.94

77072 P 00 00 00 00 ZZZ $12.33

77072 T 00 00 00 00 ZZZ $25.61

77073 C 00 00 00 00 ZZZ $56.91

77073 P 00 00 00 00 ZZZ $17.54

77073 T 00 00 00 00 ZZZ $39.36

77074 C 00 00 00 00 ZZZ $79.67

77074 P 00 00 00 00 ZZZ $29.40

77074 T 00 00 00 00 ZZZ $50.27

77075 C 00 00 00 00 ZZZ $107.18

77075 P 00 00 00 00 ZZZ $35.10

77075 T 00 00 00 00 ZZZ $72.09

77076 C 00 00 00 00 ZZZ $82.52

77076 P 00 00 00 00 ZZZ $45.53

77076 T 00 00 00 00 ZZZ $36.99

77077 C 00 00 00 00 ZZZ $75.88

77077 P 00 00 00 00 ZZZ $20.39

77077 T 00 00 00 00 ZZZ $55.49

77078 C 00 00 00 00 ZZZ $115.14

77078 P 00 00 00 00 ZZZ $16.13

77078 T 00 00 00 00 ZZZ $99.02

77080 C 00 00 00 00 ZZZ $174.52

77080 P 00 00 00 00 ZZZ $19.44

77080 T 00 00 00 00 ZZZ $155.08

77081 C 00 00 00 00 ZZZ $52.64

77081 P 00 00 00 00 ZZZ $14.70

77081 T 00 00 00 00 ZZZ $37.94

77084 C 00 00 00 00 ZZZ $478.71

77084 P 00 00 00 00 ZZZ $103.86

77084 T 00 00 00 00 ZZZ $374.86

77085 C 00 00 00 00 ZZZ $55.50

77085 P 00 00 00 00 ZZZ $19.04

77085 T 00 00 00 00 ZZZ $36.46

77086 C 00 00 00 00 ZZZ $34.78

77086 P 00 00 00 00 ZZZ $11.00

77086 T 00 00 00 00 ZZZ $23.78

77261 C 00 00 00 00 ZZZ $98.00

77261 P 00 00 00 00 ZZZ $98.00

77262 C 00 00 00 00 ZZZ $149.00

Page 320: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

77262 P 00 00 00 00 ZZZ $149.00

77263 C 00 00 00 00 ZZZ $221.00

77263 P 00 00 00 00 ZZZ $221.00

77280 C 00 00 00 00 ZZZ $219.60

77280 P 00 00 00 00 ZZZ $50.00

77280 T 00 00 00 00 ZZZ $169.60

77285 C 00 00 00 00 ZZZ $347.35

77285 P 00 00 00 00 ZZZ $74.00

77285 T 00 00 00 00 ZZZ $273.35

77290 C 00 00 00 00 ZZZ $428.94

77290 P 00 00 00 00 ZZZ $111.00

77290 T 00 00 00 00 ZZZ $317.94

77293 C 00 00 00 00 ZZZ $481.10

77293 P 00 00 00 00 ZZZ $133.07

77293 T 00 00 00 00 ZZZ $348.00

77295 C 00 00 00 00 ZZZ $953.58

77295 P 00 00 00 00 ZZZ $203.91

77295 T 00 00 00 00 ZZZ $749.67

77299 C 00 00 00 00 ZZZ $0.00

77299 P 00 00 00 00 ZZZ $0.00

77299 T 00 00 00 00 ZZZ $0.00

77300 C 00 00 00 00 ZZZ $111.00

77300 P 00 00 00 00 ZZZ $44.00

77300 T 00 00 00 00 ZZZ $67.00

77301 C 00 00 00 00 ZZZ $1,234.32

77301 P 00 00 00 00 ZZZ $428.16

77301 T 00 00 00 00 ZZZ $806.16

77306 C 00 00 00 00 ZZZ $169.24

77306 P 00 00 00 00 ZZZ $91.47

77306 T 00 00 00 00 ZZZ $77.77

77307 C 00 00 00 00 ZZZ $332.06

77307 P 00 00 00 00 ZZZ $189.76

77307 T 00 00 00 00 ZZZ $142.30

77316 C 00 00 00 00 ZZZ $212.46

77316 P 00 00 00 00 ZZZ $91.81

77316 T 00 00 00 00 ZZZ $120.66

77317 C 00 00 00 00 ZZZ $278.15

77317 P 00 00 00 00 ZZZ $120.66

77317 T 00 00 00 00 ZZZ $157.48

77318 C 00 00 00 00 ZZZ $404.09

Page 321: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

77318 P 00 00 00 00 ZZZ $190.43

77318 T 00 00 00 00 ZZZ $213.66

77321 C 00 00 00 00 ZZZ $306.00

77321 P 00 00 00 00 ZZZ $67.00

77321 T 00 00 00 00 ZZZ $239.00

77331 C 00 00 00 00 ZZZ $84.00

77331 P 00 00 00 00 ZZZ $61.00

77331 T 00 00 00 00 ZZZ $22.00

77332 C 00 00 00 00 ZZZ $103.04

77332 P 00 00 00 00 ZZZ $39.00

77332 T 00 00 00 00 ZZZ $64.04

77333 C 00 00 00 00 ZZZ $150.59

77333 P 00 00 00 00 ZZZ $59.00

77333 T 00 00 00 00 ZZZ $91.59

77334 C 00 00 00 00 ZZZ $249.00

77334 P 00 00 00 00 ZZZ $87.00

77334 T 00 00 00 00 ZZZ $162.00

77336 C 00 00 00 00 ZZZ $101.20

77336 P 00 00 00 00 ZZZ $101.20

77336 T 00 00 00 00 ZZZ $101.20

77338 C 00 00 00 00 ZZZ $519.76

77338 P 00 00 00 00 ZZZ $295.93

77338 T 00 00 00 00 ZZZ $223.83

77370 C 00 00 00 00 ZZZ $89.10

77370 P 00 00 00 00 ZZZ $49.00

77370 T 00 00 00 00 ZZZ $109.00

77371 C 00 00 00 00 ZZZ $974.17

77371 T 00 00 00 00 ZZZ $974.17

77372 C 00 00 00 00 ZZZ $739.93

77372 T 00 00 00 00 ZZZ $739.93

77373 C 00 00 00 00 ZZZ $1,378.11

77373 T 00 00 00 00 ZZZ $1,378.11

77385 C 00 00 00 00 ZZZ $382.34

77385 P 00 00 00 00 ZZZ $0.00

77385 T 00 00 00 00 ZZZ $0.00

77386 C 00 00 00 00 ZZZ $382.34

77386 P 00 00 00 00 ZZZ $0.00

77386 T 00 00 00 00 ZZZ $382.34

77387 C 00 00 00 00 ZZZ $83.65

77387 P 00 00 00 00 ZZZ $24.62

Page 322: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

77387 T 00 00 00 00 ZZZ $59.03

77399 C 00 00 00 00 ZZZ $0.00

77399 P 00 00 00 00 ZZZ $0.00

77399 T 00 00 00 00 ZZZ $0.00

77401 C 00 00 00 00 ZZZ $49.83

77401 T 00 00 00 00 ZZZ $39.60

77402 C 00 00 00 00 ZZZ $64.90

77402 T 00 00 00 00 ZZZ $64.90

77407 C 00 00 00 00 ZZZ $72.60

77407 T 00 00 00 00 ZZZ $72.60

77412 C 00 00 00 00 ZZZ $83.60

77412 T 00 00 00 00 ZZZ $83.60

77417 C 00 00 00 00 ZZZ $28.60

77417 T 00 00 00 00 ZZZ $28.60

77419 P 00 00 00 00 ZZZ $167.20

77422 C 00 00 00 00 ZZZ $60.89

77422 T 00 00 00 00 ZZZ $60.89

77423 C 00 00 00 00 ZZZ $78.49

77423 T 00 00 00 00 ZZZ $78.49

77424 P 00 00 00 00 ZZZ $0.00

77424 T 00 00 00 00 ZZZ $0.00

77425 P 00 00 00 00 ZZZ $0.00

77425 T 00 00 00 00 ZZZ $0.00

77427 C 00 00 00 00 ZZZ $185.64

77427 P 00 00 00 00 ZZZ $185.64

77431 C 00 00 00 00 ZZZ $94.60

77431 P 00 00 00 00 ZZZ $94.60

77432 C 00 00 00 00 ZZZ $620.00

77432 P 00 00 00 00 ZZZ $620.00

77435 C 00 00 00 00 ZZZ $796.45

77435 P 00 00 00 00 ZZZ $796.45

77435 T 00 00 00 00 ZZZ $796.45

77469 C 00 00 00 00 ZZZ $0.00

77469 P 00 00 00 00 ZZZ $0.00

77470 C 00 00 00 00 ZZZ $490.60

77470 P 00 00 00 00 ZZZ $267.60

77470 T 00 00 00 00 ZZZ $223.00

77499 C 00 00 00 00 ZZZ $0.00

77499 P 00 00 00 00 ZZZ $0.00

77499 T 00 00 00 00 ZZZ $0.00

Page 323: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

77520 C 00 00 00 00 ZZZ $0.00

77520 T 00 00 00 00 ZZZ $0.00

77522 C 00 00 00 00 ZZZ $0.00

77522 T 00 00 00 00 ZZZ $0.00

77523 C 00 00 00 00 ZZZ $0.00

77523 T 00 00 00 00 ZZZ $0.00

77525 C 00 00 00 00 ZZZ $0.00

77525 T 00 00 00 00 ZZZ $0.00

77600 C 00 00 00 00 ZZZ $181.50

77600 P 00 00 00 00 ZZZ $104.44

77600 T 00 00 00 00 ZZZ $165.00

77605 C 00 00 00 00 ZZZ $246.40

77605 P 00 00 00 00 ZZZ $142.20

77605 T 00 00 00 00 ZZZ $224.00

77610 C 00 00 00 00 ZZZ $181.50

77610 P 00 00 00 00 ZZZ $104.44

77610 T 00 00 00 00 ZZZ $165.00

77615 C 00 00 00 00 ZZZ $246.40

77615 P 00 00 00 00 ZZZ $224.58

77615 T 00 00 00 00 ZZZ $224.00

77620 C 00 00 00 00 ZZZ $181.50

77620 P 00 00 00 00 ZZZ $107.23

77620 T 00 00 00 00 ZZZ $165.00

77750 C 00 00 00 00 ZZZ $355.30

77750 P 00 00 00 00 ZZZ $326.26

77761 C 00 00 00 00 ZZZ $469.74

77761 P 00 00 00 00 ZZZ $251.00

77761 T 00 00 00 00 ZZZ $218.72

77762 C 00 00 00 00 ZZZ $702.27

77762 P 00 00 00 00 ZZZ $378.00

77762 T 00 00 00 00 ZZZ $324.28

77763 C 00 00 00 00 ZZZ $993.67

77763 P 00 00 00 00 ZZZ $565.00

77763 T 00 00 00 00 ZZZ $428.68

77770 C 00 00 00 00 ZZZ $309.72

77770 P 00 00 00 00 ZZZ $103.49

77770 T 00 00 00 00 ZZZ $206.24

77771 C 00 00 00 00 ZZZ $577.78

77771 P 00 00 00 00 ZZZ $202.14

77771 T 00 00 00 00 ZZZ $375.65

Page 324: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

77772 C 00 00 00 00 ZZZ $879.39

77772 P 00 00 00 00 ZZZ $286.65

77772 T 00 00 00 00 ZZZ $592.74

77778 C 00 00 00 00 ZZZ $562.55

77778 P 00 00 00 00 ZZZ $396.81

77778 T 00 00 00 00 ZZZ $165.74

77789 C 00 00 00 00 ZZZ $69.30

77789 P 00 00 00 00 ZZZ $53.90

77789 T 00 00 00 00 ZZZ $15.40

77790 C 00 00 00 00 ZZZ $100.00

77790 P 00 00 00 00 ZZZ $74.00

77790 T 00 00 00 00 ZZZ $17.00

77799 C 00 00 00 00 ZZZ $0.00

77799 P 00 00 00 00 ZZZ $0.00

77799 T 00 00 00 00 ZZZ $0.00

78012 C 00 00 00 00 ZZZ $77.42

78012 P 00 00 00 00 ZZZ $11.45

78012 T 00 00 00 00 ZZZ $65.98

78013 C 00 00 00 00 ZZZ $193.71

78013 P 00 00 00 00 ZZZ $22.10

78013 T 00 00 00 00 ZZZ $171.61

78014 C 00 00 00 00 ZZZ $225.63

78014 P 00 00 00 00 ZZZ $29.82

78014 T 00 00 00 00 ZZZ $195.81

78015 C 00 00 00 00 ZZZ $97.30

78015 P 00 00 00 00 ZZZ $37.84

78015 T 00 00 00 00 ZZZ $59.46

78016 C 00 00 00 00 ZZZ $145.20

78016 P 00 00 00 00 ZZZ $45.10

78016 T 00 00 00 00 ZZZ $100.10

78018 C 00 00 00 00 ZZZ $184.37

78018 P 00 00 00 00 ZZZ $70.00

78018 T 00 00 00 00 ZZZ $114.37

78020 C 00 00 00 00 ZZZ $35.07

78020 P 00 00 00 00 ZZZ $22.32

78020 T 00 00 00 00 ZZZ $12.75

78070 C 00 00 00 00 ZZZ $79.73

78070 P 00 00 00 00 ZZZ $48.36

78070 T 00 00 00 00 ZZZ $31.37

78071 C 00 00 00 00 ZZZ $343.90

Page 325: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78071 P 00 00 00 00 ZZZ $70.94

78071 T 00 00 00 00 ZZZ $272.82

78072 C 00 00 00 00 ZZZ $97.15

78072 P 00 00 00 00 ZZZ $97.15

78072 T 00 00 00 00 ZZZ $38.86

78075 C 00 00 00 00 ZZZ $179.65

78075 P 00 00 00 00 ZZZ $55.00

78075 T 00 00 00 00 ZZZ $124.65

78099 C 00 00 00 00 ZZZ $0.00

78099 P 00 00 00 00 ZZZ $0.00

78099 T 00 00 00 00 ZZZ $0.00

78102 C 00 00 00 00 ZZZ $128.70

78102 P 00 00 00 00 ZZZ $51.00

78102 T 00 00 00 00 ZZZ $77.70

78103 C 00 00 00 00 ZZZ $178.20

78103 P 00 00 00 00 ZZZ $97.00

78103 T 00 00 00 00 ZZZ $81.20

78104 C 00 00 00 00 ZZZ $203.50

78104 P 00 00 00 00 ZZZ $111.00

78104 T 00 00 00 00 ZZZ $92.50

78110 C 00 00 00 00 ZZZ $35.20

78110 P 00 00 00 00 ZZZ $15.00

78110 T 00 00 00 00 ZZZ $20.20

78111 C 00 00 00 00 ZZZ $86.90

78111 P 00 00 00 00 ZZZ $11.00

78111 T 00 00 00 00 ZZZ $75.90

78120 C 00 00 00 00 ZZZ $67.10

78120 P 00 00 00 00 ZZZ $13.20

78120 T 00 00 00 00 ZZZ $53.90

78121 C 00 00 00 00 ZZZ $93.10

78121 P 00 00 00 00 ZZZ $24.00

78121 T 00 00 00 00 ZZZ $69.10

78122 C 00 00 00 00 ZZZ $228.95

78122 P 00 00 00 00 ZZZ $26.82

78122 T 00 00 00 00 ZZZ $202.13

78130 C 00 00 00 00 ZZZ $116.60

78130 P 00 00 00 00 ZZZ $26.40

78130 T 00 00 00 00 ZZZ $90.20

78135 C 00 00 00 00 ZZZ $191.40

78135 P 00 00 00 00 ZZZ $104.00

Page 326: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78135 T 00 00 00 00 ZZZ $87.40

78140 C 00 00 00 00 ZZZ $145.20

78140 P 00 00 00 00 ZZZ $26.40

78140 T 00 00 00 00 ZZZ $118.80

78185 C 00 00 00 00 ZZZ $94.60

78185 P 00 00 00 00 ZZZ $48.00

78185 T 00 00 00 00 ZZZ $46.60

78190 C 00 00 00 00 ZZZ $316.82

78190 P 00 00 00 00 ZZZ $65.59

78190 T 00 00 00 00 ZZZ $251.23

78191 C 00 00 00 00 ZZZ $227.38

78191 P 00 00 00 00 ZZZ $83.00

78191 T 00 00 00 00 ZZZ $144.38

78195 C 00 00 00 00 ZZZ $155.78

78195 P 00 00 00 00 ZZZ $74.60

78195 T 00 00 00 00 ZZZ $81.18

78199 C 00 00 00 00 ZZZ $0.00

78199 P 00 00 00 00 ZZZ $0.00

78199 T 00 00 00 00 ZZZ $0.00

78201 C 00 00 00 00 ZZZ $146.86

78201 P 00 00 00 00 ZZZ $43.00

78201 T 00 00 00 00 ZZZ $103.86

78202 C 00 00 00 00 ZZZ $110.00

78202 P 00 00 00 00 ZZZ $60.00

78202 T 00 00 00 00 ZZZ $50.00

78205 C 00 00 00 00 ZZZ $191.47

78205 P 00 00 00 00 ZZZ $74.00

78205 T 00 00 00 00 ZZZ $117.47

78206 C 00 00 00 00 ZZZ $308.99

78206 P 00 00 00 00 ZZZ $59.68

78206 T 00 00 00 00 ZZZ $249.31

78215 C 00 00 00 00 ZZZ $116.60

78215 P 00 00 00 00 ZZZ $76.00

78215 T 00 00 00 00 ZZZ $40.60

78216 C 00 00 00 00 ZZZ $157.30

78216 P 00 00 00 00 ZZZ $86.00

78216 T 00 00 00 00 ZZZ $71.30

78226 C 00 00 00 00 ZZZ $357.99

78226 P 00 00 00 00 ZZZ $45.60

78226 T 00 00 00 00 ZZZ $312.39

Page 327: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78227 C 00 00 00 00 ZZZ $488.80

78227 P 00 00 00 00 ZZZ $55.00

78227 T 00 00 00 00 ZZZ $433.79

78230 C 00 00 00 00 ZZZ $78.42

78230 P 00 00 00 00 ZZZ $30.77

78230 T 00 00 00 00 ZZZ $47.65

78231 C 00 00 00 00 ZZZ $108.32

78231 P 00 00 00 00 ZZZ $34.97

78231 T 00 00 00 00 ZZZ $73.35

78232 C 00 00 00 00 ZZZ $127.60

78232 P 00 00 00 00 ZZZ $70.00

78232 T 00 00 00 00 ZZZ $57.60

78258 C 00 00 00 00 ZZZ $169.15

78258 P 00 00 00 00 ZZZ $47.20

78258 T 00 00 00 00 ZZZ $121.95

78261 C 00 00 00 00 ZZZ $140.83

78261 P 00 00 00 00 ZZZ $55.00

78261 T 00 00 00 00 ZZZ $85.83

78262 C 00 00 00 00 ZZZ $176.00

78262 P 00 00 00 00 ZZZ $96.00

78262 T 00 00 00 00 ZZZ $80.00

78264 C 00 00 00 00 ZZZ $144.77

78264 P 00 00 00 00 ZZZ $52.22

78264 T 00 00 00 00 ZZZ $92.55

78267 C 00 00 00 00 ZZZ $10.48

78267 T 00 00 00 00 ZZZ $16.29

78268 C 00 00 00 00 ZZZ $38.61

78268 P 00 00 00 00 ZZZ $42.47

78270 C 00 00 00 00 ZZZ $53.90

78270 P 00 00 00 00 ZZZ $22.00

78270 T 00 00 00 00 ZZZ $31.90

78271 C 00 00 00 00 ZZZ $58.30

78271 P 00 00 00 00 ZZZ $8.80

78271 T 00 00 00 00 ZZZ $49.50

78272 C 00 00 00 00 ZZZ $75.90

78272 P 00 00 00 00 ZZZ $24.00

78272 T 00 00 00 00 ZZZ $51.90

78278 C 00 00 00 00 ZZZ $173.35

78278 P 00 00 00 00 ZZZ $83.00

78278 T 00 00 00 00 ZZZ $90.35

Page 328: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78282 C 00 00 00 00 ZZZ $77.00

78282 P 00 00 00 00 ZZZ $42.00

78282 T 00 00 00 00 ZZZ $35.00

78290 C 00 00 00 00 ZZZ $148.50

78290 P 00 00 00 00 ZZZ $56.00

78290 T 00 00 00 00 ZZZ $92.50

78291 C 00 00 00 00 ZZZ $186.05

78291 P 00 00 00 00 ZZZ $51.57

78291 T 00 00 00 00 ZZZ $134.48

78299 C 00 00 00 00 ZZZ $0.00

78299 P 00 00 00 00 ZZZ $0.00

78299 T 00 00 00 00 ZZZ $0.00

78300 C 00 00 00 00 ZZZ $105.60

78300 P 00 00 00 00 ZZZ $73.00

78300 T 00 00 00 00 ZZZ $32.60

78305 C 00 00 00 00 ZZZ $133.23

78305 P 00 00 00 00 ZZZ $60.00

78305 T 00 00 00 00 ZZZ $73.23

78306 C 00 00 00 00 ZZZ $170.50

78306 P 00 00 00 00 ZZZ $96.00

78306 T 00 00 00 00 ZZZ $74.50

78315 C 00 00 00 00 ZZZ $184.80

78315 P 00 00 00 00 ZZZ $47.30

78315 T 00 00 00 00 ZZZ $137.50

78320 C 00 00 00 00 ZZZ $221.10

78320 P 00 00 00 00 ZZZ $79.00

78320 T 00 00 00 00 ZZZ $142.10

78350 C 00 00 00 00 ZZZ $46.62

78350 P 00 00 00 00 ZZZ $13.07

78350 T 00 00 00 00 ZZZ $33.55

78351 C 00 00 00 00 ZZZ $47.44

78351 P 00 00 00 00 ZZZ $17.25

78351 T 00 00 00 00 ZZZ $25.88

78399 C 00 00 00 00 ZZZ $0.00

78399 P 00 00 00 00 ZZZ $0.00

78399 T 00 00 00 00 ZZZ $0.00

78414 C 00 00 00 00 ZZZ $30.77

78414 P 00 00 00 00 ZZZ $30.77

78414 T 00 00 00 00 ZZZ $30.77

78428 C 00 00 00 00 ZZZ $127.60

Page 329: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78428 P 00 00 00 00 ZZZ $70.00

78428 T 00 00 00 00 ZZZ $57.60

78445 C 00 00 00 00 ZZZ $79.20

78445 P 00 00 00 00 ZZZ $43.00

78445 T 00 00 00 00 ZZZ $36.20

78451 C 00 00 00 00 ZZZ $225.81

78451 P 00 00 00 00 ZZZ $87.73

78451 T 00 00 00 00 ZZZ $138.07

78452 C 00 00 00 00 ZZZ $370.57

78452 P 00 00 00 00 ZZZ $103.86

78452 T 00 00 00 00 ZZZ $266.71

78453 C 00 00 00 00 ZZZ $192.34

78453 P 00 00 00 00 ZZZ $63.55

78453 T 00 00 00 00 ZZZ $128.79

78454 C 00 00 00 00 ZZZ $192.73

78454 P 00 00 00 00 ZZZ $84.41

78454 T 00 00 00 00 ZZZ $108.31

78456 C 00 00 00 00 ZZZ $231.02

78456 P 00 00 00 00 ZZZ $55.69

78456 T 00 00 00 00 ZZZ $175.33

78457 C 00 00 00 00 ZZZ $134.20

78457 P 00 00 00 00 ZZZ $73.00

78457 T 00 00 00 00 ZZZ $61.20

78458 C 00 00 00 00 ZZZ $203.50

78458 P 00 00 00 00 ZZZ $111.00

78458 T 00 00 00 00 ZZZ $92.50

78459 C 00 00 00 00 ZZZ $138.24

78459 P 00 00 00 00 ZZZ $82.94

78459 T 00 00 00 00 ZZZ $55.30

78466 C 00 00 00 00 ZZZ $105.60

78466 P 00 00 00 00 ZZZ $58.00

78466 T 00 00 00 00 ZZZ $47.60

78468 C 00 00 00 00 ZZZ $132.18

78468 P 00 00 00 00 ZZZ $58.00

78468 T 00 00 00 00 ZZZ $74.18

78469 C 00 00 00 00 ZZZ $180.70

78469 P 00 00 00 00 ZZZ $108.42

78469 T 00 00 00 00 ZZZ $72.28

78472 C 00 00 00 00 ZZZ $276.10

78472 P 00 00 00 00 ZZZ $99.00

Page 330: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78472 T 00 00 00 00 ZZZ $177.10

78473 C 00 00 00 00 ZZZ $285.60

78473 P 00 00 00 00 ZZZ $98.38

78473 T 00 00 00 00 ZZZ $187.22

78481 C 00 00 00 00 ZZZ $183.22

78481 P 00 00 00 00 ZZZ $70.00

78481 T 00 00 00 00 ZZZ $113.32

78483 C 00 00 00 00 ZZZ $276.16

78483 P 00 00 00 00 ZZZ $100.24

78483 T 00 00 00 00 ZZZ $175.92

78491 C 00 00 00 00 ZZZ $176.69

78491 P 00 00 00 00 ZZZ $106.01

78491 T 00 00 00 00 ZZZ $70.68

78492 C 00 00 00 00 ZZZ $208.34

78492 P 00 00 00 00 ZZZ $125.00

78492 T 00 00 00 00 ZZZ $83.34

78494 C 00 00 00 00 ZZZ $312.70

78494 P 00 00 00 00 ZZZ $74.60

78494 T 00 00 00 00 ZZZ $238.10

78496 C 00 00 00 00 ZZZ $108.09

78496 P 00 00 00 00 ZZZ $33.10

78496 T 00 00 00 00 ZZZ $74.99

78499 C 00 00 00 00 ZZZ $0.00

78499 P 00 00 00 00 ZZZ $0.00

78499 T 00 00 00 00 ZZZ $0.00

78579 C 00 00 00 00 ZZZ $191.91

78579 P 00 00 00 00 ZZZ $30.65

78579 T 00 00 00 00 ZZZ $161.27

78580 C 00 00 00 00 ZZZ $127.60

78580 P 00 00 00 00 ZZZ $53.00

78580 T 00 00 00 00 ZZZ $74.60

78582 C 00 00 00 00 ZZZ $355.58

78582 P 00 00 00 00 ZZZ $66.38

78582 T 00 00 00 00 ZZZ $289.19

78597 C 00 00 00 00 ZZZ $218.64

78597 P 00 00 00 00 ZZZ $45.78

78597 T 00 00 00 00 ZZZ $172.86

78598 C 00 00 00 00 ZZZ $332.20

78598 P 00 00 00 00 ZZZ $46.69

78598 T 00 00 00 00 ZZZ $149.23

Page 331: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78599 C 00 00 00 00 ZZZ $0.00

78599 P 00 00 00 00 ZZZ $0.00

78599 T 00 00 00 00 ZZZ $0.00

78600 C 00 00 00 00 ZZZ $116.60

78600 P 00 00 00 00 ZZZ $64.00

78600 T 00 00 00 00 ZZZ $52.60

78601 C 00 00 00 00 ZZZ $141.90

78601 P 00 00 00 00 ZZZ $83.00

78601 T 00 00 00 00 ZZZ $58.90

78605 C 00 00 00 00 ZZZ $130.90

78605 P 00 00 00 00 ZZZ $76.00

78605 T 00 00 00 00 ZZZ $54.90

78606 C 00 00 00 00 ZZZ $163.90

78606 P 00 00 00 00 ZZZ $92.00

78606 T 00 00 00 00 ZZZ $71.90

78607 C 00 00 00 00 ZZZ $229.48

78607 P 00 00 00 00 ZZZ $82.06

78607 T 00 00 00 00 ZZZ $147.42

78608 C 00 00 00 00 ZZZ $119.00

78608 P 00 00 00 00 ZZZ $76.00

78608 T 00 00 00 00 ZZZ $43.00

78609 C 00 00 00 00 ZZZ $119.00

78609 P 00 00 00 00 ZZZ $76.00

78609 T 00 00 00 00 ZZZ $43.00

78610 C 00 00 00 00 ZZZ $55.60

78610 P 00 00 00 00 ZZZ $30.00

78610 T 00 00 00 00 ZZZ $25.60

78630 C 00 00 00 00 ZZZ $173.80

78630 P 00 00 00 00 ZZZ $66.00

78630 T 00 00 00 00 ZZZ $107.80

78635 C 00 00 00 00 ZZZ $169.25

78635 P 00 00 00 00 ZZZ $66.00

78635 T 00 00 00 00 ZZZ $103.25

78645 C 00 00 00 00 ZZZ $173.80

78645 P 00 00 00 00 ZZZ $89.00

78645 T 00 00 00 00 ZZZ $84.80

78647 C 00 00 00 00 ZZZ $198.79

78647 P 00 00 00 00 ZZZ $59.68

78647 T 00 00 00 00 ZZZ $139.11

78650 C 00 00 00 00 ZZZ $152.37

Page 332: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78650 P 00 00 00 00 ZZZ $60.00

78650 T 00 00 00 00 ZZZ $92.37

78660 C 00 00 00 00 ZZZ $127.60

78660 P 00 00 00 00 ZZZ $70.00

78660 T 00 00 00 00 ZZZ $57.60

78699 C 00 00 00 00 ZZZ $0.00

78699 P 00 00 00 00 ZZZ $0.00

78699 T 00 00 00 00 ZZZ $0.00

78700 C 00 00 00 00 ZZZ $101.76

78700 P 00 00 00 00 ZZZ $48.00

78700 T 00 00 00 00 ZZZ $53.76

78701 C 00 00 00 00 ZZZ $117.49

78701 P 00 00 00 00 ZZZ $60.00

78701 T 00 00 00 00 ZZZ $57.49

78707 C 00 00 00 00 ZZZ $160.77

78707 P 00 00 00 00 ZZZ $73.00

78707 T 00 00 00 00 ZZZ $87.77

78708 C 00 00 00 00 ZZZ $256.60

78708 P 00 00 00 00 ZZZ $69.72

78708 T 00 00 00 00 ZZZ $186.88

78709 C 00 00 00 00 ZZZ $264.85

78709 P 00 00 00 00 ZZZ $77.97

78709 T 00 00 00 00 ZZZ $186.88

78710 C 00 00 00 00 ZZZ $190.14

78710 P 00 00 00 00 ZZZ $90.00

78710 T 00 00 00 00 ZZZ $100.14

78715 C 00 00 00 00 ZZZ $124.14

78715 P 00 00 00 00 ZZZ $64.12

78715 T 00 00 00 00 ZZZ $60.00

78725 C 00 00 00 00 ZZZ $77.00

78725 P 00 00 00 00 ZZZ $42.00

78725 T 00 00 00 00 ZZZ $35.00

78730 C 00 00 00 00 ZZZ $104.00

78730 P 00 00 00 00 ZZZ $62.00

78730 T 00 00 00 00 ZZZ $42.00

78740 C 00 00 00 00 ZZZ $80.51

78740 P 00 00 00 00 ZZZ $37.77

78740 T 00 00 00 00 ZZZ $42.74

78760 C 00 00 00 00 ZZZ $102.30

78760 P 00 00 00 00 ZZZ $55.00

Page 333: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78760 T 00 00 00 00 ZZZ $47.30

78761 C 00 00 00 00 ZZZ $116.18

78761 P 00 00 00 00 ZZZ $64.00

78761 T 00 00 00 00 ZZZ $52.18

78799 C 00 00 00 00 ZZZ $0.00

78799 P 00 00 00 00 ZZZ $0.00

78799 T 00 00 00 00 ZZZ $0.00

78800 C 00 00 00 00 ZZZ $119.85

78800 P 00 00 00 00 ZZZ $45.00

78800 T 00 00 00 00 ZZZ $74.85

78801 C 00 00 00 00 ZZZ $147.65

78801 P 00 00 00 00 ZZZ $63.00

78801 T 00 00 00 00 ZZZ $84.65

78802 C 00 00 00 00 ZZZ $186.99

78802 P 00 00 00 00 ZZZ $69.00

78802 T 00 00 00 00 ZZZ $117.99

78803 C 00 00 00 00 ZZZ $224.23

78803 P 00 00 00 00 ZZZ $72.74

78803 T 00 00 00 00 ZZZ $151.49

78804 C 00 00 00 00 ZZZ $250.42

78804 P 00 00 00 00 ZZZ $61.05

78804 T 00 00 00 00 ZZZ $189.37

78805 C 00 00 00 00 ZZZ $127.60

78805 P 00 00 00 00 ZZZ $70.00

78805 T 00 00 00 00 ZZZ $57.60

78806 C 00 00 00 00 ZZZ $211.91

78806 P 00 00 00 00 ZZZ $66.00

78806 T 00 00 00 00 ZZZ $145.91

78807 C 00 00 00 00 ZZZ $268.40

78807 P 00 00 00 00 ZZZ $50.60

78807 T 00 00 00 00 ZZZ $217.80

78808 C 00 00 00 00 ZZZ $58.33

78808 P 00 00 00 00 ZZZ $35.00

78808 T 00 00 00 00 ZZZ $23.33

78810 C 00 00 00 00 ZZZ $1,366.79

78810 P 00 00 00 00 ZZZ $79.79

78810 T 00 00 00 00 ZZZ $1,287.00

78811 C 00 00 00 00 ZZZ $1,558.25

78811 P 00 00 00 00 ZZZ $97.81

78811 T 00 00 00 00 ZZZ $1,850.00

Page 334: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

78812 C 00 00 00 00 ZZZ $1,576.74

78812 P 00 00 00 00 ZZZ $96.74

78812 T 00 00 00 00 ZZZ $1,480.00

78813 C 00 00 00 00 ZZZ $1,580.06

78813 P 00 00 00 00 ZZZ $100.06

78813 T 00 00 00 00 ZZZ $1,480.00

78814 C 00 00 00 00 ZZZ $1,558.25

78814 P 00 00 00 00 ZZZ $78.25

78814 T 00 00 00 00 ZZZ $1,480.00

78815 C 00 00 00 00 ZZZ $1,576.74

78815 P 00 00 00 00 ZZZ $86.74

78815 T 00 00 00 00 ZZZ $1,480.00

78816 C 00 00 00 00 ZZZ $1,580.86

78816 P 00 00 00 00 ZZZ $100.06

78816 T 00 00 00 00 ZZZ $1,480.00

78886 C 00 00 00 00 ZZZ $97.77

78999 C 00 00 00 00 ZZZ $0.00

78999 P 00 00 00 00 ZZZ $0.00

78999 T 00 00 00 00 ZZZ $0.00

79005 C 00 00 00 00 ZZZ $244.31

79005 P 00 00 00 00 ZZZ $115.62

79005 T 00 00 00 00 ZZZ $128.68

79101 C 00 00 00 00 ZZZ $255.03

79101 P 00 00 00 00 ZZZ $126.35

79101 T 00 00 00 00 ZZZ $128.68

79200 C 00 00 00 00 ZZZ $195.80

79200 P 00 00 00 00 ZZZ $178.00

79300 C 00 00 00 00 ZZZ $116.00

79300 P 00 00 00 00 ZZZ $116.00

79403 C 00 00 00 00 ZZZ $316.82

79403 P 00 00 00 00 ZZZ $134.07

79403 T 00 00 00 00 ZZZ $182.75

79440 C 00 00 00 00 ZZZ $195.80

79440 P 00 00 00 00 ZZZ $178.00

79445 C 00 00 00 00 ZZZ $285.34

79445 P 00 00 00 00 ZZZ $155.73

79445 T 00 00 00 00 ZZZ $129.62

79900 C 00 00 00 00 ZZZ $99.00

79900 T 00 00 00 00 ZZZ $99.00

80047 C 00 00 00 00 ZZZ $30.88

Page 335: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80047 T 00 00 00 00 ZZZ $30.88

80048 C 00 00 00 00 ZZZ $12.09

80048 T 00 00 00 00 ZZZ $12.09

80049 T 00 00 00 00 ZZZ $11.29

80050 C 00 00 00 00 ZZZ $48.67

80050 T 00 00 00 00 ZZZ $48.67

80051 C 00 00 00 00 ZZZ $10.01

80051 T 00 00 00 00 ZZZ $10.01

80053 C 00 00 00 00 ZZZ $15.10

80053 T 00 00 00 00 ZZZ $15.10

80055 C 00 00 00 00 ZZZ $36.52

80055 T 00 00 00 00 ZZZ $36.52

80061 C 00 00 00 00 ZZZ $18.16

80061 T 00 00 00 00 ZZZ $18.16

80069 C 00 00 00 00 ZZZ $12.40

80069 T 00 00 00 00 ZZZ $12.40

80072 C 00 00 00 00 ZZZ $36.86

80072 T 00 00 00 00 ZZZ $36.86

80074 C 00 00 00 00 ZZZ $68.01

80074 T 00 00 00 00 ZZZ $68.01

80076 C 00 00 00 00 ZZZ $11.67

80076 T 00 00 00 00 ZZZ $11.67

80081 C 00 00 00 00 ZZZ $101.97

80081 T 00 00 00 00 ZZZ $101.97

80091 C 00 00 00 00 ZZZ $17.56

80091 T 00 00 00 00 ZZZ $17.56

80150 C 00 00 00 00 ZZZ $21.52

80150 T 00 00 00 00 ZZZ $21.52

80155 C 00 00 00 00 ZZZ $0.00

80155 T 00 00 00 00 ZZZ $0.00

80156 C 00 00 00 00 ZZZ $20.79

80156 T 00 00 00 00 ZZZ $20.79

80157 C 00 00 00 00 ZZZ $14.20

80157 T 00 00 00 00 ZZZ $14.20

80158 C 00 00 00 00 ZZZ $25.78

80158 T 00 00 00 00 ZZZ $25.78

80159 C 00 00 00 00 ZZZ $25.23

80159 T 00 00 00 00 ZZZ $25.23

80162 C 00 00 00 00 ZZZ $18.96

80162 T 00 00 00 00 ZZZ $18.96

Page 336: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80163 C 00 00 00 00 ZZZ $18.07

80163 T 00 00 00 00 ZZZ $18.07

80164 C 00 00 00 00 ZZZ $19.34

80164 T 00 00 00 00 ZZZ $19.34

80165 C 00 00 00 00 ZZZ $18.44

80165 T 00 00 00 00 ZZZ $18.44

80168 C 00 00 00 00 ZZZ $23.33

80168 T 00 00 00 00 ZZZ $23.33

80169 C 00 00 00 00 ZZZ $0.00

80169 T 00 00 00 00 ZZZ $0.00

80170 C 00 00 00 00 ZZZ $23.41

80170 T 00 00 00 00 ZZZ $23.41

80171 C 00 00 00 00 ZZZ $18.09

80171 T 00 00 00 00 ZZZ $18.09

80173 C 00 00 00 00 ZZZ $20.79

80173 T 00 00 00 00 ZZZ $20.79

80175 C 00 00 00 00 ZZZ $18.09

80175 T 00 00 00 00 ZZZ $18.09

80176 C 00 00 00 00 ZZZ $20.98

80176 T 00 00 00 00 ZZZ $20.98

80177 C 00 00 00 00 ZZZ $18.09

80177 T 00 00 00 00 ZZZ $18.09

80178 C 00 00 00 00 ZZZ $9.34

80178 T 00 00 00 00 ZZZ $9.43

80180 C 00 00 00 00 ZZZ $0.00

80180 T 00 00 00 00 ZZZ $0.00

80183 C 00 00 00 00 ZZZ $18.06

80183 T 00 00 00 00 ZZZ $18.06

80184 C 00 00 00 00 ZZZ $16.36

80184 T 00 00 00 00 ZZZ $16.36

80185 C 00 00 00 00 ZZZ $18.93

80185 T 00 00 00 00 ZZZ $18.93

80186 C 00 00 00 00 ZZZ $19.66

80186 T 00 00 00 00 ZZZ $19.66

80188 C 00 00 00 00 ZZZ $23.69

80188 T 00 00 00 00 ZZZ $23.69

80190 C 00 00 00 00 ZZZ $23.92

80190 T 00 00 00 00 ZZZ $23.92

80192 C 00 00 00 00 ZZZ $23.92

80192 T 00 00 00 00 ZZZ $23.92

Page 337: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80194 C 00 00 00 00 ZZZ $20.84

80194 T 00 00 00 00 ZZZ $20.84

80195 C 00 00 00 00 ZZZ $19.81

80195 T 00 00 00 00 ZZZ $19.81

80197 C 00 00 00 00 ZZZ $19.60

80197 P 00 00 00 00 ZZZ $0.00

80197 T 00 00 00 00 ZZZ $19.60

80198 C 00 00 00 00 ZZZ $20.21

80198 T 00 00 00 00 ZZZ $20.21

80199 C 00 00 00 00 ZZZ $0.00

80199 T 00 00 00 00 ZZZ $0.00

80200 C 00 00 00 00 ZZZ $23.01

80200 T 00 00 00 00 ZZZ $23.01

80201 C 00 00 00 00 ZZZ $17.03

80201 T 00 00 00 00 ZZZ $17.03

80202 C 00 00 00 00 ZZZ $19.34

80202 T 00 00 00 00 ZZZ $19.34

80203 C 00 00 00 00 ZZZ $18.09

80203 T 00 00 00 00 ZZZ $18.09

80299 C 00 00 00 00 ZZZ $19.55

80299 T 00 00 00 00 ZZZ $19.55

80305 C 00 00 00 00 ZZZ $14.96

80305 T 00 00 00 00 ZZZ $14.96

80306 C 00 00 00 00 ZZZ $19.95

80306 T 00 00 00 00 ZZZ $19.95

80307 C 00 00 00 00 ZZZ $79.81

80307 T 00 00 00 00 ZZZ $79.81

80320 C 00 00 00 00 ZZZ $16.22

80320 P 00 00 00 00 ZZZ $1.14

80320 T 00 00 00 00 ZZZ $15.08

80321 C 00 00 00 00 ZZZ $16.22

80321 P 00 00 00 00 ZZZ $1.14

80321 T 00 00 00 00 ZZZ $15.08

80322 C 00 00 00 00 ZZZ $16.22

80322 P 00 00 00 00 ZZZ $1.14

80322 T 00 00 00 00 ZZZ $15.08

80323 C 00 00 00 00 ZZZ $49.02

80323 P 00 00 00 00 ZZZ $3.43

80323 T 00 00 00 00 ZZZ $45.59

80324 C 00 00 00 00 ZZZ $25.38

Page 338: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80324 P 00 00 00 00 ZZZ $1.78

80324 T 00 00 00 00 ZZZ $23.60

80325 C 00 00 00 00 ZZZ $25.38

80325 P 00 00 00 00 ZZZ $1.78

80325 T 00 00 00 00 ZZZ $23.60

80326 C 00 00 00 00 ZZZ $25.38

80326 P 00 00 00 00 ZZZ $1.78

80326 T 00 00 00 00 ZZZ $23.60

80327 C 00 00 00 00 ZZZ $42.16

80327 P 00 00 00 00 ZZZ $2.95

80327 T 00 00 00 00 ZZZ $39.21

80328 C 00 00 00 00 ZZZ $42.16

80328 P 00 00 00 00 ZZZ $2.95

80328 T 00 00 00 00 ZZZ $39.21

80329 C 00 00 00 00 ZZZ $11.59

80329 P 00 00 00 00 ZZZ $0.81

80329 T 00 00 00 00 ZZZ $10.78

80330 C 00 00 00 00 ZZZ $11.59

80330 P 00 00 00 00 ZZZ $0.81

80330 T 00 00 00 00 ZZZ $10.78

80331 C 00 00 00 00 ZZZ $11.59

80331 P 00 00 00 00 ZZZ $0.81

80331 T 00 00 00 00 ZZZ $10.78

80332 C 00 00 00 00 ZZZ $29.23

80332 P 00 00 00 00 ZZZ $2.05

80332 T 00 00 00 00 ZZZ $27.18

80333 C 00 00 00 00 ZZZ $29.23

80333 P 00 00 00 00 ZZZ $2.05

80333 T 00 00 00 00 ZZZ $27.18

80334 C 00 00 00 00 ZZZ $29.23

80334 P 00 00 00 00 ZZZ $2.05

80334 T 00 00 00 00 ZZZ $27.18

80335 C 00 00 00 00 ZZZ $29.23

80335 P 00 00 00 00 ZZZ $2.05

80335 T 00 00 00 00 ZZZ $27.18

80336 C 00 00 00 00 ZZZ $29.23

80336 P 00 00 00 00 ZZZ $2.05

80336 T 00 00 00 00 ZZZ $27.18

80337 C 00 00 00 00 ZZZ $29.23

80337 P 00 00 00 00 ZZZ $2.05

Page 339: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80337 T 00 00 00 00 ZZZ $27.18

80338 C 00 00 00 00 ZZZ $29.23

80338 P 00 00 00 00 ZZZ $2.05

80338 T 00 00 00 00 ZZZ $27.18

80339 C 00 00 00 00 ZZZ $21.65

80339 P 00 00 00 00 ZZZ $1.51

80339 T 00 00 00 00 ZZZ $20.14

80340 C 00 00 00 00 ZZZ $21.65

80340 P 00 00 00 00 ZZZ $1.51

80340 T 00 00 00 00 ZZZ $20.14

80341 C 00 00 00 00 ZZZ $0.00

80341 P 00 00 00 00 ZZZ $0.00

80341 T 00 00 00 00 ZZZ $0.00

80342 C 00 00 00 00 ZZZ $25.43

80342 P 00 00 00 00 ZZZ $1.78

80342 T 00 00 00 00 ZZZ $23.65

80343 C 00 00 00 00 ZZZ $25.43

80343 P 00 00 00 00 ZZZ $1.78

80343 T 00 00 00 00 ZZZ $23.65

80344 C 00 00 00 00 ZZZ $25.43

80344 P 00 00 00 00 ZZZ $1.78

80344 T 00 00 00 00 ZZZ $23.65

80345 C 00 00 00 00 ZZZ $30.21

80345 P 00 00 00 00 ZZZ $2.11

80345 T 00 00 00 00 ZZZ $28.09

80346 C 00 00 00 00 ZZZ $32.33

80346 P 00 00 00 00 ZZZ $2.26

80346 T 00 00 00 00 ZZZ $30.06

80347 C 00 00 00 00 ZZZ $32.33

80347 P 00 00 00 00 ZZZ $2.26

80347 T 00 00 00 00 ZZZ $30.06

80348 C 00 00 00 00 ZZZ $31.78

80348 P 00 00 00 00 ZZZ $2.22

80348 T 00 00 00 00 ZZZ $29.55

80349 C 00 00 00 00 ZZZ $22.96

80349 P 00 00 00 00 ZZZ $1.61

80349 T 00 00 00 00 ZZZ $21.35

80350 C 00 00 00 00 ZZZ $22.96

80350 P 00 00 00 00 ZZZ $1.61

80350 T 00 00 00 00 ZZZ $21.35

Page 340: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80351 C 00 00 00 00 ZZZ $22.96

80351 P 00 00 00 00 ZZZ $1.61

80351 T 00 00 00 00 ZZZ $21.35

80352 C 00 00 00 00 ZZZ $22.96

80352 P 00 00 00 00 ZZZ $1.61

80352 T 00 00 00 00 ZZZ $21.35

80353 C 00 00 00 00 ZZZ $24.74

80353 P 00 00 00 00 ZZZ $1.74

80353 T 00 00 00 00 ZZZ $23.01

80354 C 00 00 00 00 ZZZ $31.78

80354 P 00 00 00 00 ZZZ $2.22

80354 T 00 00 00 00 ZZZ $29.55

80355 C 00 00 00 00 ZZZ $21.78

80355 P 00 00 00 00 ZZZ $1.52

80355 T 00 00 00 00 ZZZ $20.19

80356 C 00 00 00 00 ZZZ $41.98

80356 P 00 00 00 00 ZZZ $2.94

80356 T 00 00 00 00 ZZZ $39.04

80357 C 00 00 00 00 ZZZ $22.96

80357 P 00 00 00 00 ZZZ $1.61

80357 T 00 00 00 00 ZZZ $21.35

80358 C 00 00 00 00 ZZZ $31.78

80358 P 00 00 00 00 ZZZ $2.22

80358 T 00 00 00 00 ZZZ $29.55

80359 C 00 00 00 00 ZZZ $22.96

80359 P 00 00 00 00 ZZZ $1.61

80359 T 00 00 00 00 ZZZ $21.35

80360 C 00 00 00 00 ZZZ $22.96

80360 P 00 00 00 00 ZZZ $1.61

80360 T 00 00 00 00 ZZZ $21.35

80361 C 00 00 00 00 ZZZ $41.98

80361 P 00 00 00 00 ZZZ $2.94

80361 T 00 00 00 00 ZZZ $39.04

80362 C 00 00 00 00 ZZZ $31.78

80362 P 00 00 00 00 ZZZ $2.22

80362 T 00 00 00 00 ZZZ $29.55

80363 C 00 00 00 00 ZZZ $31.78

80363 P 00 00 00 00 ZZZ $2.22

80363 T 00 00 00 00 ZZZ $29.55

80364 C 00 00 00 00 ZZZ $31.78

Page 341: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80364 P 00 00 00 00 ZZZ $2.22

80364 T 00 00 00 00 ZZZ $29.55

80365 C 00 00 00 00 ZZZ $31.78

80365 P 00 00 00 00 ZZZ $2.22

80365 T 00 00 00 00 ZZZ $29.55

80366 C 00 00 00 00 ZZZ $22.96

80366 P 00 00 00 00 ZZZ $1.61

80366 T 00 00 00 00 ZZZ $21.35

80367 C 00 00 00 00 ZZZ $22.96

80367 P 00 00 00 00 ZZZ $1.61

80367 T 00 00 00 00 ZZZ $21.35

80368 C 00 00 00 00 ZZZ $22.96

80368 P 00 00 00 00 ZZZ $1.61

80368 T 00 00 00 00 ZZZ $21.35

80369 C 00 00 00 00 ZZZ $28.78

80369 P 00 00 00 00 ZZZ $2.02

80369 T 00 00 00 00 ZZZ $26.76

80370 C 00 00 00 00 ZZZ $28.78

80370 P 00 00 00 00 ZZZ $2.02

80370 T 00 00 00 00 ZZZ $26.76

80371 C 00 00 00 00 ZZZ $22.96

80371 P 00 00 00 00 ZZZ $1.61

80371 T 00 00 00 00 ZZZ $21.35

80372 C 00 00 00 00 ZZZ $31.78

80372 P 00 00 00 00 ZZZ $2.22

80372 T 00 00 00 00 ZZZ $29.55

80373 C 00 00 00 00 ZZZ $31.78

80373 P 00 00 00 00 ZZZ $2.22

80373 T 00 00 00 00 ZZZ $29.55

80374 C 00 00 00 00 ZZZ $22.96

80374 P 00 00 00 00 ZZZ $1.61

80374 T 00 00 00 00 ZZZ $21.35

80375 C 00 00 00 00 ZZZ $22.96

80375 P 00 00 00 00 ZZZ $1.61

80375 T 00 00 00 00 ZZZ $21.35

80376 C 00 00 00 00 ZZZ $22.96

80376 P 00 00 00 00 ZZZ $1.61

80376 T 00 00 00 00 ZZZ $21.35

80377 C 00 00 00 00 ZZZ $22.96

80377 P 00 00 00 00 ZZZ $1.61

Page 342: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80377 T 00 00 00 00 ZZZ $21.35

80400 C 00 00 00 00 ZZZ $46.56

80400 T 00 00 00 00 ZZZ $46.56

80402 C 00 00 00 00 ZZZ $124.14

80402 T 00 00 00 00 ZZZ $124.14

80406 C 00 00 00 00 ZZZ $111.74

80406 T 00 00 00 00 ZZZ $111.74

80408 C 00 00 00 00 ZZZ $179.22

80408 T 00 00 00 00 ZZZ $179.22

80410 C 00 00 00 00 ZZZ $114.73

80410 T 00 00 00 00 ZZZ $114.73

80412 C 00 00 00 00 ZZZ $281.67

80412 T 00 00 00 00 ZZZ $281.67

80414 C 00 00 00 00 ZZZ $73.74

80414 T 00 00 00 00 ZZZ $73.74

80415 C 00 00 00 00 ZZZ $79.81

80415 T 00 00 00 00 ZZZ $79.81

80416 C 00 00 00 00 ZZZ $188.48

80416 P 00 00 00 00 ZZZ $0.00

80416 T 00 00 00 00 ZZZ $188.48

80417 C 00 00 00 00 ZZZ $62.83

80417 P 00 00 00 00 ZZZ $0.00

80417 T 00 00 00 00 ZZZ $62.83

80418 C 00 00 00 00 ZZZ $701.63

80418 T 00 00 00 00 ZZZ $701.63

80420 C 00 00 00 00 ZZZ $102.86

80420 T 00 00 00 00 ZZZ $102.86

80422 C 00 00 00 00 ZZZ $65.81

80422 T 00 00 00 00 ZZZ $65.81

80424 C 00 00 00 00 ZZZ $72.13

80424 T 00 00 00 00 ZZZ $72.13

80426 C 00 00 00 00 ZZZ $212.00

80426 T 00 00 00 00 ZZZ $212.00

80428 C 00 00 00 00 ZZZ $95.23

80428 T 00 00 00 00 ZZZ $95.23

80430 C 00 00 00 00 ZZZ $112.03

80430 T 00 00 00 00 ZZZ $112.03

80432 C 00 00 00 00 ZZZ $192.88

80432 T 00 00 00 00 ZZZ $192.88

80434 C 00 00 00 00 ZZZ $144.41

Page 343: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

80434 T 00 00 00 00 ZZZ $144.41

80435 C 00 00 00 00 ZZZ $147.04

80435 T 00 00 00 00 ZZZ $147.04

80436 C 00 00 00 00 ZZZ $130.18

80436 T 00 00 00 00 ZZZ $130.18

80438 C 00 00 00 00 ZZZ $71.95

80438 T 00 00 00 00 ZZZ $71.95

80439 C 00 00 00 00 ZZZ $95.95

80439 T 00 00 00 00 ZZZ $95.93

80500 C 00 00 00 00 ZZZ $23.10

80500 P 00 00 00 00 ZZZ $23.10

80502 C 00 00 00 00 ZZZ $43.00

80502 P 00 00 00 00 ZZZ $43.00

81000 A FP 00 00 00 ZZZ $4.52

81000 C 00 00 00 00 ZZZ $4.52

81000 T 00 00 00 00 ZZZ $4.52

81001 A FP 00 00 00 ZZZ $4.52

81001 C 00 00 00 00 ZZZ $4.52

81001 P 00 00 00 00 ZZZ $1.58

81001 T 00 00 00 00 ZZZ $4.52

81002 A FP 00 00 00 ZZZ $3.66

81002 C 00 00 00 00 ZZZ $3.66

81002 T 00 00 00 00 ZZZ $3.66

81003 A FP 00 00 00 ZZZ $3.20

81003 C 00 00 00 00 ZZZ $3.20

81003 T 00 00 00 00 ZZZ $3.20

81005 C 00 00 00 00 ZZZ $3.10

81005 T 00 00 00 00 ZZZ $3.10

81007 C 00 00 00 00 ZZZ $3.67

81007 T 00 00 00 00 ZZZ $3.67

81015 C 00 00 00 00 ZZZ $4.34

81015 T 00 00 00 00 ZZZ $4.34

81025 A FP 00 00 00 ZZZ $9.03

81025 C 00 00 00 00 ZZZ $9.03

81025 T 00 00 00 00 ZZZ $9.03

81050 C 00 00 00 00 ZZZ $4.28

81050 T 00 00 00 00 ZZZ $4.28

81099 C 00 00 00 00 ZZZ $3.26

81099 T 00 00 00 00 ZZZ $3.26

81161 C 00 00 00 00 ZZZ $0.00

Page 344: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81161 T 00 00 00 00 ZZZ $0.00

81162 C 00 00 00 00 ZZZ $2,485.86

81162 P 00 00 00 00 ZZZ $2,485.86

81162 T 00 00 00 00 ZZZ $2,485.86

81170 C 00 00 00 00 ZZZ $329.51

81170 P 00 00 00 00 ZZZ $329.51

81170 T 00 00 00 00 ZZZ $329.51

81200 C 00 00 00 00 ZZZ $186.14

81200 P 00 00 00 00 ZZZ $13.03

81200 T 00 00 00 00 ZZZ $173.10

81201 C 00 00 00 00 ZZZ $800.00

81201 T 00 00 00 00 ZZZ $744.00

81202 C 00 00 00 00 ZZZ $380.00

81202 T 00 00 00 00 ZZZ $353.40

81203 C 00 00 00 00 ZZZ $256.00

81203 T 00 00 00 00 ZZZ $238.08

81205 C 00 00 00 00 ZZZ $174.12

81205 P 00 00 00 00 ZZZ $12.19

81205 T 00 00 00 00 ZZZ $161.93

81206 C 00 00 00 00 ZZZ $86.70

81206 P 00 00 00 00 ZZZ $6.07

81206 T 00 00 00 00 ZZZ $80.62

81207 C 00 00 00 00 ZZZ $72.25

81207 P 00 00 00 00 ZZZ $5.06

81207 T 00 00 00 00 ZZZ $67.19

81208 C 00 00 00 00 ZZZ $120.14

81208 P 00 00 00 00 ZZZ $8.41

81208 T 00 00 00 00 ZZZ $111.73

81209 C 00 00 00 00 ZZZ $67.00

81209 P 00 00 00 00 ZZZ $4.69

81209 T 00 00 00 00 ZZZ $62.31

81210 C 00 00 00 00 ZZZ $75.72

81210 P 00 00 00 00 ZZZ $5.30

81210 T 00 00 00 00 ZZZ $70.42

81211 C 00 00 00 00 ZZZ $2,498.54

81211 P 00 00 00 00 ZZZ $174.90

81211 T 00 00 00 00 ZZZ $2,323.64

81212 C 00 00 00 00 ZZZ $428.43

81212 P 00 00 00 00 ZZZ $29.99

81212 T 00 00 00 00 ZZZ $398.44

Page 345: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81213 C 00 00 00 00 ZZZ $524.96

81213 P 00 00 00 00 ZZZ $36.74

81213 T 00 00 00 00 ZZZ $488.22

81214 C 00 00 00 00 ZZZ $1,301.32

81214 P 00 00 00 00 ZZZ $91.10

81214 T 00 00 00 00 ZZZ $1,210.22

81215 C 00 00 00 00 ZZZ $352.36

81215 P 00 00 00 00 ZZZ $24.66

81215 T 00 00 00 00 ZZZ $327.70

81216 C 00 00 00 00 ZZZ $1,561.69

81216 P 00 00 00 00 ZZZ $109.31

81216 T 00 00 00 00 ZZZ $1,452.28

81217 C 00 00 00 00 ZZZ $352.36

81217 P 00 00 00 00 ZZZ $24.66

81217 T 00 00 00 00 ZZZ $327.70

81218 C 00 00 00 00 ZZZ $329.51

81218 P 00 00 00 00 ZZZ $329.51

81218 T 00 00 00 00 ZZZ $329.51

81220 C 00 00 00 00 ZZZ $400.00

81220 P 00 00 00 00 ZZZ $28.00

81220 T 00 00 00 00 ZZZ $372.00

81221 C 00 00 00 00 ZZZ $99.18

81221 P 00 00 00 00 ZZZ $6.94

81221 T 00 00 00 00 ZZZ $92.23

81222 C 00 00 00 00 ZZZ $116.49

81222 P 00 00 00 00 ZZZ $8.15

81222 T 00 00 00 00 ZZZ $108.34

81223 C 00 00 00 00 ZZZ $960.00

81223 P 00 00 00 00 ZZZ $67.20

81223 T 00 00 00 00 ZZZ $892.80

81224 C 00 00 00 00 ZZZ $79.02

81224 P 00 00 00 00 ZZZ $5.53

81224 T 00 00 00 00 ZZZ $73.49

81225 C 00 00 00 00 ZZZ $214.24

81225 P 00 00 00 00 ZZZ $15.00

81225 T 00 00 00 00 ZZZ $199.24

81226 C 00 00 00 00 ZZZ $404.44

81226 P 00 00 00 00 ZZZ $28.31

81226 T 00 00 00 00 ZZZ $376.13

81227 C 00 00 00 00 ZZZ $107.59

Page 346: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81227 P 00 00 00 00 ZZZ $7.53

81227 T 00 00 00 00 ZZZ $100.06

81228 C 00 00 00 00 ZZZ $534.32

81228 P 00 00 00 00 ZZZ $37.40

81228 T 00 00 00 00 ZZZ $496.92

81229 C 00 00 00 00 ZZZ $672.58

81229 P 00 00 00 00 ZZZ $47.08

81229 T 00 00 00 00 ZZZ $625.50

81235 C 00 00 00 00 ZZZ $319.94

81235 T 00 00 00 00 ZZZ $297.54

81240 C 00 00 00 00 ZZZ $33.13

81240 P 00 00 00 00 ZZZ $2.32

81240 T 00 00 00 00 ZZZ $30.81

81241 C 00 00 00 00 ZZZ $62.71

81241 P 00 00 00 00 ZZZ $4.39

81241 T 00 00 00 00 ZZZ $58.32

81242 C 00 00 00 00 ZZZ $94.14

81242 P 00 00 00 00 ZZZ $6.59

81242 T 00 00 00 00 ZZZ $87.55

81243 C 00 00 00 00 ZZZ $9.52

81243 P 00 00 00 00 ZZZ $4.86

81243 T 00 00 00 00 ZZZ $64.66

81244 C 00 00 00 00 ZZZ $47.04

81244 P 00 00 00 00 ZZZ $3.30

81244 T 00 00 00 00 ZZZ $43.74

81245 C 00 00 00 00 ZZZ $89.60

81245 P 00 00 00 00 ZZZ $6.27

81245 T 00 00 00 00 ZZZ $83.33

81250 C 00 00 00 00 ZZZ $127.28

81250 P 00 00 00 00 ZZZ $8.91

81250 T 00 00 00 00 ZZZ $118.37

81251 C 00 00 00 00 ZZZ $232.98

81251 P 00 00 00 00 ZZZ $16.31

81251 T 00 00 00 00 ZZZ $216.66

81252 C 00 00 00 00 ZZZ $336.00

81252 T 00 00 00 00 ZZZ $312.48

81253 C 00 00 00 00 ZZZ $135.22

81253 T 00 00 00 00 ZZZ $125.76

81254 C 00 00 00 00 ZZZ $48.26

81254 T 00 00 00 00 ZZZ $44.89

Page 347: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81255 C 00 00 00 00 ZZZ $138.07

81255 P 00 00 00 00 ZZZ $9.66

81255 T 00 00 00 00 ZZZ $128.41

81256 C 00 00 00 00 ZZZ $83.10

81256 P 00 00 00 00 ZZZ $5.82

81256 T 00 00 00 00 ZZZ $77.28

81257 C 00 00 00 00 ZZZ $198.14

81257 P 00 00 00 00 ZZZ $13.87

81257 T 00 00 00 00 ZZZ $184.27

81260 C 00 00 00 00 ZZZ $94.98

81260 P 00 00 00 00 ZZZ $6.65

81260 T 00 00 00 00 ZZZ $88.33

81261 C 00 00 00 00 ZZZ $118.50

81261 P 00 00 00 00 ZZZ $8.30

81261 T 00 00 00 00 ZZZ $110.20

81262 C 00 00 00 00 ZZZ $40.90

81262 P 00 00 00 00 ZZZ $2.86

81262 T 00 00 00 00 ZZZ $38.03

81263 C 00 00 00 00 ZZZ $207.94

81263 P 00 00 00 00 ZZZ $14.56

81263 T 00 00 00 00 ZZZ $193.38

81264 C 00 00 00 00 ZZZ $89.58

81264 P 00 00 00 00 ZZZ $6.27

81264 T 00 00 00 00 ZZZ $83.31

81265 C 00 00 00 00 ZZZ $331.95

81265 P 00 00 00 00 ZZZ $23.24

81265 T 00 00 00 00 ZZZ $308.71

81266 C 00 00 00 00 ZZZ $127.68

81266 P 00 00 00 00 ZZZ $8.94

81266 T 00 00 00 00 ZZZ $118.74

81267 C 00 00 00 00 ZZZ $119.78

81267 P 00 00 00 00 ZZZ $8.38

81267 T 00 00 00 00 ZZZ $111.39

81268 C 00 00 00 00 ZZZ $119.78

81268 P 00 00 00 00 ZZZ $8.38

81268 T 00 00 00 00 ZZZ $111.39

81270 C 00 00 00 00 ZZZ $69.52

81270 P 00 00 00 00 ZZZ $4.86

81270 T 00 00 00 00 ZZZ $64.66

81272 C 00 00 00 00 ZZZ $329.51

Page 348: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81272 P 00 00 00 00 ZZZ $329.51

81272 T 00 00 00 00 ZZZ $329.51

81275 C 00 00 00 00 ZZZ $251.70

81275 P 00 00 00 00 ZZZ $17.62

81275 T 00 00 00 00 ZZZ $234.09

81276 C 00 00 00 00 ZZZ $197.19

81276 P 00 00 00 00 ZZZ $197.19

81276 T 00 00 00 00 ZZZ $197.19

81288 C 00 00 00 00 ZZZ $0.00

81288 P 00 00 00 00 ZZZ $0.00

81288 T 00 00 00 00 ZZZ $0.00

81290 C 00 00 00 00 ZZZ $94.14

81290 P 00 00 00 00 ZZZ $6.59

81290 T 00 00 00 00 ZZZ $87.55

81291 C 00 00 00 00 ZZZ $89.81

81291 P 00 00 00 00 ZZZ $6.29

81291 T 00 00 00 00 ZZZ $83.52

81292 C 00 00 00 00 ZZZ $825.06

81292 P 00 00 00 00 ZZZ $57.75

81292 T 00 00 00 00 ZZZ $767.31

81293 C 00 00 00 00 ZZZ $352.36

81293 P 00 00 00 00 ZZZ $24.66

81293 T 00 00 00 00 ZZZ $327.70

81294 C 00 00 00 00 ZZZ $216.00

81294 P 00 00 00 00 ZZZ $15.12

81294 T 00 00 00 00 ZZZ $200.88

81295 C 00 00 00 00 ZZZ $664.90

81295 P 00 00 00 00 ZZZ $46.54

81295 T 00 00 00 00 ZZZ $618.35

81296 C 00 00 00 00 ZZZ $352.34

81296 P 00 00 00 00 ZZZ $24.66

81296 T 00 00 00 00 ZZZ $327.67

81297 C 00 00 00 00 ZZZ $216.00

81297 P 00 00 00 00 ZZZ $15.12

81297 T 00 00 00 00 ZZZ $200.88

81298 C 00 00 00 00 ZZZ $801.04

81298 P 00 00 00 00 ZZZ $56.07

81298 T 00 00 00 00 ZZZ $744.97

81299 C 00 00 00 00 ZZZ $352.36

81299 P 00 00 00 00 ZZZ $24.66

Page 349: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81299 T 00 00 00 00 ZZZ $327.70

81300 C 00 00 00 00 ZZZ $216.00

81300 P 00 00 00 00 ZZZ $15.12

81300 T 00 00 00 00 ZZZ $200.88

81301 C 00 00 00 00 ZZZ $316.14

81301 P 00 00 00 00 ZZZ $22.13

81301 T 00 00 00 00 ZZZ $294.01

81302 C 00 00 00 00 ZZZ $483.26

81302 P 00 00 00 00 ZZZ $33.83

81302 T 00 00 00 00 ZZZ $449.43

81303 C 00 00 00 00 ZZZ $0.00

81303 T 00 00 00 00 ZZZ $0.00

81304 C 00 00 00 00 ZZZ $80.64

81304 P 00 00 00 00 ZZZ $5.65

81304 T 00 00 00 00 ZZZ $74.99

81310 C 00 00 00 00 ZZZ $47.07

81310 P 00 00 00 00 ZZZ $3.30

81310 T 00 00 00 00 ZZZ $43.68

81313 C 00 00 00 00 ZZZ $0.00

81313 P 00 00 00 00 ZZZ $0.00

81313 T 00 00 00 00 ZZZ $0.00

81314 C 00 00 00 00 ZZZ $329.51

81314 P 00 00 00 00 ZZZ $329.51

81314 T 00 00 00 00 ZZZ $329.51

81315 C 00 00 00 00 ZZZ $94.03

81315 P 00 00 00 00 ZZZ $6.58

81315 T 00 00 00 00 ZZZ $87.45

81316 C 00 00 00 00 ZZZ $94.03

81316 P 00 00 00 00 ZZZ $6.58

81316 T 00 00 00 00 ZZZ $87.45

81317 C 00 00 00 00 ZZZ $848.00

81317 P 00 00 00 00 ZZZ $59.36

81317 T 00 00 00 00 ZZZ $788.64

81318 C 00 00 00 00 ZZZ $352.36

81318 P 00 00 00 00 ZZZ $24.66

81318 T 00 00 00 00 ZZZ $327.70

81319 C 00 00 00 00 ZZZ $216.00

81319 P 00 00 00 00 ZZZ $5.12

81319 T 00 00 00 00 ZZZ $200.88

81321 C 00 00 00 00 ZZZ $483.39

Page 350: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81321 T 00 00 00 00 ZZZ $450.02

81322 C 00 00 00 00 ZZZ $0.00

81322 T 00 00 00 00 ZZZ $0.00

81323 C 00 00 00 00 ZZZ $70.61

81323 T 00 00 00 00 ZZZ $65.66

81324 C 00 00 00 00 ZZZ $1,231.28

81324 T 00 00 00 00 ZZZ $1,145.09

81325 C 00 00 00 00 ZZZ $0.00

81325 T 00 00 00 00 ZZZ $0.00

81326 C 00 00 00 00 ZZZ $0.00

81326 T 00 00 00 00 ZZZ $0.00

81330 C 00 00 00 00 ZZZ $158.02

81330 P 00 00 00 00 ZZZ $11.06

81330 T 00 00 00 00 ZZZ $146.96

81331 C 00 00 00 00 ZZZ $57.74

81331 P 00 00 00 00 ZZZ $4.04

81331 T 00 00 00 00 ZZZ $53.70

81332 C 00 00 00 00 ZZZ $83.10

81332 P 00 00 00 00 ZZZ $5.82

81332 T 00 00 00 00 ZZZ $77.28

81340 C 00 00 00 00 ZZZ $118.50

81340 P 00 00 00 00 ZZZ $8.30

81340 T 00 00 00 00 ZZZ $110.20

81341 C 00 00 00 00 ZZZ $36.35

81341 P 00 00 00 00 ZZZ $2.54

81341 T 00 00 00 00 ZZZ $33.81

81342 C 00 00 00 00 ZZZ $118.50

81342 P 00 00 00 00 ZZZ $8.30

81342 T 00 00 00 00 ZZZ $110.20

81350 C 00 00 00 00 ZZZ $129.32

81350 P 00 00 00 00 ZZZ $9.06

81350 T 00 00 00 00 ZZZ $120.26

81355 C 00 00 00 00 ZZZ $0.00

81355 T 00 00 00 00 ZZZ $0.00

81370 C 00 00 00 00 ZZZ $442.20

81370 P 00 00 00 00 ZZZ $30.95

81370 T 00 00 00 00 ZZZ $411.25

81371 C 00 00 00 00 ZZZ $264.67

81371 P 00 00 00 00 ZZZ $18.53

81371 T 00 00 00 00 ZZZ $246.14

Page 351: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81372 C 00 00 00 00 ZZZ $242.91

81372 P 00 00 00 00 ZZZ $17.00

81372 T 00 00 00 00 ZZZ $225.91

81373 C 00 00 00 00 ZZZ $122.46

81373 P 00 00 00 00 ZZZ $8.58

81373 T 00 00 00 00 ZZZ $113.89

81374 C 00 00 00 00 ZZZ $80.00

81374 P 00 00 00 00 ZZZ $5.60

81374 T 00 00 00 00 ZZZ $74.40

81375 C 00 00 00 00 ZZZ $242.74

81375 P 00 00 00 00 ZZZ $16.99

81375 T 00 00 00 00 ZZZ $225.75

81376 C 00 00 00 00 ZZZ $134.40

81376 P 00 00 00 00 ZZZ $9.41

81376 T 00 00 00 00 ZZZ $124.99

81377 C 00 00 00 00 ZZZ $100.96

81377 P 00 00 00 00 ZZZ $7.06

81377 T 00 00 00 00 ZZZ $93.90

81378 C 00 00 00 00 ZZZ $380.00

81378 P 00 00 00 00 ZZZ $26.60

81378 T 00 00 00 00 ZZZ $353.40

81379 C 00 00 00 00 ZZZ $368.80

81379 P 00 00 00 00 ZZZ $25.82

81379 T 00 00 00 00 ZZZ $342.98

81380 C 00 00 00 00 ZZZ $194.91

81380 P 00 00 00 00 ZZZ $13.64

81380 T 00 00 00 00 ZZZ $181.27

81381 C 00 00 00 00 ZZZ $104.00

81381 P 00 00 00 00 ZZZ $7.28

81381 T 00 00 00 00 ZZZ $96.72

81382 C 00 00 00 00 ZZZ $136.00

81382 P 00 00 00 00 ZZZ $9.52

81382 T 00 00 00 00 ZZZ $126.48

81383 C 00 00 00 00 ZZZ $120.00

81383 P 00 00 00 00 ZZZ $8.40

81383 T 00 00 00 00 ZZZ $111.60

81400 C 00 00 00 00 ZZZ $54.98

81400 P 00 00 00 00 ZZZ $3.85

81400 T 00 00 00 00 ZZZ $51.14

81401 C 00 00 00 00 ZZZ $102.02

Page 352: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81401 P 00 00 00 00 ZZZ $7.14

81401 T 00 00 00 00 ZZZ $94.88

81402 C 00 00 00 00 ZZZ $177.02

81402 P 00 00 00 00 ZZZ $12.39

81402 T 00 00 00 00 ZZZ $164.63

81403 C 00 00 00 00 ZZZ $135.22

81403 P 00 00 00 00 ZZZ $9.46

81403 T 00 00 00 00 ZZZ $125.76

81404 C 00 00 00 00 ZZZ $378.79

81404 P 00 00 00 00 ZZZ $26.51

81404 T 00 00 00 00 ZZZ $352.28

81405 C 00 00 00 00 ZZZ $516.86

81405 P 00 00 00 00 ZZZ $36.18

81405 T 00 00 00 00 ZZZ $480.68

81406 C 00 00 00 00 ZZZ $1,013.10

81406 P 00 00 00 00 ZZZ $70.92

81406 T 00 00 00 00 ZZZ $942.18

81407 C 00 00 00 00 ZZZ $1,718.42

81407 P 00 00 00 00 ZZZ $120.29

81407 T 00 00 00 00 ZZZ $1,598.13

81408 C 00 00 00 00 ZZZ $1,032.52

81408 P 00 00 00 00 ZZZ $72.28

81408 T 00 00 00 00 ZZZ $960.24

81410 C 00 00 00 00 ZZZ $360.00

81410 T 00 00 00 00 ZZZ $360.00

81411 C 00 00 00 00 ZZZ $0.00

81411 P 00 00 00 00 ZZZ $0.00

81411 T 00 00 00 00 ZZZ $0.00

81412 C 00 00 00 00 ZZZ $0.00

81412 P 00 00 00 00 ZZZ $0.00

81412 T 00 00 00 00 ZZZ $0.00

81413 C 00 00 00 00 ZZZ $802.33

81413 T 00 00 00 00 ZZZ $802.33

81414 C 00 00 00 00 ZZZ $802.33

81414 T 00 00 00 00 ZZZ $802.33

81415 C 00 00 00 00 ZZZ $0.00

81415 P 00 00 00 00 ZZZ $0.00

81415 T 00 00 00 00 ZZZ $0.00

81416 C 00 00 00 00 ZZZ $0.00

81416 P 00 00 00 00 ZZZ $0.00

Page 353: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81416 T 00 00 00 00 ZZZ $0.00

81417 C 00 00 00 00 ZZZ $0.00

81417 P 00 00 00 00 ZZZ $0.00

81417 T 00 00 00 00 ZZZ $0.00

81420 C 00 00 00 00 ZZZ $1,060.00

81420 P 00 00 00 00 ZZZ $74.00

81420 T 00 00 00 00 ZZZ $985.80

81431 C 00 00 00 00 ZZZ $0.00

81431 P 00 00 00 00 ZZZ $0.00

81431 T 00 00 00 00 ZZZ $0.00

81432 C 00 00 00 00 ZZZ $0.00

81432 P 00 00 00 00 ZZZ $0.00

81432 T 00 00 00 00 ZZZ $0.00

81433 C 00 00 00 00 ZZZ $0.00

81433 P 00 00 00 00 ZZZ $0.00

81433 T 00 00 00 00 ZZZ $0.00

81434 C 00 00 00 00 ZZZ $0.00

81434 P 00 00 00 00 ZZZ $0.00

81434 T 00 00 00 00 ZZZ $0.00

81435 C 00 00 00 00 ZZZ $0.00

81435 P 00 00 00 00 ZZZ $0.00

81435 T 00 00 00 00 ZZZ $0.00

81436 C 00 00 00 00 ZZZ $0.00

81436 P 00 00 00 00 ZZZ $0.00

81436 T 00 00 00 00 ZZZ $0.00

81437 C 00 00 00 00 ZZZ $0.00

81437 P 00 00 00 00 ZZZ $0.00

81437 T 00 00 00 00 ZZZ $0.00

81438 C 00 00 00 00 ZZZ $0.00

81438 P 00 00 00 00 ZZZ $0.00

81438 T 00 00 00 00 ZZZ $0.00

81439 C 00 00 00 00 ZZZ $802.33

81439 T 00 00 00 00 ZZZ $802.33

81440 C 00 00 00 00 ZZZ $0.00

81440 P 00 00 00 00 ZZZ $0.00

81440 T 00 00 00 00 ZZZ $0.00

81442 C 00 00 00 00 ZZZ $0.00

81442 P 00 00 00 00 ZZZ $0.00

81442 T 00 00 00 00 ZZZ $0.00

81445 C 00 00 00 00 ZZZ $0.00

Page 354: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

81445 P 00 00 00 00 ZZZ $0.00

81445 T 00 00 00 00 ZZZ $0.00

81450 C 00 00 00 00 ZZZ $0.00

81450 P 00 00 00 00 ZZZ $0.00

81450 T 00 00 00 00 ZZZ $0.00

81455 C 00 00 00 00 ZZZ $0.00

81455 P 00 00 00 00 ZZZ $0.00

81455 T 00 00 00 00 ZZZ $0.00

81460 C 00 00 00 00 ZZZ $0.00

81460 P 00 00 00 00 ZZZ $0.00

81460 T 00 00 00 00 ZZZ $0.00

81465 C 00 00 00 00 ZZZ $0.00

81465 P 00 00 00 00 ZZZ $0.00

81465 T 00 00 00 00 ZZZ $0.00

81479 C 00 00 00 00 ZZZ $0.00

81479 T 00 00 00 00 ZZZ $0.00

81500 C 00 00 00 00 ZZZ $0.00

81500 T 00 00 00 00 ZZZ $0.00

81503 C 00 00 00 00 ZZZ $0.00

81503 T 00 00 00 00 ZZZ $0.00

81506 C 00 00 00 00 ZZZ $0.00

81506 T 00 00 00 00 ZZZ $0.00

81508 C 00 00 00 00 ZZZ $0.00

81508 T 00 00 00 00 ZZZ $0.00

81509 C 00 00 00 00 ZZZ $0.00

81509 T 00 00 00 00 ZZZ $0.00

81510 C 00 00 00 00 ZZZ $0.00

81510 T 00 00 00 00 ZZZ $0.00

81511 C 00 00 00 00 ZZZ $0.00

81511 T 00 00 00 00 ZZZ $0.00

81512 C 00 00 00 00 ZZZ $0.00

81512 T 00 00 00 00 ZZZ $0.00

81519 C 00 00 00 00 ZZZ $3,443.36

81519 T 00 00 00 00 ZZZ $3,443.36

81595 C 00 00 00 00 ZZZ $0.00

81595 T 00 00 00 00 ZZZ $0.00

81599 C 00 00 00 00 ZZZ $0.00

81599 T 00 00 00 00 ZZZ $0.00

82009 C 00 00 00 00 ZZZ $6.46

82009 T 00 00 00 00 ZZZ $6.46

Page 355: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82010 C 00 00 00 00 ZZZ $10.01

82010 T 00 00 00 00 ZZZ $10.01

82013 C 00 00 00 00 ZZZ $15.95

82013 T 00 00 00 00 ZZZ $15.95

82016 C 00 00 00 00 ZZZ $19.08

82016 T 00 00 00 00 ZZZ $19.08

82017 C 00 00 00 00 ZZZ $24.09

82017 T 00 00 00 00 ZZZ $24.09

82024 C 00 00 00 00 ZZZ $23.66

82024 T 00 00 00 00 ZZZ $23.66

82030 C 00 00 00 00 ZZZ $36.84

82030 T 00 00 00 00 ZZZ $36.84

82040 C 00 00 00 00 ZZZ $7.08

82040 T 00 00 00 00 ZZZ $7.08

82042 C 00 00 00 00 ZZZ $7.39

82042 T 00 00 00 00 ZZZ $7.39

82043 C 00 00 00 00 ZZZ $8.27

82043 T 00 00 00 00 ZZZ $8.27

82044 C 00 00 00 00 ZZZ $2.71

82044 T 00 00 00 00 ZZZ $2.71

82045 C 00 00 00 00 ZZZ $49.01

82045 T 00 00 00 00 ZZZ $49.01

82075 C 00 00 00 00 ZZZ $10.77

82075 T 00 00 00 00 ZZZ $10.77

82085 C 00 00 00 00 ZZZ $13.87

82085 T 00 00 00 00 ZZZ $13.87

82088 C 00 00 00 00 ZZZ $58.20

82088 T 00 00 00 00 ZZZ $58.20

82103 C 00 00 00 00 ZZZ $19.18

82103 T 00 00 00 00 ZZZ $19.18

82104 C 00 00 00 00 ZZZ $20.65

82104 T 00 00 00 00 ZZZ $20.65

82105 C 00 00 00 00 ZZZ $23.95

82105 T 00 00 00 00 ZZZ $23.95

82106 1 00 00 00 00 ZZZ $39.05

82106 C 00 00 00 00 ZZZ $23.95

82106 T 00 00 00 00 ZZZ $23.95

82107 C 00 00 00 00 ZZZ $92.99

82107 T 00 00 00 00 ZZZ $92.99

82108 C 00 00 00 00 ZZZ $12.47

Page 356: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82108 T 00 00 00 00 ZZZ $12.47

82120 C 00 00 00 00 ZZZ $5.36

82120 T 00 00 00 00 ZZZ $5.36

82127 C 00 00 00 00 ZZZ $19.08

82127 T 00 00 00 00 ZZZ $19.08

82128 C 00 00 00 00 ZZZ $19.08

82128 T 00 00 00 00 ZZZ $19.08

82131 C 00 00 00 00 ZZZ $24.09

82131 T 00 00 00 00 ZZZ $24.09

82135 C 00 00 00 00 ZZZ $23.51

82135 T 00 00 00 00 ZZZ $23.51

82136 C 00 00 00 00 ZZZ $24.09

82136 T 00 00 00 00 ZZZ $24.09

82139 C 00 00 00 00 ZZZ $24.09

82139 T 00 00 00 00 ZZZ $24.09

82140 C 00 00 00 00 ZZZ $12.49

82140 T 00 00 00 00 ZZZ $12.49

82143 C 00 00 00 00 ZZZ $9.53

82143 T 00 00 00 00 ZZZ $9.53

82150 C 00 00 00 00 ZZZ $9.26

82150 T 00 00 00 00 ZZZ $9.26

82154 C 00 00 00 00 ZZZ $41.18

82154 T 00 00 00 00 ZZZ $41.18

82157 C 00 00 00 00 ZZZ $41.81

82157 T 00 00 00 00 ZZZ $41.81

82160 C 00 00 00 00 ZZZ $35.72

82160 T 00 00 00 00 ZZZ $35.72

82163 C 00 00 00 00 ZZZ $29.32

82163 T 00 00 00 00 ZZZ $29.32

82164 C 00 00 00 00 ZZZ $20.84

82164 T 00 00 00 00 ZZZ $20.84

82172 C 00 00 00 00 ZZZ $22.12

82172 T 00 00 00 00 ZZZ $22.12

82175 C 00 00 00 00 ZZZ $27.09

82175 T 00 00 00 00 ZZZ $27.09

82180 C 00 00 00 00 ZZZ $14.12

82180 T 00 00 00 00 ZZZ $14.12

82190 C 00 00 00 00 ZZZ $21.29

82190 T 00 00 00 00 ZZZ $21.29

82232 C 00 00 00 00 ZZZ $23.11

Page 357: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82232 T 00 00 00 00 ZZZ $23.11

82239 C 00 00 00 00 ZZZ $24.46

82239 T 00 00 00 00 ZZZ $24.46

82240 C 00 00 00 00 ZZZ $37.95

82240 T 00 00 00 00 ZZZ $37.95

82247 C 00 00 00 00 ZZZ $7.17

82247 T 00 00 00 00 ZZZ $7.17

82248 C 00 00 00 00 ZZZ $7.17

82248 T 00 00 00 00 ZZZ $7.17

82252 C 00 00 00 00 ZZZ $3.86

82252 T 00 00 00 00 ZZZ $3.86

82261 C 00 00 00 00 ZZZ $24.09

82261 T 00 00 00 00 ZZZ $24.09

82270 C 00 00 00 00 ZZZ $4.64

82270 T 00 00 00 00 ZZZ $4.64

82271 C 00 00 00 00 ZZZ $4.69

82271 T 00 00 00 00 ZZZ $4.69

82272 C 00 00 00 00 ZZZ $4.69

82272 T 00 00 00 00 ZZZ $4.69

82274 C 00 00 00 00 ZZZ $22.22

82274 T 00 00 00 00 ZZZ $22.00

82286 C 00 00 00 00 ZZZ $9.84

82286 T 00 00 00 00 ZZZ $9.84

82300 C 00 00 00 00 ZZZ $33.05

82300 T 00 00 00 00 ZZZ $33.05

82306 C 00 00 00 00 ZZZ $42.27

82306 T 00 00 00 00 ZZZ $42.27

82308 C 00 00 00 00 ZZZ $38.24

82308 T 00 00 00 00 ZZZ $38.24

82310 C 00 00 00 00 ZZZ $7.36

82310 T 00 00 00 00 ZZZ $7.36

82330 C 00 00 00 00 ZZZ $18.87

82330 T 00 00 00 00 ZZZ $18.87

82331 C 00 00 00 00 ZZZ $7.39

82331 T 00 00 00 00 ZZZ $7.39

82340 C 00 00 00 00 ZZZ $8.62

82340 T 00 00 00 00 ZZZ $8.62

82355 C 00 00 00 00 ZZZ $16.52

82355 T 00 00 00 00 ZZZ $16.52

82360 C 00 00 00 00 ZZZ $18.39

Page 358: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82360 T 00 00 00 00 ZZZ $18.39

82365 C 00 00 00 00 ZZZ $18.41

82365 T 00 00 00 00 ZZZ $18.41

82370 C 00 00 00 00 ZZZ $17.90

82370 T 00 00 00 00 ZZZ $17.90

82373 C 00 00 00 00 ZZZ $10.28

82373 T 00 00 00 00 ZZZ $10.28

82374 C 00 00 00 00 ZZZ $6.99

82374 T 00 00 00 00 ZZZ $6.99

82375 C 00 00 00 00 ZZZ $17.60

82375 T 00 00 00 00 ZZZ $17.60

82376 C 00 00 00 00 ZZZ $8.56

82376 T 00 00 00 00 ZZZ $8.56

82378 C 00 00 00 00 ZZZ $27.09

82378 T 00 00 00 00 ZZZ $27.09

82379 C 00 00 00 00 ZZZ $24.09

82379 T 00 00 00 00 ZZZ $24.09

82380 C 00 00 00 00 ZZZ $13.18

82380 T 00 00 00 00 ZZZ $13.18

82382 C 00 00 00 00 ZZZ $24.55

82382 T 00 00 00 00 ZZZ $24.55

82383 C 00 00 00 00 ZZZ $35.78

82383 T 00 00 00 00 ZZZ $35.78

82384 C 00 00 00 00 ZZZ $36.06

82384 T 00 00 00 00 ZZZ $36.06

82387 C 00 00 00 00 ZZZ $29.71

82387 T 00 00 00 00 ZZZ $29.71

82390 C 00 00 00 00 ZZZ $15.33

82390 T 00 00 00 00 ZZZ $15.33

82397 C 00 00 00 00 ZZZ $20.18

82397 T 00 00 00 00 ZZZ $20.18

82415 C 00 00 00 00 ZZZ $18.09

82415 T 00 00 00 00 ZZZ $18.09

82435 C 00 00 00 00 ZZZ $6.56

82435 T 00 00 00 00 ZZZ $6.56

82436 C 00 00 00 00 ZZZ $7.18

82436 T 00 00 00 00 ZZZ $7.18

82438 C 00 00 00 00 ZZZ $6.99

82438 T 00 00 00 00 ZZZ $6.99

82441 C 00 00 00 00 ZZZ $7.71

Page 359: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82441 T 00 00 00 00 ZZZ $7.71

82465 C 00 00 00 00 ZZZ $6.22

82465 T 00 00 00 00 ZZZ $6.22

82480 C 00 00 00 00 ZZZ $11.25

82480 T 00 00 00 00 ZZZ $11.25

82482 C 00 00 00 00 ZZZ $10.97

82482 T 00 00 00 00 ZZZ $10.97

82485 C 00 00 00 00 ZZZ $7.17

82485 T 00 00 00 00 ZZZ $7.17

82495 C 00 00 00 00 ZZZ $9.98

82495 T 00 00 00 00 ZZZ $9.98

82507 C 00 00 00 00 ZZZ $39.71

82507 T 00 00 00 00 ZZZ $39.71

82523 C 00 00 00 00 ZZZ $26.69

82523 P 00 00 00 00 ZZZ $0.00

82523 T 00 00 00 00 ZZZ $26.69

82525 C 00 00 00 00 ZZZ $17.72

82525 T 00 00 00 00 ZZZ $17.72

82528 C 00 00 00 00 ZZZ $32.15

82528 T 00 00 00 00 ZZZ $32.15

82530 C 00 00 00 00 ZZZ $23.87

82530 T 00 00 00 00 ZZZ $23.87

82533 C 00 00 00 00 ZZZ $23.28

82533 T 00 00 00 00 ZZZ $23.28

82540 C 00 00 00 00 ZZZ $6.61

82540 T 00 00 00 00 ZZZ $6.61

82542 C 00 00 00 00 ZZZ $25.79

82542 T 00 00 00 00 ZZZ $25.79

82550 C 00 00 00 00 ZZZ $9.31

82550 T 00 00 00 00 ZZZ $9.31

82552 C 00 00 00 00 ZZZ $19.13

82552 T 00 00 00 00 ZZZ $19.13

82553 C 00 00 00 00 ZZZ $16.48

82553 T 00 00 00 00 ZZZ $16.48

82554 C 00 00 00 00 ZZZ $16.95

82554 T 00 00 00 00 ZZZ $16.95

82565 C 00 00 00 00 ZZZ $7.31

82565 T 00 00 00 00 ZZZ $7.31

82570 C 00 00 00 00 ZZZ $7.39

82570 T 00 00 00 00 ZZZ $7.39

Page 360: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82575 C 00 00 00 00 ZZZ $13.50

82575 T 00 00 00 00 ZZZ $13.50

82585 C 00 00 00 00 ZZZ $12.25

82585 T 00 00 00 00 ZZZ $12.25

82595 C 00 00 00 00 ZZZ $9.25

82595 T 00 00 00 00 ZZZ $9.25

82600 C 00 00 00 00 ZZZ $27.70

82600 T 00 00 00 00 ZZZ $27.70

82607 C 00 00 00 00 ZZZ $21.52

82607 T 00 00 00 00 ZZZ $21.52

82608 C 00 00 00 00 ZZZ $20.46

82608 T 00 00 00 00 ZZZ $20.46

82610 C 00 00 00 00 ZZZ $19.63

82610 T 00 00 00 00 ZZZ $19.63

82615 C 00 00 00 00 ZZZ $11.67

82615 T 00 00 00 00 ZZZ $11.67

82626 C 00 00 00 00 ZZZ $36.09

82626 T 00 00 00 00 ZZZ $36.09

82627 C 00 00 00 00 ZZZ $31.74

82627 T 00 00 00 00 ZZZ $31.74

82633 C 00 00 00 00 ZZZ $44.24

82633 T 00 00 00 00 ZZZ $44.24

82634 C 00 00 00 00 ZZZ $41.81

82634 T 00 00 00 00 ZZZ $41.81

82638 C 00 00 00 00 ZZZ $17.48

82638 T 00 00 00 00 ZZZ $17.48

82652 C 00 00 00 00 ZZZ $54.96

82652 T 00 00 00 00 ZZZ $54.96

82656 C 00 00 00 00 ZZZ $16.56

82656 T 00 00 00 00 ZZZ $16.56

82657 C 00 00 00 00 ZZZ $25.97

82657 T 00 00 00 00 ZZZ $25.79

82658 C 00 00 00 00 ZZZ $25.79

82658 T 00 00 00 00 ZZZ $25.79

82664 C 00 00 00 00 ZZZ $49.06

82664 T 00 00 00 00 ZZZ $49.06

82668 C 00 00 00 00 ZZZ $26.84

82668 T 00 00 00 00 ZZZ $26.84

82670 C 00 00 00 00 ZZZ $39.91

82670 T 00 00 00 00 ZZZ $39.91

Page 361: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82671 C 00 00 00 00 ZZZ $34.28

82671 T 00 00 00 00 ZZZ $34.28

82672 C 00 00 00 00 ZZZ $30.97

82672 T 00 00 00 00 ZZZ $30.97

82677 C 00 00 00 00 ZZZ $34.54

82677 T 00 00 00 00 ZZZ $34.54

82679 C 00 00 00 00 ZZZ $35.65

82679 T 00 00 00 00 ZZZ $35.65

82693 C 00 00 00 00 ZZZ $21.28

82693 T 00 00 00 00 ZZZ $21.28

82696 C 00 00 00 00 ZZZ $33.69

82696 T 00 00 00 00 ZZZ $33.69

82705 C 00 00 00 00 ZZZ $7.27

82705 T 00 00 00 00 ZZZ $7.27

82710 C 00 00 00 00 ZZZ $16.62

82710 T 00 00 00 00 ZZZ $16.62

82715 C 00 00 00 00 ZZZ $24.58

82715 T 00 00 00 00 ZZZ $24.58

82725 C 00 00 00 00 ZZZ $19.01

82725 T 00 00 00 00 ZZZ $19.01

82726 C 00 00 00 00 ZZZ $25.79

82726 T 00 00 00 00 ZZZ $25.79

82728 C 00 00 00 00 ZZZ $19.46

82728 T 00 00 00 00 ZZZ $18.83

82731 C 00 00 00 00 ZZZ $91.98

82731 T 00 00 00 00 ZZZ $91.98

82735 C 00 00 00 00 ZZZ $26.48

82735 T 00 00 00 00 ZZZ $26.48

82746 C 00 00 00 00 ZZZ $21.00

82746 T 00 00 00 00 ZZZ $21.00

82747 C 00 00 00 00 ZZZ $24.73

82747 T 00 00 00 00 ZZZ $24.73

82757 C 00 00 00 00 ZZZ $24.77

82757 T 00 00 00 00 ZZZ $24.77

82759 C 00 00 00 00 ZZZ $30.68

82759 T 00 00 00 00 ZZZ $30.68

82760 C 00 00 00 00 ZZZ $11.56

82760 T 00 00 00 00 ZZZ $11.56

82775 C 00 00 00 00 ZZZ $30.08

82775 T 00 00 00 00 ZZZ $30.08

Page 362: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82776 C 00 00 00 00 ZZZ $9.17

82776 T 00 00 00 00 ZZZ $9.17

82777 C 00 00 00 00 ZZZ $17.80

82777 T 00 00 00 00 ZZZ $17.80

82784 C 00 00 00 00 ZZZ $8.24

82784 T 00 00 00 00 ZZZ $8.24

82785 C 00 00 00 00 ZZZ $23.13

82785 T 00 00 00 00 ZZZ $23.13

82787 C 00 00 00 00 ZZZ $11.46

82787 T 00 00 00 00 ZZZ $11.46

82800 C 00 00 00 00 ZZZ $12.10

82800 T 00 00 00 00 ZZZ $12.10

82803 C 00 00 00 00 ZZZ $27.63

82803 T 00 00 00 00 ZZZ $27.63

82805 C 00 00 00 00 ZZZ $40.52

82805 T 00 00 00 00 ZZZ $40.52

82810 C 00 00 00 00 ZZZ $12.46

82810 T 00 00 00 00 ZZZ $12.46

82820 C 00 00 00 00 ZZZ $14.28

82820 T 00 00 00 00 ZZZ $14.28

82930 C 00 00 00 00 ZZZ $5.26

82930 T 00 00 00 00 ZZZ $5.26

82938 C 00 00 00 00 ZZZ $25.28

82938 T 00 00 00 00 ZZZ $25.28

82941 C 00 00 00 00 ZZZ $25.19

82941 T 00 00 00 00 ZZZ $25.19

82943 C 00 00 00 00 ZZZ $20.41

82943 T 00 00 00 00 ZZZ $20.41

82945 C 00 00 00 00 ZZZ $5.60

82945 T 00 00 00 00 ZZZ $5.60

82946 C 00 00 00 00 ZZZ $21.52

82946 T 00 00 00 00 ZZZ $21.52

82947 C 00 00 00 00 ZZZ $5.60

82947 T 00 00 00 00 ZZZ $5.60

82948 C 00 00 00 00 ZZZ $4.52

82948 T 00 00 00 00 ZZZ $4.52

82950 C 00 00 00 00 ZZZ $6.78

82950 T 00 00 00 00 ZZZ $6.78

82951 C 00 00 00 00 ZZZ $18.39

82951 T 00 00 00 00 ZZZ $18.39

Page 363: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

82952 C 00 00 00 00 ZZZ $5.60

82952 T 00 00 00 00 ZZZ $5.60

82955 C 00 00 00 00 ZZZ $13.85

82955 T 00 00 00 00 ZZZ $13.85

82960 C 00 00 00 00 ZZZ $8.66

82960 T 00 00 00 00 ZZZ $8.66

82962 C 00 00 00 00 ZZZ $4.37

82962 T 00 00 00 00 ZZZ $4.37

82963 C 00 00 00 00 ZZZ $30.68

82963 T 00 00 00 00 ZZZ $30.68

82965 C 00 00 00 00 ZZZ $9.98

82965 T 00 00 00 00 ZZZ $9.98

82977 C 00 00 00 00 ZZZ $10.28

82977 T 00 00 00 00 ZZZ $10.28

82978 C 00 00 00 00 ZZZ $20.36

82978 T 00 00 00 00 ZZZ $20.36

82979 C 00 00 00 00 ZZZ $8.24

82979 T 00 00 00 00 ZZZ $8.24

82985 C 00 00 00 00 ZZZ $21.52

82985 T 00 00 00 00 ZZZ $21.52

83001 C 00 00 00 00 ZZZ $26.55

83001 T 00 00 00 00 ZZZ $26.55

83002 C 00 00 00 00 ZZZ $26.45

83002 T 00 00 00 00 ZZZ $26.45

83003 C 00 00 00 00 ZZZ $23.81

83003 T 00 00 00 00 ZZZ $23.81

83006 C 00 00 00 00 ZZZ $29.93

83006 T 00 00 00 00 ZZZ $29.93

83009 C 00 00 00 00 ZZZ $41.79

83009 T 00 00 00 00 ZZZ $41.79

83010 C 00 00 00 00 ZZZ $17.96

83010 T 00 00 00 00 ZZZ $17.96

83012 C 00 00 00 00 ZZZ $24.55

83012 T 00 00 00 00 ZZZ $24.55

83013 C 00 00 00 00 ZZZ $41.33

83013 T 00 00 00 00 ZZZ $41.33

83014 C 00 00 00 00 ZZZ $11.22

83014 T 00 00 00 00 ZZZ $11.22

83015 C 00 00 00 00 ZZZ $26.90

83015 T 00 00 00 00 ZZZ $26.90

Page 364: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

83018 C 00 00 00 00 ZZZ $31.28

83018 T 00 00 00 00 ZZZ $30.27

83020 A FP 00 00 00 ZZZ $18.39

83020 C 00 00 00 00 ZZZ $18.39

83020 T 00 00 00 00 ZZZ $18.39

83021 C 00 00 00 00 ZZZ $25.79

83021 T 00 00 00 00 ZZZ $25.79

83026 C 00 00 00 00 ZZZ $3.37

83026 T 00 00 00 00 ZZZ $3.37

83030 C 00 00 00 00 ZZZ $11.81

83030 T 00 00 00 00 ZZZ $11.81

83033 C 00 00 00 00 ZZZ $8.11

83033 T 00 00 00 00 ZZZ $8.11

83036 C 00 00 00 00 ZZZ $13.87

83036 T 00 00 00 00 ZZZ $13.87

83045 C 00 00 00 00 ZZZ $7.08

83045 T 00 00 00 00 ZZZ $7.08

83050 C 00 00 00 00 ZZZ $8.26

83050 T 00 00 00 00 ZZZ $8.26

83051 C 00 00 00 00 ZZZ $10.44

83051 T 00 00 00 00 ZZZ $10.44

83060 C 00 00 00 00 ZZZ $11.81

83060 T 00 00 00 00 ZZZ $11.81

83065 C 00 00 00 00 ZZZ $9.84

83065 T 00 00 00 00 ZZZ $9.84

83068 C 00 00 00 00 ZZZ $12.10

83068 T 00 00 00 00 ZZZ $12.10

83069 C 00 00 00 00 ZZZ $5.63

83069 T 00 00 00 00 ZZZ $5.63

83070 C 00 00 00 00 ZZZ $4.77

83070 T 00 00 00 00 ZZZ $4.77

83080 C 00 00 00 00 ZZZ $24.09

83080 T 00 00 00 00 ZZZ $24.09

83088 C 00 00 00 00 ZZZ $39.86

83088 T 00 00 00 00 ZZZ $39.86

83090 C 00 00 00 00 ZZZ $24.09

83090 T 00 00 00 00 ZZZ $24.09

83150 C 00 00 00 00 ZZZ $12.89

83150 T 00 00 00 00 ZZZ $12.89

83491 C 00 00 00 00 ZZZ $25.02

Page 365: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

83491 T 00 00 00 00 ZZZ $25.02

83497 C 00 00 00 00 ZZZ $18.41

83497 T 00 00 00 00 ZZZ $18.41

83498 C 00 00 00 00 ZZZ $38.79

83498 T 00 00 00 00 ZZZ $38.79

83499 C 00 00 00 00 ZZZ $35.99

83499 T 00 00 00 00 ZZZ $35.99

83500 C 00 00 00 00 ZZZ $32.34

83500 T 00 00 00 00 ZZZ $32.34

83505 C 00 00 00 00 ZZZ $34.71

83505 T 00 00 00 00 ZZZ $34.71

83516 C 00 00 00 00 ZZZ $16.48

83516 T 00 00 00 00 ZZZ $16.48

83518 C 00 00 00 00 ZZZ $6.55

83518 T 00 00 00 00 ZZZ $6.55

83519 C 00 00 00 00 ZZZ $12.87

83519 T 00 00 00 00 ZZZ $12.87

83520 A FP 00 00 00 ZZZ $18.49

83520 C 00 00 00 00 ZZZ $18.49

83520 T 00 00 00 00 ZZZ $18.49

83525 C 00 00 00 00 ZZZ $16.34

83525 T 00 00 00 00 ZZZ $16.34

83527 C 00 00 00 00 ZZZ $18.50

83527 T 00 00 00 00 ZZZ $18.50

83528 C 00 00 00 00 ZZZ $22.71

83528 T 00 00 00 00 ZZZ $22.71

83540 C 00 00 00 00 ZZZ $9.25

83540 T 00 00 00 00 ZZZ $9.25

83550 C 00 00 00 00 ZZZ $12.48

83550 T 00 00 00 00 ZZZ $12.48

83570 C 00 00 00 00 ZZZ $12.63

83570 T 00 00 00 00 ZZZ $12.63

83582 C 00 00 00 00 ZZZ $20.24

83582 T 00 00 00 00 ZZZ $20.24

83586 C 00 00 00 00 ZZZ $18.28

83586 T 00 00 00 00 ZZZ $18.28

83593 C 00 00 00 00 ZZZ $37.56

83593 T 00 00 00 00 ZZZ $37.56

83605 C 00 00 00 00 ZZZ $15.25

83605 T 00 00 00 00 ZZZ $15.25

Page 366: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

83615 C 00 00 00 00 ZZZ $8.63

83615 T 00 00 00 00 ZZZ $8.63

83625 C 00 00 00 00 ZZZ $18.28

83625 T 00 00 00 00 ZZZ $18.28

83630 C 00 00 00 00 ZZZ $16.66

83630 T 00 00 00 00 ZZZ $16.66

83631 C 00 00 00 00 ZZZ $28.33

83631 T 00 00 00 00 ZZZ $28.33

83632 C 00 00 00 00 ZZZ $28.86

83632 T 00 00 00 00 ZZZ $28.86

83633 C 00 00 00 00 ZZZ $7.86

83633 T 00 00 00 00 ZZZ $7.86

83655 C 00 00 00 00 ZZZ $17.28

83655 T 00 00 00 00 ZZZ $17.28

83661 C 00 00 00 00 ZZZ $18.28

83661 T 00 00 00 00 ZZZ $31.39

83662 C 00 00 00 00 ZZZ $27.01

83662 T 00 00 00 00 ZZZ $27.01

83663 C 00 00 00 00 ZZZ $13.51

83663 T 00 00 00 00 ZZZ $13.51

83664 C 00 00 00 00 ZZZ $6.75

83664 T 00 00 00 00 ZZZ $6.75

83670 C 00 00 00 00 ZZZ $13.08

83670 T 00 00 00 00 ZZZ $13.08

83690 C 00 00 00 00 ZZZ $9.84

83690 T 00 00 00 00 ZZZ $9.84

83695 C 00 00 00 00 ZZZ $18.69

83695 T 00 00 00 00 ZZZ $18.69

83698 C 00 00 00 00 ZZZ $49.01

83698 T 00 00 00 00 ZZZ $49.01

83700 C 00 00 00 00 ZZZ $16.25

83700 T 00 00 00 00 ZZZ $16.25

83701 C 00 00 00 00 ZZZ $35.19

83701 T 00 00 00 00 ZZZ $35.19

83704 C 00 00 00 00 ZZZ $45.55

83704 T 00 00 00 00 ZZZ $45.55

83718 C 00 00 00 00 ZZZ $11.69

83718 T 00 00 00 00 ZZZ $11.69

83719 C 00 00 00 00 ZZZ $16.62

83719 T 00 00 00 00 ZZZ $16.62

Page 367: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

83721 C 00 00 00 00 ZZZ $13.62

83721 T 00 00 00 00 ZZZ $13.62

83727 C 00 00 00 00 ZZZ $24.55

83727 T 00 00 00 00 ZZZ $24.55

83735 C 00 00 00 00 ZZZ $9.57

83735 T 00 00 00 00 ZZZ $9.57

83775 C 00 00 00 00 ZZZ $10.53

83775 T 00 00 00 00 ZZZ $10.53

83785 C 00 00 00 00 ZZZ $35.11

83785 T 00 00 00 00 ZZZ $35.11

83789 C 00 00 00 00 ZZZ $25.79

83789 T 00 00 00 00 ZZZ $25.79

83825 C 00 00 00 00 ZZZ $23.22

83825 T 00 00 00 00 ZZZ $23.22

83835 C 00 00 00 00 ZZZ $21.51

83835 T 00 00 00 00 ZZZ $21.51

83857 C 00 00 00 00 ZZZ $15.33

83857 T 00 00 00 00 ZZZ $15.33

83861 C 00 00 00 00 ZZZ $23.58

83861 T 00 00 00 00 ZZZ $23.58

83864 C 00 00 00 00 ZZZ $28.43

83864 T 00 00 00 00 ZZZ $28.43

83872 C 00 00 00 00 ZZZ $7.44

83872 T 00 00 00 00 ZZZ $7.44

83873 C 00 00 00 00 ZZZ $24.57

83873 T 00 00 00 00 ZZZ $24.57

83874 C 00 00 00 00 ZZZ $18.43

83874 T 00 00 00 00 ZZZ $18.43

83876 C 00 00 00 00 ZZZ $18.91

83876 T 00 00 00 00 ZZZ $18.91

83880 C 00 00 00 00 ZZZ $47.43

83880 T 00 00 00 00 ZZZ $47.43

83883 C 00 00 00 00 ZZZ $19.42

83883 T 00 00 00 00 ZZZ $19.42

83885 C 00 00 00 00 ZZZ $34.99

83885 T 00 00 00 00 ZZZ $34.99

83915 C 00 00 00 00 ZZZ $15.92

83915 T 00 00 00 00 ZZZ $15.92

83916 C 00 00 00 00 ZZZ $28.72

83916 T 00 00 00 00 ZZZ $28.72

Page 368: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

83918 C 00 00 00 00 ZZZ $23.51

83918 T 00 00 00 00 ZZZ $23.51

83919 C 00 00 00 00 ZZZ $23.51

83919 T 00 00 00 00 ZZZ $23.51

83921 C 00 00 00 00 ZZZ $23.51

83921 T 00 00 00 00 ZZZ $23.51

83930 C 00 00 00 00 ZZZ $9.43

83930 T 00 00 00 00 ZZZ $9.43

83935 C 00 00 00 00 ZZZ $9.73

83935 T 00 00 00 00 ZZZ $9.73

83937 C 00 00 00 00 ZZZ $42.64

83937 T 00 00 00 00 ZZZ $42.64

83945 C 00 00 00 00 ZZZ $18.39

83945 T 00 00 00 00 ZZZ $18.39

83950 C 00 00 00 00 ZZZ $89.01

83950 T 00 00 00 00 ZZZ $89.01

83951 C 00 00 00 00 ZZZ $94.04

83951 T 00 00 00 00 ZZZ $94.04

83970 C 00 00 00 00 ZZZ $58.94

83970 T 00 00 00 00 ZZZ $58.94

83986 C 00 00 00 00 ZZZ $5.12

83986 T 00 00 00 00 ZZZ $5.12

83992 C 00 00 00 00 ZZZ $19.92

83992 T 00 00 00 00 ZZZ $19.92

83993 C 00 00 00 00 ZZZ $28.33

83993 T 00 00 00 00 ZZZ $28.33

84030 C 00 00 00 00 ZZZ $7.83

84030 T 00 00 00 00 ZZZ $7.83

84035 C 00 00 00 00 ZZZ $3.44

84035 T 00 00 00 00 ZZZ $3.44

84060 C 00 00 00 00 ZZZ $10.54

84060 T 00 00 00 00 ZZZ $10.54

84066 C 00 00 00 00 ZZZ $13.80

84066 T 00 00 00 00 ZZZ $13.80

84075 C 00 00 00 00 ZZZ $7.39

84075 T 00 00 00 00 ZZZ $7.39

84078 C 00 00 00 00 ZZZ $6.78

84078 T 00 00 00 00 ZZZ $6.78

84080 C 00 00 00 00 ZZZ $21.12

84080 T 00 00 00 00 ZZZ $21.12

Page 369: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

84081 C 00 00 00 00 ZZZ $23.60

84081 T 00 00 00 00 ZZZ $23.60

84085 C 00 00 00 00 ZZZ $9.17

84085 T 00 00 00 00 ZZZ $9.17

84087 C 00 00 00 00 ZZZ $14.75

84087 T 00 00 00 00 ZZZ $14.75

84100 C 00 00 00 00 ZZZ $6.78

84100 T 00 00 00 00 ZZZ $6.78

84105 C 00 00 00 00 ZZZ $7.39

84105 T 00 00 00 00 ZZZ $7.39

84106 C 00 00 00 00 ZZZ $6.12

84106 T 00 00 00 00 ZZZ $6.12

84110 C 00 00 00 00 ZZZ $9.17

84110 T 00 00 00 00 ZZZ $9.17

84112 C 00 00 00 00 ZZZ $90.64

84112 T 00 00 00 00 ZZZ $90.64

84119 C 00 00 00 00 ZZZ $12.30

84119 T 00 00 00 00 ZZZ $12.30

84120 C 00 00 00 00 ZZZ $19.11

84120 T 00 00 00 00 ZZZ $19.11

84126 C 00 00 00 00 ZZZ $36.37

84126 T 00 00 00 00 ZZZ $36.37

84132 C 00 00 00 00 ZZZ $6.56

84132 T 00 00 00 00 ZZZ $6.56

84133 C 00 00 00 00 ZZZ $6.14

84133 T 00 00 00 00 ZZZ $6.14

84134 C 00 00 00 00 ZZZ $20.83

84134 T 00 00 00 00 ZZZ $20.83

84135 C 00 00 00 00 ZZZ $27.32

84135 T 00 00 00 00 ZZZ $27.32

84138 C 00 00 00 00 ZZZ $27.03

84138 T 00 00 00 00 ZZZ $27.03

84140 C 00 00 00 00 ZZZ $29.53

84140 T 00 00 00 00 ZZZ $29.53

84143 C 00 00 00 00 ZZZ $32.59

84143 T 00 00 00 00 ZZZ $32.59

84144 C 00 00 00 00 ZZZ $29.79

84144 T 00 00 00 00 ZZZ $29.79

84145 C 00 00 00 00 ZZZ $28.69

84145 T 00 00 00 00 ZZZ $28.69

Page 370: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

84146 C 00 00 00 00 ZZZ $27.67

84146 T 00 00 00 00 ZZZ $27.67

84150 C 00 00 00 00 ZZZ $35.67

84150 T 00 00 00 00 ZZZ $35.65

84152 C 00 00 00 00 ZZZ $26.27

84152 T 00 00 00 00 ZZZ $26.27

84153 C 00 00 00 00 ZZZ $26.27

84153 T 00 00 00 00 ZZZ $26.27

84154 C 00 00 00 00 ZZZ $26.27

84154 T 00 00 00 00 ZZZ $26.27

84155 C 00 00 00 00 ZZZ $5.23

84155 T 00 00 00 00 ZZZ $5.23

84156 C 00 00 00 00 ZZZ $5.25

84156 T 00 00 00 00 ZZZ $5.25

84157 C 00 00 00 00 ZZZ $5.25

84157 T 00 00 00 00 ZZZ $5.25

84160 C 00 00 00 00 ZZZ $7.39

84160 T 00 00 00 00 ZZZ $7.39

84163 C 00 00 00 00 ZZZ $11.67

84163 T 00 00 00 00 ZZZ $11.67

84165 C 00 00 00 00 ZZZ $15.33

84165 P 00 00 00 00 ZZZ $24.37

84165 T 00 00 00 00 ZZZ $15.33

84166 C 00 00 00 00 ZZZ $27.75

84166 T 00 00 00 00 ZZZ $27.75

84181 C 00 00 00 00 ZZZ $24.32

84181 T 00 00 00 00 ZZZ $24.32

84182 C 00 00 00 00 ZZZ $25.70

84182 T 00 00 00 00 ZZZ $25.70

84202 C 00 00 00 00 ZZZ $20.49

84202 T 00 00 00 00 ZZZ $20.49

84203 C 00 00 00 00 ZZZ $9.17

84203 T 00 00 00 00 ZZZ $9.17

84206 C 00 00 00 00 ZZZ $25.44

84206 T 00 00 00 00 ZZZ $25.44

84207 C 00 00 00 00 ZZZ $40.11

84207 T 00 00 00 00 ZZZ $40.11

84210 C 00 00 00 00 ZZZ $15.51

84210 T 00 00 00 00 ZZZ $15.51

84220 C 00 00 00 00 ZZZ $6.13

Page 371: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

84220 T 00 00 00 00 ZZZ $6.13

84228 C 00 00 00 00 ZZZ $16.62

84228 T 00 00 00 00 ZZZ $16.62

84233 C 00 00 00 00 ZZZ $91.98

84233 T 00 00 00 00 ZZZ $91.98

84234 C 00 00 00 00 ZZZ $92.63

84234 T 00 00 00 00 ZZZ $92.63

84235 C 00 00 00 00 ZZZ $74.72

84235 T 00 00 00 00 ZZZ $74.72

84238 C 00 00 00 00 ZZZ $52.21

84238 T 00 00 00 00 ZZZ $52.21

84244 C 00 00 00 00 ZZZ $31.41

84244 T 00 00 00 00 ZZZ $31.41

84252 C 00 00 00 00 ZZZ $28.89

84252 T 00 00 00 00 ZZZ $28.89

84255 C 00 00 00 00 ZZZ $36.46

84255 T 00 00 00 00 ZZZ $36.46

84260 C 00 00 00 00 ZZZ $44.24

84260 T 00 00 00 00 ZZZ $44.24

84270 C 00 00 00 00 ZZZ $31.03

84270 T 00 00 00 00 ZZZ $31.03

84275 C 00 00 00 00 ZZZ $19.18

84275 T 00 00 00 00 ZZZ $19.18

84285 C 00 00 00 00 ZZZ $33.64

84285 T 00 00 00 00 ZZZ $33.64

84295 C 00 00 00 00 ZZZ $6.87

84295 T 00 00 00 00 ZZZ $6.87

84300 C 00 00 00 00 ZZZ $6.94

84300 T 00 00 00 00 ZZZ $6.94

84302 C 00 00 00 00 ZZZ $6.79

84302 T 00 00 00 00 ZZZ $6.79

84305 C 00 00 00 00 ZZZ $30.36

84305 T 00 00 00 00 ZZZ $30.36

84307 C 00 00 00 00 ZZZ $26.11

84307 T 00 00 00 00 ZZZ $26.11

84311 C 00 00 00 00 ZZZ $9.43

84311 T 00 00 00 00 ZZZ $9.43

84315 C 00 00 00 00 ZZZ $1.86

84315 T 00 00 00 00 ZZZ $1.86

84375 C 00 00 00 00 ZZZ $27.09

Page 372: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

84375 T 00 00 00 00 ZZZ $27.09

84376 C 00 00 00 00 ZZZ $7.86

84376 T 00 00 00 00 ZZZ $7.86

84377 C 00 00 00 00 ZZZ $7.86

84377 T 00 00 00 00 ZZZ $7.86

84378 C 00 00 00 00 ZZZ $16.45

84378 T 00 00 00 00 ZZZ $16.45

84379 C 00 00 00 00 ZZZ $16.45

84379 T 00 00 00 00 ZZZ $16.45

84392 C 00 00 00 00 ZZZ $6.78

84392 T 00 00 00 00 ZZZ $6.78

84402 C 00 00 00 00 ZZZ $36.36

84402 T 00 00 00 00 ZZZ $36.36

84403 C 00 00 00 00 ZZZ $36.87

84403 T 00 00 00 00 ZZZ $36.87

84410 C 00 00 00 00 ZZZ $72.55

84410 T 00 00 00 00 ZZZ $72.55

84425 C 00 00 00 00 ZZZ $30.33

84425 T 00 00 00 00 ZZZ $30.33

84430 C 00 00 00 00 ZZZ $16.62

84430 T 00 00 00 00 ZZZ $16.62

84431 C 00 00 00 00 ZZZ $19.16

84431 T 00 00 00 00 ZZZ $19.16

84432 C 00 00 00 00 ZZZ $22.94

84432 T 00 00 00 00 ZZZ $22.94

84436 C 00 00 00 00 ZZZ $8.90

84436 T 00 00 00 00 ZZZ $8.90

84437 C 00 00 00 00 ZZZ $9.25

84437 T 00 00 00 00 ZZZ $9.25

84439 C 00 00 00 00 ZZZ $12.88

84439 T 00 00 00 00 ZZZ $12.88

84442 C 00 00 00 00 ZZZ $21.12

84442 T 00 00 00 00 ZZZ $21.12

84443 C 00 00 00 00 ZZZ $23.98

84443 T 00 00 00 00 ZZZ $23.98

84445 C 00 00 00 00 ZZZ $72.62

84445 T 00 00 00 00 ZZZ $72.62

84446 C 00 00 00 00 ZZZ $20.25

84446 T 00 00 00 00 ZZZ $20.25

84449 C 00 00 00 00 ZZZ $25.70

Page 373: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

84449 T 00 00 00 00 ZZZ $25.70

84450 C 00 00 00 00 ZZZ $7.38

84450 T 00 00 00 00 ZZZ $7.38

84460 C 00 00 00 00 ZZZ $7.56

84460 T 00 00 00 00 ZZZ $7.56

84466 C 00 00 00 00 ZZZ $18.24

84466 T 00 00 00 00 ZZZ $18.24

84478 C 00 00 00 00 ZZZ $8.22

84478 T 00 00 00 00 ZZZ $8.22

84479 C 00 00 00 00 ZZZ $9.25

84479 T 00 00 00 00 ZZZ $9.25

84480 C 00 00 00 00 ZZZ $20.25

84480 T 00 00 00 00 ZZZ $20.25

84481 C 00 00 00 00 ZZZ $24.19

84481 T 00 00 00 00 ZZZ $24.19

84482 C 00 00 00 00 ZZZ $22.51

84482 T 00 00 00 00 ZZZ $22.51

84484 C 00 00 00 00 ZZZ $14.05

84484 T 00 00 00 00 ZZZ $14.05

84485 C 00 00 00 00 ZZZ $7.56

84485 T 00 00 00 00 ZZZ $7.56

84488 C 00 00 00 00 ZZZ $7.84

84488 T 00 00 00 00 ZZZ $7.84

84490 C 00 00 00 00 ZZZ $9.43

84490 T 00 00 00 00 ZZZ $9.43

84510 C 00 00 00 00 ZZZ $9.17

84510 T 00 00 00 00 ZZZ $9.17

84512 C 00 00 00 00 ZZZ $10.99

84512 P 00 00 00 00 ZZZ $0.78

84512 T 00 00 00 00 ZZZ $10.99

84520 C 00 00 00 00 ZZZ $5.63

84520 T 00 00 00 00 ZZZ $5.63

84525 C 00 00 00 00 ZZZ $5.36

84525 T 00 00 00 00 ZZZ $5.36

84540 C 00 00 00 00 ZZZ $6.78

84540 T 00 00 00 00 ZZZ $6.78

84545 C 00 00 00 00 ZZZ $8.77

84545 T 00 00 00 00 ZZZ $8.77

84550 C 00 00 00 00 ZZZ $6.46

84550 T 00 00 00 00 ZZZ $6.46

Page 374: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

84560 C 00 00 00 00 ZZZ $6.78

84560 T 00 00 00 00 ZZZ $6.78

84577 C 00 00 00 00 ZZZ $17.81

84577 T 00 00 00 00 ZZZ $17.81

84578 C 00 00 00 00 ZZZ $4.11

84578 T 00 00 00 00 ZZZ $4.11

84580 C 00 00 00 00 ZZZ $10.14

84580 T 00 00 00 00 ZZZ $10.14

84583 C 00 00 00 00 ZZZ $7.18

84583 T 00 00 00 00 ZZZ $7.18

84585 C 00 00 00 00 ZZZ $22.13

84585 T 00 00 00 00 ZZZ $22.13

84586 C 00 00 00 00 ZZZ $50.46

84586 T 00 00 00 00 ZZZ $50.46

84588 C 00 00 00 00 ZZZ $48.47

84588 T 00 00 00 00 ZZZ $48.47

84590 C 00 00 00 00 ZZZ $15.26

84590 T 00 00 00 00 ZZZ $15.26

84591 C 00 00 00 00 ZZZ $15.26

84591 T 00 00 00 00 ZZZ $15.26

84597 C 00 00 00 00 ZZZ $19.57

84597 T 00 00 00 00 ZZZ $19.57

84600 C 00 00 00 00 ZZZ $22.06

84600 T 00 00 00 00 ZZZ $22.06

84620 C 00 00 00 00 ZZZ $16.92

84620 T 00 00 00 00 ZZZ $16.92

84630 C 00 00 00 00 ZZZ $16.26

84630 T 00 00 00 00 ZZZ $16.26

84681 C 00 00 00 00 ZZZ $29.71

84681 T 00 00 00 00 ZZZ $29.71

84702 1 U1 00 00 00 ZZZ $0.01

84702 C 00 00 00 00 ZZZ $11.54

84702 T 00 00 00 00 ZZZ $11.54

84703 A FP 00 00 00 ZZZ $10.73

84703 C 00 00 00 00 ZZZ $10.73

84703 T 00 00 00 00 ZZZ $10.73

84704 C 00 00 00 00 ZZZ $11.67

84704 T 00 00 00 00 ZZZ $11.67

84830 C 00 00 00 00 ZZZ $14.33

84830 T 00 00 00 00 ZZZ $14.33

Page 375: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

84999 C 00 00 00 00 ZZZ $0.00

84999 P 00 00 00 00 ZZZ $0.00

84999 T 00 00 00 00 ZZZ $0.00

85002 C 00 00 00 00 ZZZ $6.43

85002 T 00 00 00 00 ZZZ $6.43

85004 C 00 00 00 00 ZZZ $9.04

85004 T 00 00 00 00 ZZZ $9.04

85007 C 00 00 00 00 ZZZ $4.92

85007 T 00 00 00 00 ZZZ $4.92

85008 C 00 00 00 00 ZZZ $4.92

85008 T 00 00 00 00 ZZZ $4.92

85009 C 00 00 00 00 ZZZ $5.31

85009 T 00 00 00 00 ZZZ $5.31

85013 C 00 00 00 00 ZZZ $3.38

85013 T 00 00 00 00 ZZZ $3.38

85014 A FP 00 00 00 ZZZ $3.38

85014 C 00 00 00 00 ZZZ $3.38

85014 T 00 00 00 00 ZZZ $3.38

85018 A FP 00 00 00 ZZZ $3.38

85018 C 00 00 00 00 ZZZ $3.38

85018 T 00 00 00 00 ZZZ $3.38

85025 C 00 00 00 00 ZZZ $11.10

85025 T 00 00 00 00 ZZZ $11.10

85027 C 00 00 00 00 ZZZ $9.25

85027 T 00 00 00 00 ZZZ $9.25

85032 C 00 00 00 00 ZZZ $6.01

85032 T 00 00 00 00 ZZZ $6.01

85041 C 00 00 00 00 ZZZ $4.30

85041 T 00 00 00 00 ZZZ $4.30

85044 C 00 00 00 00 ZZZ $6.14

85044 T 00 00 00 00 ZZZ $6.14

85045 C 00 00 00 00 ZZZ $5.72

85045 T 00 00 00 00 ZZZ $5.72

85046 C 00 00 00 00 ZZZ $7.98

85046 T 00 00 00 00 ZZZ $7.98

85048 C 00 00 00 00 ZZZ $3.64

85048 T 00 00 00 00 ZZZ $3.64

85049 C 00 00 00 00 ZZZ $6.25

85049 T 00 00 00 00 ZZZ $6.25

85055 C 00 00 00 00 ZZZ $28.00

Page 376: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

85055 P 00 00 00 00 ZZZ $2.00

85055 T 00 00 00 00 ZZZ $26.00

85060 C 00 00 00 00 ZZZ $17.83

85060 P 00 00 00 00 ZZZ $7.13

85060 T 00 00 00 00 ZZZ $10.70

85097 C 00 00 00 00 ZZZ $41.80

85097 P 00 00 00 00 ZZZ $41.80

85130 C 00 00 00 00 ZZZ $8.90

85130 T 00 00 00 00 ZZZ $8.90

85170 C 00 00 00 00 ZZZ $5.17

85170 T 00 00 00 00 ZZZ $5.17

85175 C 00 00 00 00 ZZZ $6.49

85175 T 00 00 00 00 ZZZ $6.49

85210 C 00 00 00 00 ZZZ $9.17

85210 T 00 00 00 00 ZZZ $9.17

85220 C 00 00 00 00 ZZZ $25.20

85220 T 00 00 00 00 ZZZ $25.20

85230 C 00 00 00 00 ZZZ $25.58

85230 T 00 00 00 00 ZZZ $25.58

85240 C 00 00 00 00 ZZZ $25.58

85240 T 00 00 00 00 ZZZ $25.58

85244 C 00 00 00 00 ZZZ $29.16

85244 T 00 00 00 00 ZZZ $29.16

85245 C 00 00 00 00 ZZZ $32.78

85245 T 00 00 00 00 ZZZ $32.78

85246 C 00 00 00 00 ZZZ $32.78

85246 T 00 00 00 00 ZZZ $32.78

85247 C 00 00 00 00 ZZZ $32.78

85247 T 00 00 00 00 ZZZ $32.78

85250 C 00 00 00 00 ZZZ $27.19

85250 T 00 00 00 00 ZZZ $27.19

85260 C 00 00 00 00 ZZZ $25.58

85260 T 00 00 00 00 ZZZ $25.58

85270 C 00 00 00 00 ZZZ $25.58

85270 T 00 00 00 00 ZZZ $25.58

85280 C 00 00 00 00 ZZZ $27.63

85280 T 00 00 00 00 ZZZ $27.63

85290 C 00 00 00 00 ZZZ $23.33

85290 T 00 00 00 00 ZZZ $23.33

85291 C 00 00 00 00 ZZZ $12.69

Page 377: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

85291 T 00 00 00 00 ZZZ $12.69

85292 C 00 00 00 00 ZZZ $27.04

85292 T 00 00 00 00 ZZZ $27.04

85293 C 00 00 00 00 ZZZ $27.04

85293 T 00 00 00 00 ZZZ $27.04

85300 C 00 00 00 00 ZZZ $16.93

85300 T 00 00 00 00 ZZZ $16.93

85301 C 00 00 00 00 ZZZ $15.45

85301 T 00 00 00 00 ZZZ $15.45

85302 C 00 00 00 00 ZZZ $17.16

85302 T 00 00 00 00 ZZZ $17.16

85303 C 00 00 00 00 ZZZ $19.75

85303 T 00 00 00 00 ZZZ $19.75

85305 C 00 00 00 00 ZZZ $16.55

85305 T 00 00 00 00 ZZZ $16.55

85306 C 00 00 00 00 ZZZ $21.89

85306 T 00 00 00 00 ZZZ $21.89

85307 C 00 00 00 00 ZZZ $21.89

85307 T 00 00 00 00 ZZZ $21.89

85335 C 00 00 00 00 ZZZ $18.39

85335 T 00 00 00 00 ZZZ $18.39

85337 C 00 00 00 00 ZZZ $14.89

85337 T 00 00 00 00 ZZZ $14.89

85345 C 00 00 00 00 ZZZ $6.14

85345 T 00 00 00 00 ZZZ $6.14

85347 C 00 00 00 00 ZZZ $5.71

85347 T 00 00 00 00 ZZZ $5.71

85348 C 00 00 00 00 ZZZ $5.31

85348 T 00 00 00 00 ZZZ $5.31

85360 C 00 00 00 00 ZZZ $12.00

85360 T 00 00 00 00 ZZZ $12.00

85362 C 00 00 00 00 ZZZ $9.84

85362 T 00 00 00 00 ZZZ $9.84

85366 C 00 00 00 00 ZZZ $12.30

85366 T 00 00 00 00 ZZZ $12.30

85370 C 00 00 00 00 ZZZ $16.22

85370 T 00 00 00 00 ZZZ $16.22

85378 C 00 00 00 00 ZZZ $10.19

85378 T 00 00 00 00 ZZZ $10.19

85379 C 00 00 00 00 ZZZ $14.53

Page 378: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

85379 T 00 00 00 00 ZZZ $14.53

85380 C 00 00 00 00 ZZZ $14.22

85380 T 00 00 00 00 ZZZ $14.22

85384 C 00 00 00 00 ZZZ $12.13

85384 T 00 00 00 00 ZZZ $12.13

85385 C 00 00 00 00 ZZZ $12.13

85385 T 00 00 00 00 ZZZ $12.13

85390 C 00 00 00 00 ZZZ $7.37

85390 T 00 00 00 00 ZZZ $7.37

85396 C 00 00 00 00 ZZZ $0.00

85396 P 00 00 00 00 ZZZ $0.00

85396 T 00 00 00 00 ZZZ $0.00

85397 C 00 00 00 00 ZZZ $33.51

85397 T 00 00 00 00 ZZZ $33.51

85400 C 00 00 00 00 ZZZ $12.63

85400 T 00 00 00 00 ZZZ $12.63

85410 C 00 00 00 00 ZZZ $11.02

85410 T 00 00 00 00 ZZZ $11.02

85415 C 00 00 00 00 ZZZ $24.55

85415 T 00 00 00 00 ZZZ $24.55

85420 C 00 00 00 00 ZZZ $9.17

85420 T 00 00 00 00 ZZZ $9.17

85421 C 00 00 00 00 ZZZ $14.54

85421 T 00 00 00 00 ZZZ $14.54

85441 C 00 00 00 00 ZZZ $6.00

85441 T 00 00 00 00 ZZZ $6.00

85445 C 00 00 00 00 ZZZ $9.73

85445 T 00 00 00 00 ZZZ $9.73

85460 C 00 00 00 00 ZZZ $11.05

85460 T 00 00 00 00 ZZZ $11.05

85461 C 00 00 00 00 ZZZ $8.72

85461 T 00 00 00 00 ZZZ $8.72

85475 C 00 00 00 00 ZZZ $12.67

85475 T 00 00 00 00 ZZZ $12.67

85520 C 00 00 00 00 ZZZ $11.15

85520 T 00 00 00 00 ZZZ $11.15

85525 C 00 00 00 00 ZZZ $16.37

85525 T 00 00 00 00 ZZZ $16.37

85530 C 00 00 00 00 ZZZ $20.25

85530 T 00 00 00 00 ZZZ $20.25

Page 379: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

85536 C 00 00 00 00 ZZZ $9.25

85536 T 00 00 00 00 ZZZ $9.25

85540 C 00 00 00 00 ZZZ $12.28

85540 T 00 00 00 00 ZZZ $12.28

85547 C 00 00 00 00 ZZZ $9.57

85547 T 00 00 00 00 ZZZ $9.57

85549 C 00 00 00 00 ZZZ $26.78

85549 T 00 00 00 00 ZZZ $26.78

85555 C 00 00 00 00 ZZZ $9.55

85555 T 00 00 00 00 ZZZ $9.55

85557 C 00 00 00 00 ZZZ $19.08

85557 T 00 00 00 00 ZZZ $19.08

85576 C 00 00 00 00 ZZZ $30.68

85576 T 00 00 00 00 ZZZ $30.68

85597 C 00 00 00 00 ZZZ $25.67

85597 T 00 00 00 00 ZZZ $25.67

85598 C 00 00 00 00 ZZZ $25.30

85598 T 00 00 00 00 ZZZ $25.30

85610 C 00 00 00 00 ZZZ $5.61

85610 T 00 00 00 00 ZZZ $5.61

85611 C 00 00 00 00 ZZZ $5.63

85611 T 00 00 00 00 ZZZ $5.63

85612 C 00 00 00 00 ZZZ $8.24

85612 T 00 00 00 00 ZZZ $8.24

85613 C 00 00 00 00 ZZZ $8.24

85613 T 00 00 00 00 ZZZ $8.24

85635 C 00 00 00 00 ZZZ $14.06

85635 T 00 00 00 00 ZZZ $14.06

85651 C 00 00 00 00 ZZZ $5.07

85651 T 00 00 00 00 ZZZ $5.07

85652 C 00 00 00 00 ZZZ $3.85

85652 P 00 00 00 00 ZZZ $0.00

85652 T 00 00 00 00 ZZZ $3.85

85660 A FP 00 00 00 ZZZ $7.88

85660 C 00 00 00 00 ZZZ $7.88

85660 T 00 00 00 00 ZZZ $7.88

85670 C 00 00 00 00 ZZZ $8.25

85670 T 00 00 00 00 ZZZ $8.25

85675 C 00 00 00 00 ZZZ $9.79

85675 T 00 00 00 00 ZZZ $9.79

Page 380: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

85705 C 00 00 00 00 ZZZ $13.75

85705 T 00 00 00 00 ZZZ $13.75

85730 C 00 00 00 00 ZZZ $8.58

85730 T 00 00 00 00 ZZZ $8.58

85732 C 00 00 00 00 ZZZ $9.25

85732 T 00 00 00 00 ZZZ $9.25

85810 C 00 00 00 00 ZZZ $16.68

85810 T 00 00 00 00 ZZZ $16.68

85999 C 00 00 00 00 ZZZ $0.00

85999 P 00 00 00 00 ZZZ $0.00

85999 T 00 00 00 00 ZZZ $0.00

86000 C 00 00 00 00 ZZZ $2.26

86000 T 00 00 00 00 ZZZ $2.26

86001 C 00 00 00 00 ZZZ $7.46

86001 T 00 00 00 00 ZZZ $7.46

86003 C 00 00 00 00 ZZZ $7.46

86003 T 00 00 00 00 ZZZ $7.46

86005 C 00 00 00 00 ZZZ $11.39

86005 T 00 00 00 00 ZZZ $11.39

86021 C 00 00 00 00 ZZZ $21.49

86021 T 00 00 00 00 ZZZ $21.49

86022 C 00 00 00 00 ZZZ $26.23

86022 T 00 00 00 00 ZZZ $26.23

86023 C 00 00 00 00 ZZZ $17.78

86023 T 00 00 00 00 ZZZ $17.78

86038 C 00 00 00 00 ZZZ $17.26

86038 T 00 00 00 00 ZZZ $17.26

86039 C 00 00 00 00 ZZZ $15.94

86039 T 00 00 00 00 ZZZ $15.94

86060 C 00 00 00 00 ZZZ $10.43

86060 T 00 00 00 00 ZZZ $10.43

86063 C 00 00 00 00 ZZZ $8.25

86063 T 00 00 00 00 ZZZ $8.25

86077 C 00 00 00 00 ZZZ $38.50

86077 P 00 00 00 00 ZZZ $28.60

86078 C 00 00 00 00 ZZZ $38.50

86078 P 00 00 00 00 ZZZ $38.50

86079 C 00 00 00 00 ZZZ $38.50

86079 P 00 00 00 00 ZZZ $38.50

86140 C 00 00 00 00 ZZZ $7.39

Page 381: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86140 T 00 00 00 00 ZZZ $7.39

86141 C 00 00 00 00 ZZZ $17.89

86141 T 00 00 00 00 ZZZ $17.89

86146 C 00 00 00 00 ZZZ $36.33

86146 T 00 00 00 00 ZZZ $36.33

86147 C 00 00 00 00 ZZZ $36.33

86147 T 00 00 00 00 ZZZ $36.33

86148 C 00 00 00 00 ZZZ $16.60

86148 T 00 00 00 00 ZZZ $16.60

86152 C 00 00 00 00 ZZZ $0.00

86152 T 00 00 00 00 ZZZ $0.00

86153 C 00 00 00 00 ZZZ $41.80

86153 P 00 00 00 00 ZZZ $41.80

86155 C 00 00 00 00 ZZZ $22.82

86155 T 00 00 00 00 ZZZ $22.82

86156 C 00 00 00 00 ZZZ $9.57

86156 T 00 00 00 00 ZZZ $9.57

86157 C 00 00 00 00 ZZZ $11.51

86157 T 00 00 00 00 ZZZ $11.51

86160 C 00 00 00 00 ZZZ $17.14

86160 T 00 00 00 00 ZZZ $17.14

86161 C 00 00 00 00 ZZZ $17.14

86161 T 00 00 00 00 ZZZ $17.14

86162 C 00 00 00 00 ZZZ $29.02

86162 T 00 00 00 00 ZZZ $29.02

86171 C 00 00 00 00 ZZZ $14.31

86171 T 00 00 00 00 ZZZ $14.31

86185 C 00 00 00 00 ZZZ $12.49

86185 T 00 00 00 00 ZZZ $12.49

86200 C 00 00 00 00 ZZZ $18.69

86200 T 00 00 00 00 ZZZ $18.69

86215 C 00 00 00 00 ZZZ $17.40

86215 T 00 00 00 00 ZZZ $17.40

86225 C 00 00 00 00 ZZZ $19.62

86225 T 00 00 00 00 ZZZ $19.62

86226 C 00 00 00 00 ZZZ $17.29

86226 T 00 00 00 00 ZZZ $17.29

86235 C 00 00 00 00 ZZZ $25.61

86235 T 00 00 00 00 ZZZ $25.61

86243 C 00 00 00 00 ZZZ $29.31

Page 382: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86243 T 00 00 00 00 ZZZ $29.31

86255 C 00 00 00 00 ZZZ $17.22

86255 T 00 00 00 00 ZZZ $17.22

86256 C 00 00 00 00 ZZZ $17.22

86256 T 00 00 00 00 ZZZ $17.22

86277 C 00 00 00 00 ZZZ $22.48

86277 T 00 00 00 00 ZZZ $22.48

86280 C 00 00 00 00 ZZZ $11.69

86280 T 00 00 00 00 ZZZ $11.69

86294 C 00 00 00 00 ZZZ $15.40

86294 T 00 00 00 00 ZZZ $15.40

86300 C 00 00 00 00 ZZZ $29.72

86300 T 00 00 00 00 ZZZ $29.72

86301 C 00 00 00 00 ZZZ $29.72

86301 T 00 00 00 00 ZZZ $29.72

86304 C 00 00 00 00 ZZZ $29.72

86304 T 00 00 00 00 ZZZ $29.72

86308 C 00 00 00 00 ZZZ $7.39

86308 T 00 00 00 00 ZZZ $7.39

86309 C 00 00 00 00 ZZZ $9.25

86309 T 00 00 00 00 ZZZ $9.25

86310 C 00 00 00 00 ZZZ $10.53

86310 T 00 00 00 00 ZZZ $10.53

86316 C 00 00 00 00 ZZZ $29.72

86316 T 00 00 00 00 ZZZ $29.72

86317 C 00 00 00 00 ZZZ $21.41

86317 T 00 00 00 00 ZZZ $21.41

86318 C 00 00 00 00 ZZZ $18.49

86318 T 00 00 00 00 ZZZ $18.49

86320 C 00 00 00 00 ZZZ $32.01

86320 T 00 00 00 00 ZZZ $32.01

86325 C 00 00 00 00 ZZZ $31.93

86325 T 00 00 00 00 ZZZ $31.93

86327 C 00 00 00 00 ZZZ $32.40

86327 T 00 00 00 00 ZZZ $32.40

86329 C 00 00 00 00 ZZZ $20.05

86329 T 00 00 00 00 ZZZ $20.05

86331 C 00 00 00 00 ZZZ $16.21

86331 T 00 00 00 00 ZZZ $16.21

86332 C 00 00 00 00 ZZZ $34.80

Page 383: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86332 T 00 00 00 00 ZZZ $34.80

86334 C 00 00 00 00 ZZZ $31.90

86334 T 00 00 00 00 ZZZ $31.90

86335 C 00 00 00 00 ZZZ $42.37

86335 T 00 00 00 00 ZZZ $42.37

86336 C 00 00 00 00 ZZZ $21.77

86336 T 00 00 00 00 ZZZ $21.77

86337 C 00 00 00 00 ZZZ $30.58

86337 T 00 00 00 00 ZZZ $30.58

86340 C 00 00 00 00 ZZZ $21.52

86340 T 00 00 00 00 ZZZ $21.52

86341 C 00 00 00 00 ZZZ $28.25

86341 T 00 00 00 00 ZZZ $28.25

86343 C 00 00 00 00 ZZZ $17.79

86343 T 00 00 00 00 ZZZ $17.79

86344 C 00 00 00 00 ZZZ $11.41

86344 T 00 00 00 00 ZZZ $11.41

86352 C 00 00 00 00 ZZZ $0.54

86352 T 00 00 00 00 ZZZ $0.54

86353 C 00 00 00 00 ZZZ $65.11

86353 T 00 00 00 00 ZZZ $65.11

86355 C 00 00 00 00 ZZZ $54.46

86355 T 00 00 00 00 ZZZ $54.46

86356 C 00 00 00 00 ZZZ $29.07

86356 T 00 00 00 00 ZZZ $29.07

86357 C 00 00 00 00 ZZZ $54.46

86357 T 00 00 00 00 ZZZ $54.46

86359 C 00 00 00 00 ZZZ $53.87

86359 T 00 00 00 00 ZZZ $53.87

86360 C 00 00 00 00 ZZZ $57.49

86360 T 00 00 00 00 ZZZ $57.49

86361 C 00 00 00 00 ZZZ $28.75

86361 P 00 00 00 00 ZZZ $1.88

86361 T 00 00 00 00 ZZZ $28.75

86367 C 00 00 00 00 ZZZ $54.46

86367 T 00 00 00 00 ZZZ $54.46

86376 C 00 00 00 00 ZZZ $20.78

86376 T 00 00 00 00 ZZZ $20.78

86378 C 00 00 00 00 ZZZ $28.13

86378 T 00 00 00 00 ZZZ $28.13

Page 384: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86382 C 00 00 00 00 ZZZ $24.14

86382 T 00 00 00 00 ZZZ $24.14

86384 C 00 00 00 00 ZZZ $14.08

86384 T 00 00 00 00 ZZZ $14.08

86386 C 00 00 00 00 ZZZ $22.61

86386 P 00 00 00 00 ZZZ $22.61

86403 C 00 00 00 00 ZZZ $14.55

86403 T 00 00 00 00 ZZZ $14.55

86406 C 00 00 00 00 ZZZ $15.19

86406 T 00 00 00 00 ZZZ $15.19

86430 C 00 00 00 00 ZZZ $8.11

86430 T 00 00 00 00 ZZZ $8.11

86431 C 00 00 00 00 ZZZ $8.11

86431 T 00 00 00 00 ZZZ $8.11

86480 C 00 00 00 00 ZZZ $89.48

86480 T 00 00 00 00 ZZZ $89.48

86481 C 00 00 00 00 ZZZ $87.22

86481 T 00 00 00 00 ZZZ $87.22

86485 C 00 00 00 00 ZZZ $0.95

86485 P 00 00 00 00 ZZZ $0.29

86485 T 00 00 00 00 ZZZ $0.66

86486 C 00 00 00 00 ZZZ $7.11

86486 P 00 00 00 00 ZZZ $2.20

86486 T 00 00 00 00 ZZZ $4.91

86490 C 00 00 00 00 ZZZ $9.00

86490 P 00 00 00 00 ZZZ $9.00

86490 T 00 00 00 00 ZZZ $9.00

86510 C 00 00 00 00 ZZZ $11.00

86510 P 00 00 00 00 ZZZ $10.00

86510 T 00 00 00 00 ZZZ $10.00

86580 C 00 00 00 00 ZZZ $8.80

86580 T 00 00 00 00 ZZZ $8.80

86588 T 00 00 00 00 ZZZ $9.82

86590 C 00 00 00 00 ZZZ $14.08

86590 T 00 00 00 00 ZZZ $14.08

86592 A FP 00 00 00 ZZZ $6.10

86592 C 00 00 00 00 ZZZ $6.10

86592 T 00 00 00 00 ZZZ $6.10

86593 A FP 00 00 00 ZZZ $6.29

86593 C 00 00 00 00 ZZZ $6.29

Page 385: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86593 T 00 00 00 00 ZZZ $6.29

86602 C 00 00 00 00 ZZZ $14.53

86602 T 00 00 00 00 ZZZ $14.53

86603 C 00 00 00 00 ZZZ $18.38

86603 T 00 00 00 00 ZZZ $18.38

86606 C 00 00 00 00 ZZZ $21.49

86606 T 00 00 00 00 ZZZ $21.49

86609 C 00 00 00 00 ZZZ $18.40

86609 T 00 00 00 00 ZZZ $18.40

86611 C 00 00 00 00 ZZZ $14.53

86611 T 00 00 00 00 ZZZ $14.53

86612 C 00 00 00 00 ZZZ $18.42

86612 T 00 00 00 00 ZZZ $18.42

86615 C 00 00 00 00 ZZZ $18.84

86615 T 00 00 00 00 ZZZ $18.84

86617 C 00 00 00 00 ZZZ $22.11

86617 T 00 00 00 00 ZZZ $22.11

86618 C 00 00 00 00 ZZZ $24.32

86618 T 00 00 00 00 ZZZ $24.32

86619 C 00 00 00 00 ZZZ $19.11

86619 T 00 00 00 00 ZZZ $19.11

86622 C 00 00 00 00 ZZZ $12.76

86622 T 00 00 00 00 ZZZ $12.76

86625 C 00 00 00 00 ZZZ $18.73

86625 T 00 00 00 00 ZZZ $18.73

86628 C 00 00 00 00 ZZZ $17.15

86628 T 00 00 00 00 ZZZ $17.15

86631 C 00 00 00 00 ZZZ $16.90

86631 T 00 00 00 00 ZZZ $16.90

86632 C 00 00 00 00 ZZZ $18.14

86632 T 00 00 00 00 ZZZ $18.14

86635 C 00 00 00 00 ZZZ $16.38

86635 T 00 00 00 00 ZZZ $16.38

86638 C 00 00 00 00 ZZZ $17.31

86638 T 00 00 00 00 ZZZ $17.31

86641 C 00 00 00 00 ZZZ $20.58

86641 T 00 00 00 00 ZZZ $20.58

86644 C 00 00 00 00 ZZZ $20.55

86644 T 00 00 00 00 ZZZ $20.55

86645 C 00 00 00 00 ZZZ $24.06

Page 386: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86645 T 00 00 00 00 ZZZ $24.06

86648 C 00 00 00 00 ZZZ $21.72

86648 T 00 00 00 00 ZZZ $21.72

86651 C 00 00 00 00 ZZZ $18.84

86651 T 00 00 00 00 ZZZ $18.84

86652 C 00 00 00 00 ZZZ $18.84

86652 T 00 00 00 00 ZZZ $18.84

86653 C 00 00 00 00 ZZZ $18.84

86653 T 00 00 00 00 ZZZ $18.84

86654 C 00 00 00 00 ZZZ $18.84

86654 T 00 00 00 00 ZZZ $18.84

86658 C 00 00 00 00 ZZZ $18.61

86658 T 00 00 00 00 ZZZ $18.61

86663 C 00 00 00 00 ZZZ $18.73

86663 T 00 00 00 00 ZZZ $18.73

86664 C 00 00 00 00 ZZZ $21.84

86664 T 00 00 00 00 ZZZ $21.84

86665 C 00 00 00 00 ZZZ $25.91

86665 T 00 00 00 00 ZZZ $25.91

86666 C 00 00 00 00 ZZZ $14.53

86666 T 00 00 00 00 ZZZ $14.53

86668 C 00 00 00 00 ZZZ $14.86

86668 T 00 00 00 00 ZZZ $14.86

86671 C 00 00 00 00 ZZZ $17.52

86671 T 00 00 00 00 ZZZ $17.52

86674 C 00 00 00 00 ZZZ $21.02

86674 T 00 00 00 00 ZZZ $21.02

86677 C 00 00 00 00 ZZZ $20.72

86677 T 00 00 00 00 ZZZ $20.72

86682 C 00 00 00 00 ZZZ $18.57

86682 T 00 00 00 00 ZZZ $18.57

86683 C 00 00 00 00 ZZZ $3.62

86683 T 00 00 00 00 ZZZ $3.62

86684 C 00 00 00 00 ZZZ $20.97

86684 T 00 00 00 00 ZZZ $20.97

86687 A FP 00 00 00 ZZZ $11.99

86687 C 00 00 00 00 ZZZ $11.99

86687 T 00 00 00 00 ZZZ $11.99

86688 C 00 00 00 00 ZZZ $20.02

86688 T 00 00 00 00 ZZZ $20.02

Page 387: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86689 C 00 00 00 00 ZZZ $27.64

86689 T 00 00 00 00 ZZZ $27.64

86692 C 00 00 00 00 ZZZ $24.51

86692 T 00 00 00 00 ZZZ $24.51

86694 C 00 00 00 00 ZZZ $20.55

86694 T 00 00 00 00 ZZZ $20.55

86695 C 00 00 00 00 ZZZ $13.55

86695 T 00 00 00 00 ZZZ $13.55

86696 C 00 00 00 00 ZZZ $27.64

86696 T 00 00 00 00 ZZZ $27.64

86698 C 00 00 00 00 ZZZ $17.86

86698 T 00 00 00 00 ZZZ $17.86

86701 A FP 00 00 00 ZZZ $12.69

86701 C 00 00 00 00 ZZZ $12.69

86701 T 00 00 00 00 ZZZ $12.69

86702 C 00 00 00 00 ZZZ $19.31

86702 T 00 00 00 00 ZZZ $19.31

86703 C 00 00 00 00 ZZZ $19.59

86703 T 00 00 00 00 ZZZ $19.59

86704 C 00 00 00 00 ZZZ $17.22

86704 T 00 00 00 00 ZZZ $17.22

86705 C 00 00 00 00 ZZZ $16.81

86705 T 00 00 00 00 ZZZ $16.81

86706 C 00 00 00 00 ZZZ $15.33

86706 T 00 00 00 00 ZZZ $15.33

86707 C 00 00 00 00 ZZZ $16.51

86707 T 00 00 00 00 ZZZ $16.51

86708 C 00 00 00 00 ZZZ $17.69

86708 T 00 00 00 00 ZZZ $17.69

86709 C 00 00 00 00 ZZZ $16.07

86709 T 00 00 00 00 ZZZ $16.07

86710 C 00 00 00 00 ZZZ $19.36

86710 T 00 00 00 00 ZZZ $19.36

86711 C 00 00 00 00 ZZZ $16.00

86711 T 00 00 00 00 ZZZ $16.00

86713 C 00 00 00 00 ZZZ $21.86

86713 T 00 00 00 00 ZZZ $21.86

86717 C 00 00 00 00 ZZZ $17.49

86717 T 00 00 00 00 ZZZ $17.49

86720 C 00 00 00 00 ZZZ $18.84

Page 388: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86720 T 00 00 00 00 ZZZ $18.84

86723 C 00 00 00 00 ZZZ $18.84

86723 T 00 00 00 00 ZZZ $18.84

86727 C 00 00 00 00 ZZZ $18.38

86727 T 00 00 00 00 ZZZ $18.38

86729 C 00 00 00 00 ZZZ $17.06

86729 T 00 00 00 00 ZZZ $17.06

86732 C 00 00 00 00 ZZZ $18.84

86732 T 00 00 00 00 ZZZ $18.84

86735 C 00 00 00 00 ZZZ $18.63

86735 T 00 00 00 00 ZZZ $18.63

86738 C 00 00 00 00 ZZZ $18.92

86738 T 00 00 00 00 ZZZ $18.92

86741 C 00 00 00 00 ZZZ $18.84

86741 T 00 00 00 00 ZZZ $18.84

86744 C 00 00 00 00 ZZZ $18.84

86744 T 00 00 00 00 ZZZ $18.84

86747 C 00 00 00 00 ZZZ $21.46

86747 T 00 00 00 00 ZZZ $21.46

86750 C 00 00 00 00 ZZZ $18.84

86750 T 00 00 00 00 ZZZ $18.84

86753 C 00 00 00 00 ZZZ $17.69

86753 T 00 00 00 00 ZZZ $17.69

86756 C 00 00 00 00 ZZZ $18.40

86756 T 00 00 00 00 ZZZ $18.40

86757 C 00 00 00 00 ZZZ $27.64

86757 T 00 00 00 00 ZZZ $27.64

86759 C 00 00 00 00 ZZZ $18.84

86759 T 00 00 00 00 ZZZ $18.84

86762 C 00 00 00 00 ZZZ $20.55

86762 T 00 00 00 00 ZZZ $20.55

86765 C 00 00 00 00 ZZZ $18.40

86765 T 00 00 00 00 ZZZ $18.40

86768 C 00 00 00 00 ZZZ $18.84

86768 T 00 00 00 00 ZZZ $18.84

86771 C 00 00 00 00 ZZZ $18.84

86771 T 00 00 00 00 ZZZ $18.84

86774 C 00 00 00 00 ZZZ $21.13

86774 T 00 00 00 00 ZZZ $21.13

86777 C 00 00 00 00 ZZZ $20.55

Page 389: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86777 T 00 00 00 00 ZZZ $20.55

86778 C 00 00 00 00 ZZZ $20.56

86778 T 00 00 00 00 ZZZ $20.56

86780 C 00 00 00 00 ZZZ $19.55

86780 T 00 00 00 00 ZZZ $19.55

86784 C 00 00 00 00 ZZZ $17.94

86784 T 00 00 00 00 ZZZ $17.94

86787 C 00 00 00 00 ZZZ $18.40

86787 T 00 00 00 00 ZZZ $18.40

86788 C 00 00 00 00 ZZZ $24.32

86788 T 00 00 00 00 ZZZ $24.32

86789 C 00 00 00 00 ZZZ $20.78

86789 T 00 00 00 00 ZZZ $20.78

86790 C 00 00 00 00 ZZZ $18.40

86790 T 00 00 00 00 ZZZ $18.40

86793 C 00 00 00 00 ZZZ $18.84

86793 T 00 00 00 00 ZZZ $18.84

86800 C 00 00 00 00 ZZZ $22.71

86800 T 00 00 00 00 ZZZ $22.71

86803 C 00 00 00 00 ZZZ $20.39

86803 T 00 00 00 00 ZZZ $20.39

86804 C 00 00 00 00 ZZZ $22.11

86804 T 00 00 00 00 ZZZ $22.11

86805 C 00 00 00 00 ZZZ $74.67

86805 T 00 00 00 00 ZZZ $74.67

86806 C 00 00 00 00 ZZZ $67.95

86806 T 00 00 00 00 ZZZ $67.95

86807 C 00 00 00 00 ZZZ $33.22

86807 T 00 00 00 00 ZZZ $33.22

86808 C 00 00 00 00 ZZZ $33.22

86808 T 00 00 00 00 ZZZ $33.22

86812 C 00 00 00 00 ZZZ $36.85

86812 T 00 00 00 00 ZZZ $36.85

86813 C 00 00 00 00 ZZZ $82.80

86813 T 00 00 00 00 ZZZ $82.80

86816 C 00 00 00 00 ZZZ $39.77

86816 T 00 00 00 00 ZZZ $39.77

86817 C 00 00 00 00 ZZZ $91.95

86817 T 00 00 00 00 ZZZ $91.95

86821 C 00 00 00 00 ZZZ $80.63

Page 390: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86821 T 00 00 00 00 ZZZ $80.63

86822 C 00 00 00 00 ZZZ $52.20

86822 T 00 00 00 00 ZZZ $52.20

86825 C 00 00 00 00 ZZZ $89.40

86825 T 00 00 00 00 ZZZ $89.40

86826 C 00 00 00 00 ZZZ $29.80

86826 T 00 00 00 00 ZZZ $29.80

86828 C 00 00 00 00 ZZZ $54.40

86828 T 00 00 00 00 ZZZ $54.40

86829 C 00 00 00 00 ZZZ $40.80

86829 T 00 00 00 00 ZZZ $40.80

86830 C 00 00 00 00 ZZZ $102.83

86830 T 00 00 00 00 ZZZ $102.83

86831 C 00 00 00 00 ZZZ $88.14

86831 T 00 00 00 00 ZZZ $88.14

86832 C 00 00 00 00 ZZZ $161.59

86832 T 00 00 00 00 ZZZ $161.59

86833 C 00 00 00 00 ZZZ $146.90

86833 T 00 00 00 00 ZZZ $146.90

86834 C 00 00 00 00 ZZZ $455.39

86834 T 00 00 00 00 ZZZ $455.39

86835 C 00 00 00 00 ZZZ $411.32

86835 T 00 00 00 00 ZZZ $411.32

86849 C 00 00 00 00 ZZZ $0.00

86849 T 00 00 00 00 ZZZ $0.00

86850 C 00 00 00 00 ZZZ $8.80

86850 P 00 00 00 00 ZZZ $2.51

86850 T 00 00 00 00 ZZZ $6.29

86860 C 00 00 00 00 ZZZ $22.00

86860 P 00 00 00 00 ZZZ $7.00

86860 T 00 00 00 00 ZZZ $16.00

86870 C 00 00 00 00 ZZZ $16.50

86870 P 00 00 00 00 ZZZ $4.40

86870 T 00 00 00 00 ZZZ $12.10

86880 C 00 00 00 00 ZZZ $7.67

86880 T 00 00 00 00 ZZZ $7.67

86885 C 00 00 00 00 ZZZ $8.16

86885 T 00 00 00 00 ZZZ $8.16

86886 C 00 00 00 00 ZZZ $7.39

86886 T 00 00 00 00 ZZZ $7.39

Page 391: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86890 C 00 00 00 00 ZZZ $69.00

86890 P 00 00 00 00 ZZZ $20.00

86890 T 00 00 00 00 ZZZ $49.00

86891 C 00 00 00 00 ZZZ $86.00

86891 P 00 00 00 00 ZZZ $26.00

86891 T 00 00 00 00 ZZZ $60.00

86900 C 00 00 00 00 ZZZ $4.26

86900 T 00 00 00 00 ZZZ $4.26

86901 C 00 00 00 00 ZZZ $20.00

86901 P 00 00 00 00 ZZZ $6.50

86901 T 00 00 00 00 ZZZ $13.50

86902 C 00 00 00 00 ZZZ $5.38

86902 T 00 00 00 00 ZZZ $5.38

86904 C 00 00 00 00 ZZZ $13.58

86904 T 00 00 00 00 ZZZ $13.58

86905 C 00 00 00 00 ZZZ $5.46

86905 T 00 00 00 00 ZZZ $5.46

86906 C 00 00 00 00 ZZZ $11.07

86906 T 00 00 00 00 ZZZ $11.07

86910 C 00 00 00 00 ZZZ $25.45

86910 T 00 00 00 00 ZZZ $25.45

86911 C 00 00 00 00 ZZZ $7.23

86911 T 00 00 00 00 ZZZ $7.23

86920 C 00 00 00 00 ZZZ $55.00

86920 P 00 00 00 00 ZZZ $16.84

86920 T 00 00 00 00 ZZZ $38.16

86921 C 00 00 00 00 ZZZ $32.26

86921 P 00 00 00 00 ZZZ $10.00

86921 T 00 00 00 00 ZZZ $22.26

86922 C 00 00 00 00 ZZZ $68.84

86922 P 00 00 00 00 ZZZ $21.34

86922 T 00 00 00 00 ZZZ $47.50

86923 C 00 00 00 00 ZZZ $7.32

86923 P 00 00 00 00 ZZZ $0.52

86923 T 00 00 00 00 ZZZ $6.80

86927 C 00 00 00 00 ZZZ $7.00

86927 P 00 00 00 00 ZZZ $2.00

86927 T 00 00 00 00 ZZZ $5.00

86930 C 00 00 00 00 ZZZ $47.00

86930 P 00 00 00 00 ZZZ $15.00

Page 392: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86930 T 00 00 00 00 ZZZ $32.00

86931 C 00 00 00 00 ZZZ $47.00

86931 P 00 00 00 00 ZZZ $15.00

86931 T 00 00 00 00 ZZZ $32.00

86932 C 00 00 00 00 ZZZ $65.00

86932 P 00 00 00 00 ZZZ $20.00

86932 T 00 00 00 00 ZZZ $45.00

86940 C 00 00 00 00 ZZZ $11.71

86940 T 00 00 00 00 ZZZ $11.71

86941 C 00 00 00 00 ZZZ $16.08

86941 T 00 00 00 00 ZZZ $16.08

86945 C 00 00 00 00 ZZZ $24.00

86945 P 00 00 00 00 ZZZ $7.00

86945 T 00 00 00 00 ZZZ $17.00

86950 C 00 00 00 00 ZZZ $0.00

86950 P 00 00 00 00 ZZZ $0.00

86950 T 00 00 00 00 ZZZ $0.00

86960 C 00 00 00 00 ZZZ $0.00

86960 P 00 00 00 00 ZZZ $0.00

86960 T 00 00 00 00 ZZZ $0.00

86965 C 00 00 00 00 ZZZ $7.70

86965 P 00 00 00 00 ZZZ $2.20

86965 T 00 00 00 00 ZZZ $5.50

86970 C 00 00 00 00 ZZZ $34.00

86970 P 00 00 00 00 ZZZ $10.00

86970 T 00 00 00 00 ZZZ $24.00

86971 C 00 00 00 00 ZZZ $34.00

86971 P 00 00 00 00 ZZZ $10.00

86971 T 00 00 00 00 ZZZ $24.00

86972 C 00 00 00 00 ZZZ $34.00

86972 P 00 00 00 00 ZZZ $10.00

86972 T 00 00 00 00 ZZZ $24.00

86975 C 00 00 00 00 ZZZ $0.00

86975 P 00 00 00 00 ZZZ $0.00

86975 T 00 00 00 00 ZZZ $0.00

86976 C 00 00 00 00 ZZZ $12.00

86976 P 00 00 00 00 ZZZ $3.00

86976 T 00 00 00 00 ZZZ $8.00

86977 C 00 00 00 00 ZZZ $12.00

86977 P 00 00 00 00 ZZZ $3.00

Page 393: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

86977 T 00 00 00 00 ZZZ $8.00

86978 C 00 00 00 00 ZZZ $27.00

86978 P 00 00 00 00 ZZZ $8.00

86978 T 00 00 00 00 ZZZ $19.00

86985 C 00 00 00 00 ZZZ $7.00

86985 P 00 00 00 00 ZZZ $2.00

86985 T 00 00 00 00 ZZZ $5.00

86999 C 00 00 00 00 ZZZ $0.00

86999 P 00 00 00 00 ZZZ $0.00

86999 T 00 00 00 00 ZZZ $0.00

87015 C 00 00 00 00 ZZZ $9.54

87015 T 00 00 00 00 ZZZ $9.54

87040 C 00 00 00 00 ZZZ $14.75

87040 T 00 00 00 00 ZZZ $14.75

87045 C 00 00 00 00 ZZZ $13.47

87045 T 00 00 00 00 ZZZ $13.47

87046 C 00 00 00 00 ZZZ $3.37

87046 T 00 00 00 00 ZZZ $3.37

87070 C 00 00 00 00 ZZZ $12.30

87070 T 00 00 00 00 ZZZ $12.30

87071 C 00 00 00 00 ZZZ $6.74

87071 T 00 00 00 00 ZZZ $6.74

87073 C 00 00 00 00 ZZZ $6.74

87073 T 00 00 00 00 ZZZ $6.74

87075 A FP 00 00 00 ZZZ $12.49

87075 C 00 00 00 00 ZZZ $12.49

87075 T 00 00 00 00 ZZZ $12.49

87076 C 00 00 00 00 ZZZ $11.53

87076 T 00 00 00 00 ZZZ $11.53

87077 C 00 00 00 00 ZZZ $11.53

87077 T 00 00 00 00 ZZZ $11.53

87081 A FP 00 00 00 ZZZ $9.47

87081 C 00 00 00 00 ZZZ $9.47

87081 T 00 00 00 00 ZZZ $9.47

87084 C 00 00 00 00 ZZZ $12.30

87084 T 00 00 00 00 ZZZ $12.30

87086 C 00 00 00 00 ZZZ $11.53

87086 T 00 00 00 00 ZZZ $11.53

87088 A FP 00 00 00 ZZZ $11.55

87088 C 00 00 00 00 ZZZ $11.55

Page 394: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87088 T 00 00 00 00 ZZZ $11.55

87101 C 00 00 00 00 ZZZ $8.24

87101 T 00 00 00 00 ZZZ $8.24

87102 C 00 00 00 00 ZZZ $12.00

87102 T 00 00 00 00 ZZZ $12.00

87103 C 00 00 00 00 ZZZ $12.88

87103 T 00 00 00 00 ZZZ $12.88

87106 C 00 00 00 00 ZZZ $11.70

87106 T 00 00 00 00 ZZZ $11.70

87107 C 00 00 00 00 ZZZ $11.70

87107 T 00 00 00 00 ZZZ $11.70

87109 C 00 00 00 00 ZZZ $21.97

87109 T 00 00 00 00 ZZZ $21.97

87110 C 00 00 00 00 ZZZ $27.98

87110 T 00 00 00 00 ZZZ $27.98

87116 C 00 00 00 00 ZZZ $15.43

87116 T 00 00 00 00 ZZZ $15.43

87118 C 00 00 00 00 ZZZ $15.63

87118 T 00 00 00 00 ZZZ $15.63

87140 C 00 00 00 00 ZZZ $7.97

87140 T 00 00 00 00 ZZZ $7.97

87143 C 00 00 00 00 ZZZ $17.90

87143 T 00 00 00 00 ZZZ $17.90

87147 C 00 00 00 00 ZZZ $7.39

87147 T 00 00 00 00 ZZZ $7.39

87149 C 00 00 00 00 ZZZ $28.63

87149 T 00 00 00 00 ZZZ $28.63

87150 C 00 00 00 00 ZZZ $51.95

87150 T 00 00 00 00 ZZZ $51.95

87152 C 00 00 00 00 ZZZ $7.47

87152 T 00 00 00 00 ZZZ $7.47

87153 C 00 00 00 00 ZZZ $70.73

87153 T 00 00 00 00 ZZZ $70.73

87158 C 00 00 00 00 ZZZ $7.47

87158 T 00 00 00 00 ZZZ $7.47

87164 C 00 00 00 00 ZZZ $15.33

87164 T 00 00 00 00 ZZZ $15.33

87166 C 00 00 00 00 ZZZ $16.13

87166 T 00 00 00 00 ZZZ $16.13

87168 C 00 00 00 00 ZZZ $6.10

Page 395: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87168 T 00 00 00 00 ZZZ $6.10

87169 C 00 00 00 00 ZZZ $6.10

87169 T 00 00 00 00 ZZZ $6.10

87172 C 00 00 00 00 ZZZ $6.10

87172 T 00 00 00 00 ZZZ $6.10

87176 C 00 00 00 00 ZZZ $7.84

87176 T 00 00 00 00 ZZZ $7.84

87177 C 00 00 00 00 ZZZ $12.71

87177 T 00 00 00 00 ZZZ $12.71

87181 C 00 00 00 00 ZZZ $6.78

87181 T 00 00 00 00 ZZZ $6.78

87184 C 00 00 00 00 ZZZ $9.85

87184 T 00 00 00 00 ZZZ $9.85

87185 C 00 00 00 00 ZZZ $6.78

87185 T 00 00 00 00 ZZZ $6.78

87186 C 00 00 00 00 ZZZ $8.24

87186 T 00 00 00 00 ZZZ $8.24

87187 C 00 00 00 00 ZZZ $8.24

87187 T 00 00 00 00 ZZZ $8.24

87188 C 00 00 00 00 ZZZ $6.64

87188 T 00 00 00 00 ZZZ $6.64

87190 C 00 00 00 00 ZZZ $8.07

87190 T 00 00 00 00 ZZZ $8.07

87197 C 00 00 00 00 ZZZ $15.80

87197 T 00 00 00 00 ZZZ $15.80

87198 C 00 00 00 00 ZZZ $12.45

87198 T 00 00 00 00 ZZZ $12.45

87199 C 00 00 00 00 ZZZ $12.45

87199 T 00 00 00 00 ZZZ $12.45

87205 C 00 00 00 00 ZZZ $6.10

87205 T 00 00 00 00 ZZZ $6.10

87206 C 00 00 00 00 ZZZ $7.67

87206 T 00 00 00 00 ZZZ $7.67

87207 C 00 00 00 00 ZZZ $8.56

87207 T 00 00 00 00 ZZZ $8.56

87209 C 00 00 00 00 ZZZ $25.95

87209 T 00 00 00 00 ZZZ $25.95

87210 A FP 00 00 00 ZZZ $6.10

87210 C 00 00 00 00 ZZZ $6.10

87210 T 00 00 00 00 ZZZ $6.10

Page 396: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87220 C 00 00 00 00 ZZZ $4.94

87220 T 00 00 00 00 ZZZ $4.94

87230 C 00 00 00 00 ZZZ $28.19

87230 T 00 00 00 00 ZZZ $28.19

87250 C 00 00 00 00 ZZZ $27.92

87250 T 00 00 00 00 ZZZ $27.92

87252 C 00 00 00 00 ZZZ $37.22

87252 T 00 00 00 00 ZZZ $37.22

87253 C 00 00 00 00 ZZZ $28.84

87253 T 00 00 00 00 ZZZ $28.84

87254 C 00 00 00 00 ZZZ $6.99

87254 T 00 00 00 00 ZZZ $6.99

87255 C 00 00 00 00 ZZZ $47.31

87255 T 00 00 00 00 ZZZ $47.31

87260 C 00 00 00 00 ZZZ $12.87

87260 T 00 00 00 00 ZZZ $12.87

87265 C 00 00 00 00 ZZZ $12.87

87265 T 00 00 00 00 ZZZ $12.87

87267 C 00 00 00 00 ZZZ $12.59

87267 T 00 00 00 00 ZZZ $12.59

87269 C 00 00 00 00 ZZZ $12.92

87269 T 00 00 00 00 ZZZ $12.92

87270 C 00 00 00 00 ZZZ $12.87

87270 T 00 00 00 00 ZZZ $12.87

87271 C 00 00 00 00 ZZZ $12.59

87271 T 00 00 00 00 ZZZ $12.59

87272 C 00 00 00 00 ZZZ $12.87

87272 T 00 00 00 00 ZZZ $12.87

87273 C 00 00 00 00 ZZZ $12.45

87273 T 00 00 00 00 ZZZ $12.87

87274 C 00 00 00 00 ZZZ $12.87

87274 T 00 00 00 00 ZZZ $12.87

87275 C 00 00 00 00 ZZZ $12.87

87275 T 00 00 00 00 ZZZ $12.87

87276 C 00 00 00 00 ZZZ $12.87

87276 T 00 00 00 00 ZZZ $12.87

87277 C 00 00 00 00 ZZZ $12.87

87277 T 00 00 00 00 ZZZ $12.87

87278 C 00 00 00 00 ZZZ $12.87

87278 T 00 00 00 00 ZZZ $12.87

Page 397: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87279 C 00 00 00 00 ZZZ $12.87

87279 T 00 00 00 00 ZZZ $12.87

87280 C 00 00 00 00 ZZZ $12.87

87280 T 00 00 00 00 ZZZ $12.87

87281 C 00 00 00 00 ZZZ $12.87

87281 T 00 00 00 00 ZZZ $12.87

87283 C 00 00 00 00 ZZZ $12.87

87283 T 00 00 00 00 ZZZ $12.87

87285 C 00 00 00 00 ZZZ $12.87

87285 T 00 00 00 00 ZZZ $12.87

87290 C 00 00 00 00 ZZZ $12.87

87290 T 00 00 00 00 ZZZ $12.87

87299 C 00 00 00 00 ZZZ $12.87

87299 T 00 00 00 00 ZZZ $12.87

87300 C 00 00 00 00 ZZZ $6.43

87300 T 00 00 00 00 ZZZ $6.43

87301 C 00 00 00 00 ZZZ $12.87

87301 T 00 00 00 00 ZZZ $12.87

87305 C 00 00 00 00 ZZZ $13.01

87305 T 00 00 00 00 ZZZ $13.01

87320 C 00 00 00 00 ZZZ $12.87

87320 T 00 00 00 00 ZZZ $12.87

87324 C 00 00 00 00 ZZZ $12.87

87324 T 00 00 00 00 ZZZ $12.87

87327 C 00 00 00 00 ZZZ $12.87

87327 T 00 00 00 00 ZZZ $12.87

87328 C 00 00 00 00 ZZZ $12.87

87328 T 00 00 00 00 ZZZ $12.87

87329 C 00 00 00 00 ZZZ $12.92

87329 T 00 00 00 00 ZZZ $12.92

87332 C 00 00 00 00 ZZZ $12.87

87332 T 00 00 00 00 ZZZ $12.87

87335 C 00 00 00 00 ZZZ $12.87

87335 T 00 00 00 00 ZZZ $12.87

87336 C 00 00 00 00 ZZZ $12.87

87336 T 00 00 00 00 ZZZ $12.87

87337 C 00 00 00 00 ZZZ $12.87

87337 T 00 00 00 00 ZZZ $12.87

87338 C 00 00 00 00 ZZZ $6.12

87338 T 00 00 00 00 ZZZ $6.12

Page 398: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87339 C 00 00 00 00 ZZZ $12.87

87339 T 00 00 00 00 ZZZ $12.87

87340 C 00 00 00 00 ZZZ $14.75

87340 T 00 00 00 00 ZZZ $14.75

87341 C 00 00 00 00 ZZZ $14.75

87341 T 00 00 00 00 ZZZ $14.75

87350 C 00 00 00 00 ZZZ $16.45

87350 T 00 00 00 00 ZZZ $16.45

87380 C 00 00 00 00 ZZZ $23.45

87380 T 00 00 00 00 ZZZ $23.45

87385 C 00 00 00 00 ZZZ $12.87

87385 T 00 00 00 00 ZZZ $12.87

87389 A FP 00 00 00 ZZZ $34.12

87389 C 00 00 00 00 ZZZ $34.12

87389 T 00 00 00 00 ZZZ $34.12

87390 A FP 00 00 00 ZZZ $25.19

87390 C 00 00 00 00 ZZZ $25.19

87390 T 00 00 00 00 ZZZ $25.19

87391 C 00 00 00 00 ZZZ $25.19

87391 T 00 00 00 00 ZZZ $25.19

87400 C 00 00 00 00 ZZZ $6.43

87400 T 00 00 00 00 ZZZ $6.43

87420 C 00 00 00 00 ZZZ $12.87

87420 T 00 00 00 00 ZZZ $12.87

87425 C 00 00 00 00 ZZZ $12.87

87425 T 00 00 00 00 ZZZ $12.87

87427 C 00 00 00 00 ZZZ $12.87

87427 T 00 00 00 00 ZZZ $12.87

87430 C 00 00 00 00 ZZZ $12.87

87430 T 00 00 00 00 ZZZ $12.87

87449 C 00 00 00 00 ZZZ $12.87

87449 T 00 00 00 00 ZZZ $12.87

87450 C 00 00 00 00 ZZZ $6.55

87450 T 00 00 00 00 ZZZ $6.55

87451 C 00 00 00 00 ZZZ $6.55

87451 T 00 00 00 00 ZZZ $6.55

87470 A FP 00 00 00 ZZZ $28.63

87470 C 00 00 00 00 ZZZ $28.63

87470 T 00 00 00 00 ZZZ $28.63

87471 C 00 00 00 00 ZZZ $50.12

Page 399: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87471 T 00 00 00 00 ZZZ $50.12

87475 C 00 00 00 00 ZZZ $28.63

87475 T 00 00 00 00 ZZZ $28.63

87476 C 00 00 00 00 ZZZ $50.12

87476 T 00 00 00 00 ZZZ $50.12

87480 C 00 00 00 00 ZZZ $28.63

87480 T 00 00 00 00 ZZZ $28.63

87481 C 00 00 00 00 ZZZ $50.12

87481 T 00 00 00 00 ZZZ $50.12

87482 C 00 00 00 00 ZZZ $23.52

87482 T 00 00 00 00 ZZZ $23.52

87483 C 00 00 00 00 ZZZ $571.72

87483 T 00 00 00 00 ZZZ $571.72

87485 C 00 00 00 00 ZZZ $28.63

87485 T 00 00 00 00 ZZZ $28.63

87486 C 00 00 00 00 ZZZ $50.12

87486 T 00 00 00 00 ZZZ $50.12

87487 C 00 00 00 00 ZZZ $61.17

87487 T 00 00 00 00 ZZZ $61.17

87489 T 00 00 00 00 ZZZ $48.50

87490 A FP 00 00 00 ZZZ $28.63

87490 C 00 00 00 00 ZZZ $28.63

87490 T 00 00 00 00 ZZZ $28.63

87491 A FP 00 00 00 ZZZ $50.12

87491 C 00 00 00 00 ZZZ $50.12

87491 T 00 00 00 00 ZZZ $50.12

87492 C 00 00 00 00 ZZZ $23.52

87492 T 00 00 00 00 ZZZ $23.52

87493 C 00 00 00 00 ZZZ $51.95

87493 T 00 00 00 00 ZZZ $51.95

87495 C 00 00 00 00 ZZZ $28.63

87495 T 00 00 00 00 ZZZ $28.63

87496 C 00 00 00 00 ZZZ $50.12

87496 T 00 00 00 00 ZZZ $50.12

87497 C 00 00 00 00 ZZZ $61.17

87497 T 00 00 00 00 ZZZ $61.17

87498 C 00 00 00 00 ZZZ $50.67

87498 T 00 00 00 00 ZZZ $50.67

87500 C 00 00 00 00 ZZZ $50.67

87500 T 00 00 00 00 ZZZ $50.67

Page 400: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87501 C 00 00 00 00 ZZZ $72.22

87501 T 00 00 00 00 ZZZ $72.22

87502 C 00 00 00 00 ZZZ $119.75

87502 T 00 00 00 00 ZZZ $119.75

87503 C 00 00 00 00 ZZZ $29.22

87503 T 00 00 00 00 ZZZ $29.22

87505 C 00 00 00 00 ZZZ $174.58

87505 T 00 00 00 00 ZZZ $174.58

87506 C 00 00 00 00 ZZZ $290.45

87506 T 00 00 00 00 ZZZ $290.45

87507 C 00 00 00 00 ZZZ $567.18

87507 T 00 00 00 00 ZZZ $567.18

87510 C 00 00 00 00 ZZZ $28.63

87510 T 00 00 00 00 ZZZ $28.63

87511 C 00 00 00 00 ZZZ $50.12

87511 T 00 00 00 00 ZZZ $50.12

87512 C 00 00 00 00 ZZZ $23.52

87512 T 00 00 00 00 ZZZ $23.52

87515 C 00 00 00 00 ZZZ $28.63

87515 T 00 00 00 00 ZZZ $28.63

87516 C 00 00 00 00 ZZZ $50.12

87516 T 00 00 00 00 ZZZ $50.12

87517 C 00 00 00 00 ZZZ $61.17

87517 T 00 00 00 00 ZZZ $61.17

87520 C 00 00 00 00 ZZZ $28.63

87520 T 00 00 00 00 ZZZ $28.63

87521 C 00 00 00 00 ZZZ $50.12

87521 T 00 00 00 00 ZZZ $50.12

87522 C 00 00 00 00 ZZZ $61.17

87522 T 00 00 00 00 ZZZ $61.17

87525 C 00 00 00 00 ZZZ $28.63

87525 T 00 00 00 00 ZZZ $28.63

87526 C 00 00 00 00 ZZZ $50.12

87526 T 00 00 00 00 ZZZ $50.12

87527 C 00 00 00 00 ZZZ $23.52

87527 T 00 00 00 00 ZZZ $23.52

87528 C 00 00 00 00 ZZZ $28.63

87528 T 00 00 00 00 ZZZ $28.63

87529 C 00 00 00 00 ZZZ $50.12

87529 T 00 00 00 00 ZZZ $50.12

Page 401: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87530 C 00 00 00 00 ZZZ $61.17

87530 T 00 00 00 00 ZZZ $61.17

87531 A FP 00 00 00 ZZZ $50.12

87531 C 00 00 00 00 ZZZ $28.63

87531 T 00 00 00 00 ZZZ $28.63

87532 C 00 00 00 00 ZZZ $50.12

87532 T 00 00 00 00 ZZZ $50.12

87533 C 00 00 00 00 ZZZ $23.52

87533 T 00 00 00 00 ZZZ $23.52

87534 C 00 00 00 00 ZZZ $28.63

87534 T 00 00 00 00 ZZZ $28.63

87535 C 00 00 00 00 ZZZ $50.12

87535 T 00 00 00 00 ZZZ $50.12

87536 A FP 00 00 00 ZZZ $121.51

87536 C 00 00 00 00 ZZZ $121.51

87536 T 00 00 00 00 ZZZ $121.51

87537 C 00 00 00 00 ZZZ $28.63

87537 T 00 00 00 00 ZZZ $28.63

87538 C 00 00 00 00 ZZZ $50.12

87538 T 00 00 00 00 ZZZ $50.12

87539 C 00 00 00 00 ZZZ $23.52

87539 T 00 00 00 00 ZZZ $23.52

87540 C 00 00 00 00 ZZZ $28.63

87540 T 00 00 00 00 ZZZ $28.63

87541 C 00 00 00 00 ZZZ $50.12

87541 T 00 00 00 00 ZZZ $50.12

87542 C 00 00 00 00 ZZZ $23.52

87542 T 00 00 00 00 ZZZ $23.52

87550 C 00 00 00 00 ZZZ $28.63

87550 T 00 00 00 00 ZZZ $28.63

87551 C 00 00 00 00 ZZZ $50.12

87551 T 00 00 00 00 ZZZ $50.12

87552 C 00 00 00 00 ZZZ $61.17

87552 T 00 00 00 00 ZZZ $61.17

87555 C 00 00 00 00 ZZZ $28.63

87555 T 00 00 00 00 ZZZ $28.63

87556 C 00 00 00 00 ZZZ $50.12

87556 T 00 00 00 00 ZZZ $50.12

87557 C 00 00 00 00 ZZZ $61.17

87557 T 00 00 00 00 ZZZ $61.17

Page 402: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87560 C 00 00 00 00 ZZZ $28.63

87560 T 00 00 00 00 ZZZ $28.63

87561 C 00 00 00 00 ZZZ $50.12

87561 T 00 00 00 00 ZZZ $50.12

87562 C 00 00 00 00 ZZZ $61.17

87562 T 00 00 00 00 ZZZ $61.17

87580 C 00 00 00 00 ZZZ $28.63

87580 T 00 00 00 00 ZZZ $28.63

87581 C 00 00 00 00 ZZZ $50.12

87581 T 00 00 00 00 ZZZ $50.12

87582 C 00 00 00 00 ZZZ $23.52

87582 T 00 00 00 00 ZZZ $23.52

87590 A FP 00 00 00 ZZZ $28.63

87590 C 00 00 00 00 ZZZ $28.63

87590 T 00 00 00 00 ZZZ $28.63

87591 A FP 00 00 00 ZZZ $50.12

87591 C 00 00 00 00 ZZZ $50.12

87591 T 00 00 00 00 ZZZ $50.12

87592 C 00 00 00 00 ZZZ $23.52

87592 T 00 00 00 00 ZZZ $23.52

87621 A FP 00 00 00 ZZZ $50.12

87623 C 00 00 00 00 ZZZ $47.76

87623 T 00 00 00 00 ZZZ $47.76

87624 C 00 00 00 00 ZZZ $47.76

87624 T 00 00 00 00 ZZZ $47.76

87625 C 00 00 00 00 ZZZ $47.76

87625 T 00 00 00 00 ZZZ $47.76

87631 C 00 00 00 00 ZZZ $92.72

87631 T 00 00 00 00 ZZZ $92.72

87632 C 00 00 00 00 ZZZ $135.48

87632 T 00 00 00 00 ZZZ $135.48

87633 C 00 00 00 00 ZZZ $242.38

87633 T 00 00 00 00 ZZZ $242.38

87640 C 00 00 00 00 ZZZ $50.67

87640 T 00 00 00 00 ZZZ $50.67

87641 C 00 00 00 00 ZZZ $50.67

87641 T 00 00 00 00 ZZZ $50.67

87650 C 00 00 00 00 ZZZ $28.63

87650 T 00 00 00 00 ZZZ $28.63

87651 C 00 00 00 00 ZZZ $50.12

Page 403: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87651 T 00 00 00 00 ZZZ $50.12

87652 C 00 00 00 00 ZZZ $23.52

87652 T 00 00 00 00 ZZZ $23.52

87653 C 00 00 00 00 ZZZ $50.67

87653 T 00 00 00 00 ZZZ $50.67

87660 C 00 00 00 00 ZZZ $28.74

87660 T 00 00 00 00 ZZZ $28.74

87661 C 00 00 00 00 ZZZ $47.87

87661 T 00 00 00 00 ZZZ $47.87

87797 C 00 00 00 00 ZZZ $28.63

87797 T 00 00 00 00 ZZZ $28.63

87798 C 00 00 00 00 ZZZ $50.12

87798 T 00 00 00 00 ZZZ $50.12

87799 C 00 00 00 00 ZZZ $61.17

87799 T 00 00 00 00 ZZZ $61.17

87800 C 00 00 00 00 ZZZ $28.63

87800 T 00 00 00 00 ZZZ $28.63

87801 C 00 00 00 00 ZZZ $50.12

87801 T 00 00 00 00 ZZZ $50.12

87802 C 00 00 00 00 ZZZ $12.45

87802 T 00 00 00 00 ZZZ $12.45

87803 C 00 00 00 00 ZZZ $12.45

87803 T 00 00 00 00 ZZZ $12.45

87804 C 00 00 00 00 ZZZ $12.45

87804 T 00 00 00 00 ZZZ $12.45

87806 C 00 00 00 00 ZZZ $32.77

87806 T 00 00 00 00 ZZZ $32.77

87807 C 00 00 00 00 ZZZ $13.01

87807 T 00 00 00 00 ZZZ $13.01

87808 C 00 00 00 00 ZZZ $13.01

87808 T 00 00 00 00 ZZZ $13.01

87809 C 00 00 00 00 ZZZ $13.01

87809 T 00 00 00 00 ZZZ $13.01

87810 C 00 00 00 00 ZZZ $12.87

87810 T 00 00 00 00 ZZZ $12.87

87850 C 00 00 00 00 ZZZ $12.87

87850 T 00 00 00 00 ZZZ $12.87

87880 C 00 00 00 00 ZZZ $12.87

87880 T 00 00 00 00 ZZZ $12.87

87899 C 00 00 00 00 ZZZ $12.87

Page 404: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

87899 T 00 00 00 00 ZZZ $12.87

87900 C 00 00 00 00 ZZZ $188.18

87900 T 00 00 00 00 ZZZ $188.18

87901 C 00 00 00 00 ZZZ $367.64

87901 T 00 00 00 00 ZZZ $367.64

87902 C 00 00 00 00 ZZZ $364.64

87902 T 00 00 00 00 ZZZ $364.64

87903 C 00 00 00 00 ZZZ $697.80

87903 T 00 00 00 00 ZZZ $697.80

87904 C 00 00 00 00 ZZZ $37.22

87904 T 00 00 00 00 ZZZ $37.22

87905 C 00 00 00 00 ZZZ $17.84

87905 T 00 00 00 00 ZZZ $17.84

87906 C 00 00 00 00 ZZZ $181.14

87906 T 00 00 00 00 ZZZ $181.14

87910 C 00 00 00 00 ZZZ $119.88

87910 T 00 00 00 00 ZZZ $119.88

87912 C 00 00 00 00 ZZZ $119.88

87912 T 00 00 00 00 ZZZ $119.88

87999 C 00 00 00 00 ZZZ $0.00

87999 T 00 00 00 00 ZZZ $0.00

88104 C 00 00 00 00 ZZZ $33.31

88104 P 00 00 00 00 ZZZ $14.04

88104 T 00 00 00 00 ZZZ $19.27

88106 C 00 00 00 00 ZZZ $29.90

88106 P 00 00 00 00 ZZZ $12.90

88106 T 00 00 00 00 ZZZ $17.00

88108 C 00 00 00 00 ZZZ $35.67

88108 P 00 00 00 00 ZZZ $11.89

88108 T 00 00 00 00 ZZZ $23.78

88112 C 00 00 00 00 ZZZ $121.51

88112 P 00 00 00 00 ZZZ $65.63

88112 T 00 00 00 00 ZZZ $55.88

88120 C 00 00 00 00 ZZZ $549.36

88120 P 00 00 00 00 ZZZ $70.41

88120 T 00 00 00 00 ZZZ $478.95

88121 C 00 00 00 00 ZZZ $463.68

88121 P 00 00 00 00 ZZZ $61.78

88121 T 00 00 00 00 ZZZ $401.90

88125 C 00 00 00 00 ZZZ $43.00

Page 405: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88125 P 00 00 00 00 ZZZ $13.00

88125 T 00 00 00 00 ZZZ $30.00

88130 C 00 00 00 00 ZZZ $21.48

88130 T 00 00 00 00 ZZZ $21.48

88140 C 00 00 00 00 ZZZ $11.42

88140 T 00 00 00 00 ZZZ $11.42

88141 C 00 00 00 00 ZZZ $7.58

88141 P 00 00 00 00 ZZZ $6.89

88142 A FP 00 00 00 ZZZ $19.00

88142 C 00 00 00 00 ZZZ $19.00

88142 T 00 00 00 00 ZZZ $19.00

88143 A FP 00 00 00 ZZZ $19.00

88143 C 00 00 00 00 ZZZ $19.00

88143 T 00 00 00 00 ZZZ $19.00

88147 A FP 00 00 00 ZZZ $7.15

88147 C 00 00 00 00 ZZZ $7.15

88147 T 00 00 00 00 ZZZ $7.15

88148 A FP 00 00 00 ZZZ $7.15

88148 C 00 00 00 00 ZZZ $7.15

88148 T 00 00 00 00 ZZZ $7.15

88150 A FP 00 00 00 ZZZ $7.39

88150 C 00 00 00 00 ZZZ $7.39

88150 T 00 00 00 00 ZZZ $7.39

88152 A FP 00 00 00 ZZZ $7.39

88152 C 00 00 00 00 ZZZ $7.39

88152 T 00 00 00 00 ZZZ $7.39

88153 A FP 00 00 00 ZZZ $7.39

88153 C 00 00 00 00 ZZZ $7.39

88153 T 00 00 00 00 ZZZ $7.39

88154 A FP 00 00 00 ZZZ $7.39

88154 C 00 00 00 00 ZZZ $7.39

88154 T 00 00 00 00 ZZZ $7.39

88155 A FP 00 00 00 ZZZ $8.56

88155 C 00 00 00 00 ZZZ $8.56

88155 T 00 00 00 00 ZZZ $8.56

88160 C 00 00 00 00 ZZZ $35.93

88160 P 00 00 00 00 ZZZ $22.46

88160 T 00 00 00 00 ZZZ $13.47

88161 C 00 00 00 00 ZZZ $27.27

88161 P 00 00 00 00 ZZZ $26.19

Page 406: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88162 C 00 00 00 00 ZZZ $72.19

88162 P 00 00 00 00 ZZZ $48.27

88162 T 00 00 00 00 ZZZ $23.92

88164 A FP 00 00 00 ZZZ $7.39

88164 C 00 00 00 00 ZZZ $7.39

88164 T 00 00 00 00 ZZZ $7.39

88165 A FP 00 00 00 ZZZ $7.39

88165 C 00 00 00 00 ZZZ $7.39

88165 T 00 00 00 00 ZZZ $7.39

88166 A FP 00 00 00 ZZZ $7.39

88166 C 00 00 00 00 ZZZ $7.39

88166 T 00 00 00 00 ZZZ $7.39

88167 A FP 00 00 00 ZZZ $7.39

88167 C 00 00 00 00 ZZZ $7.39

88167 T 00 00 00 00 ZZZ $7.39

88172 C 00 00 00 00 ZZZ $78.33

88172 P 00 00 00 00 ZZZ $25.44

88172 T 00 00 00 00 ZZZ $52.89

88173 C 00 00 00 00 ZZZ $71.60

88173 P 00 00 00 00 ZZZ $61.00

88174 A FP 00 00 00 ZZZ $20.39

88174 C 00 00 00 00 ZZZ $20.39

88174 T 00 00 00 00 ZZZ $20.39

88175 A FP 00 00 00 ZZZ $20.75

88175 C 00 00 00 00 ZZZ $20.75

88175 T 00 00 00 00 ZZZ $20.75

88177 C 00 00 00 00 ZZZ $35.87

88177 P 00 00 00 00 ZZZ $28.30

88177 T 00 00 00 00 ZZZ $7.58

88182 C 00 00 00 00 ZZZ $91.30

88182 P 00 00 00 00 ZZZ $54.93

88182 T 00 00 00 00 ZZZ $36.37

88184 C 00 00 00 00 ZZZ $43.18

88184 T 00 00 00 00 ZZZ $43.18

88185 C 00 00 00 00 ZZZ $21.42

88185 T 00 00 00 00 ZZZ $21.42

88187 C 00 00 00 00 ZZZ $84.86

88187 P 00 00 00 00 ZZZ $84.86

88188 C 00 00 00 00 ZZZ $106.96

88188 P 00 00 00 00 ZZZ $106.96

Page 407: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88189 C 00 00 00 00 ZZZ $133.20

88189 P 00 00 00 00 ZZZ $133.20

88199 C 00 00 00 00 ZZZ $0.00

88199 P 00 00 00 00 ZZZ $0.00

88199 T 00 00 00 00 ZZZ $0.00

88230 C 00 00 00 00 ZZZ $91.26

88230 T 00 00 00 00 ZZZ $91.26

88233 C 00 00 00 00 ZZZ $91.26

88233 T 00 00 00 00 ZZZ $91.26

88235 C 00 00 00 00 ZZZ $91.26

88235 T 00 00 00 00 ZZZ $91.26

88237 C 00 00 00 00 ZZZ $91.26

88237 T 00 00 00 00 ZZZ $91.26

88239 C 00 00 00 00 ZZZ $91.26

88239 T 00 00 00 00 ZZZ $91.26

88240 C 00 00 00 00 ZZZ $14.43

88240 T 00 00 00 00 ZZZ $14.43

88241 C 00 00 00 00 ZZZ $14.43

88241 T 00 00 00 00 ZZZ $14.43

88245 C 00 00 00 00 ZZZ $91.26

88245 T 00 00 00 00 ZZZ $91.26

88248 C 00 00 00 00 ZZZ $247.30

88248 T 00 00 00 00 ZZZ $247.30

88249 C 00 00 00 00 ZZZ $247.30

88249 T 00 00 00 00 ZZZ $247.30

88261 C 00 00 00 00 ZZZ $252.38

88261 T 00 00 00 00 ZZZ $252.38

88262 C 00 00 00 00 ZZZ $177.99

88262 T 00 00 00 00 ZZZ $177.99

88263 C 00 00 00 00 ZZZ $91.26

88263 T 00 00 00 00 ZZZ $91.26

88264 C 00 00 00 00 ZZZ $177.99

88264 T 00 00 00 00 ZZZ $177.99

88267 C 00 00 00 00 ZZZ $256.72

88267 T 00 00 00 00 ZZZ $256.72

88269 C 00 00 00 00 ZZZ $237.51

88269 T 00 00 00 00 ZZZ $237.51

88271 C 00 00 00 00 ZZZ $30.59

88271 T 00 00 00 00 ZZZ $30.59

88272 C 00 00 00 00 ZZZ $38.23

Page 408: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88272 T 00 00 00 00 ZZZ $38.23

88273 C 00 00 00 00 ZZZ $45.88

88273 T 00 00 00 00 ZZZ $45.88

88274 C 00 00 00 00 ZZZ $49.70

88274 T 00 00 00 00 ZZZ $49.70

88275 C 00 00 00 00 ZZZ $57.35

88275 T 00 00 00 00 ZZZ $57.35

88280 C 00 00 00 00 ZZZ $35.84

88280 T 00 00 00 00 ZZZ $35.84

88283 C 00 00 00 00 ZZZ $39.86

88283 T 00 00 00 00 ZZZ $39.86

88285 C 00 00 00 00 ZZZ $27.14

88285 T 00 00 00 00 ZZZ $27.14

88289 C 00 00 00 00 ZZZ $49.17

88289 T 00 00 00 00 ZZZ $49.17

88291 C 00 00 00 00 ZZZ $5.72

88291 T 00 00 00 00 ZZZ $5.72

88299 C 00 00 00 00 ZZZ $0.00

88299 T 00 00 00 00 ZZZ $0.00

88300 C 00 00 00 00 ZZZ $18.70

88300 P 00 00 00 00 ZZZ $9.00

88300 T 00 00 00 00 ZZZ $9.70

88302 A FP 00 00 00 ZZZ $33.00

88302 A FP U1 00 00 ZZZ $12.00

88302 A FP U2 00 00 ZZZ $12.12

88302 A FP U3 00 00 ZZZ $20.88

88302 C 00 00 00 00 ZZZ $33.00

88302 J U1 00 00 00 ZZZ $12.12

88302 P 00 00 00 00 ZZZ $12.12

88302 T 00 00 00 00 ZZZ $20.88

88304 C 00 00 00 00 ZZZ $41.80

88304 P 00 00 00 00 ZZZ $16.94

88304 T 00 00 00 00 ZZZ $24.86

88305 C 00 00 00 00 ZZZ $54.55

88305 P 00 00 00 00 ZZZ $22.06

88305 T 00 00 00 00 ZZZ $32.49

88307 C 00 00 00 00 ZZZ $110.41

88307 P 00 00 00 00 ZZZ $44.67

88307 T 00 00 00 00 ZZZ $65.74

88309 C 00 00 00 00 ZZZ $276.48

Page 409: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88309 P 00 00 00 00 ZZZ $158.06

88309 T 00 00 00 00 ZZZ $118.42

88311 C 00 00 00 00 ZZZ $19.80

88311 P 00 00 00 00 ZZZ $6.80

88311 T 00 00 00 00 ZZZ $13.00

88312 C 00 00 00 00 ZZZ $35.93

88312 P 00 00 00 00 ZZZ $12.58

88312 T 00 00 00 00 ZZZ $23.35

88313 C 00 00 00 00 ZZZ $37.22

88313 P 00 00 00 00 ZZZ $13.54

88313 T 00 00 00 00 ZZZ $23.68

88314 C 00 00 00 00 ZZZ $72.91

88314 P 00 00 00 00 ZZZ $22.63

88314 T 00 00 00 00 ZZZ $50.28

88319 C 00 00 00 00 ZZZ $71.33

88319 P 00 00 00 00 ZZZ $37.30

88319 T 00 00 00 00 ZZZ $34.03

88321 C 00 00 00 00 ZZZ $55.00

88321 P 00 00 00 00 ZZZ $55.00

88323 C 00 00 00 00 ZZZ $77.37

88323 P 00 00 00 00 ZZZ $41.80

88325 C 00 00 00 00 ZZZ $58.00

88325 P 00 00 00 00 ZZZ $58.00

88329 C 00 00 00 00 ZZZ $44.00

88329 P 00 00 00 00 ZZZ $44.00

88331 C 00 00 00 00 ZZZ $62.15

88331 P 00 00 00 00 ZZZ $53.00

88332 C 00 00 00 00 ZZZ $44.00

88332 P 00 00 00 00 ZZZ $40.00

88332 T 00 00 00 00 ZZZ $14.40

88333 C 00 00 00 00 ZZZ $103.44

88333 P 00 00 00 00 ZZZ $83.94

88333 T 00 00 00 00 ZZZ $19.50

88334 C 00 00 00 00 ZZZ $53.09

88334 P 00 00 00 00 ZZZ $41.26

88334 T 00 00 00 00 ZZZ $11.83

88341 C 00 00 00 00 ZZZ $67.17

88341 P 00 00 00 00 ZZZ $28.03

88341 T 00 00 00 00 ZZZ $40.26

88342 C 00 00 00 00 ZZZ $64.90

Page 410: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88342 P 00 00 00 00 ZZZ $25.30

88342 T 00 00 00 00 ZZZ $39.60

88344 C 00 00 00 00 ZZZ $117.51

88344 P 00 00 00 00 ZZZ $51.49

88344 T 00 00 00 00 ZZZ $68.15

88346 C 00 00 00 00 ZZZ $63.71

88346 P 00 00 00 00 ZZZ $50.96

88346 T 00 00 00 00 ZZZ $12.75

88348 C 00 00 00 00 ZZZ $268.40

88348 P 00 00 00 00 ZZZ $83.60

88348 T 00 00 00 00 ZZZ $184.80

88350 C 00 00 00 00 ZZZ $69.98

88350 P 00 00 00 00 ZZZ $29.37

88350 T 00 00 00 00 ZZZ $40.62

88355 C 00 00 00 00 ZZZ $157.52

88355 P 00 00 00 00 ZZZ $105.76

88355 T 00 00 00 00 ZZZ $51.76

88356 C 00 00 00 00 ZZZ $241.15

88356 P 00 00 00 00 ZZZ $168.76

88356 T 00 00 00 00 ZZZ $72.38

88358 C 00 00 00 00 ZZZ $229.78

88358 P 00 00 00 00 ZZZ $171.61

88358 T 00 00 00 00 ZZZ $58.17

88360 C 00 00 00 00 ZZZ $135.67

88360 P 00 00 00 00 ZZZ $76.00

88360 T 00 00 00 00 ZZZ $59.68

88361 C 00 00 00 00 ZZZ $139.51

88361 P 00 00 00 00 ZZZ $55.13

88361 T 00 00 00 00 ZZZ $84.38

88362 C 00 00 00 00 ZZZ $198.02

88362 P 00 00 00 00 ZZZ $122.26

88362 T 00 00 00 00 ZZZ $75.76

88363 C 00 00 00 00 ZZZ $47.50

88363 P 00 00 00 00 ZZZ $14.73

88363 T 00 00 00 00 ZZZ $32.78

88364 C 00 00 00 00 ZZZ $95.77

88364 P 00 00 00 00 ZZZ $35.02

88364 T 00 00 00 00 ZZZ $62.13

88365 C 00 00 00 00 ZZZ $114.69

88365 P 00 00 00 00 ZZZ $56.10

Page 411: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88365 T 00 00 00 00 ZZZ $58.59

88366 C 00 00 00 00 ZZZ $154.48

88366 P 00 00 00 00 ZZZ $81.29

88366 T 00 00 00 00 ZZZ $76.39

88367 C 00 00 00 00 ZZZ $257.83

88367 P 00 00 00 00 ZZZ $88.58

88367 T 00 00 00 00 ZZZ $169.25

88368 C 00 00 00 00 ZZZ $234.06

88368 P 00 00 00 00 ZZZ $96.05

88368 T 00 00 00 00 ZZZ $138.01

88369 C 00 00 00 00 ZZZ $74.85

88369 P 00 00 00 00 ZZZ $32.74

88369 T 00 00 00 00 ZZZ $43.12

88371 C 00 00 00 00 ZZZ $31.73

88371 T 00 00 00 00 ZZZ $31.73

88372 C 00 00 00 00 ZZZ $32.49

88372 T 00 00 00 00 ZZZ $32.49

88373 C 00 00 00 00 ZZZ $61.01

88373 P 00 00 00 00 ZZZ $27.39

88373 T 00 00 00 00 ZZZ $34.56

88374 C 00 00 00 00 ZZZ $198.34

88374 P 00 00 00 00 ZZZ $58.68

88374 T 00 00 00 00 ZZZ $141.67

88375 C 00 00 00 00 ZZZ $0.00

88375 P 00 00 00 00 ZZZ $0.00

88375 T 00 00 00 00 ZZZ $0.00

88377 C 00 00 00 00 ZZZ $215.04

88377 P 00 00 00 00 ZZZ $85.82

88377 T 00 00 00 00 ZZZ $131.85

88380 C 00 00 00 00 ZZZ $0.00

88380 P 00 00 00 00 ZZZ $0.00

88380 T 00 00 00 00 ZZZ $0.00

88381 C 00 00 00 00 ZZZ $207.42

88381 P 00 00 00 00 ZZZ $73.98

88381 T 00 00 00 00 ZZZ $133.44

88387 C 00 00 00 00 ZZZ $51.69

88387 P 00 00 00 00 ZZZ $41.26

88388 C 00 00 00 00 ZZZ $30.83

88388 P 00 00 00 00 ZZZ $25.61

88399 C 00 00 00 00 ZZZ $0.00

Page 412: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

88399 P 00 00 00 00 ZZZ $0.00

88399 T 00 00 00 00 ZZZ $0.00

88720 C 00 00 00 00 ZZZ $7.33

88720 T 00 00 00 00 ZZZ $7.33

88738 C 00 00 00 00 ZZZ $7.43

88738 T 00 00 00 00 ZZZ $7.43

88740 C 00 00 00 00 ZZZ $7.33

88740 T 00 00 00 00 ZZZ $7.33

88741 C 00 00 00 00 ZZZ $7.33

88741 T 00 00 00 00 ZZZ $7.33

88749 C 00 00 00 00 ZZZ $0.00

88749 P 00 00 00 00 ZZZ $0.00

88749 T 00 00 00 00 ZZZ $0.00

89049 C 00 00 00 00 ZZZ $183.16

89049 P 00 00 00 00 ZZZ $109.90

89049 T 00 00 00 00 ZZZ $73.27

89050 C 00 00 00 00 ZZZ $6.75

89050 T 00 00 00 00 ZZZ $6.75

89051 C 00 00 00 00 ZZZ $7.86

89051 T 00 00 00 00 ZZZ $7.86

89055 C 00 00 00 00 ZZZ $5.96

89055 T 00 00 00 00 ZZZ $5.96

89060 C 00 00 00 00 ZZZ $10.21

89060 T 00 00 00 00 ZZZ $10.21

89125 C 00 00 00 00 ZZZ $6.16

89125 T 00 00 00 00 ZZZ $6.16

89160 C 00 00 00 00 ZZZ $5.26

89160 T 00 00 00 00 ZZZ $5.26

89190 C 00 00 00 00 ZZZ $6.78

89190 T 00 00 00 00 ZZZ $6.78

89220 C 00 00 00 00 ZZZ $14.00

89220 P 00 00 00 00 ZZZ $4.34

89220 T 00 00 00 00 ZZZ $9.66

89230 C 00 00 00 00 ZZZ $14.21

89230 P 00 00 00 00 ZZZ $14.21

89230 T 00 00 00 00 ZZZ $14.21

89240 C 00 00 00 00 ZZZ $0.00

89240 P 00 00 00 00 ZZZ $0.00

89240 T 00 00 00 00 ZZZ $0.00

89300 A FP 00 00 00 ZZZ $12.73

Page 413: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

89300 C 00 00 00 00 ZZZ $12.73

89300 T 00 00 00 00 ZZZ $12.73

89310 A 00 00 00 00 ZZZ $12.29

89310 A FP 00 00 00 ZZZ $12.29

89310 C 00 00 00 00 ZZZ $12.29

89310 C U1 00 00 00 ZZZ $8.99

89310 P U1 00 00 00 ZZZ $8.99

89310 P U2 00 00 00 ZZZ $8.99

89310 T 00 00 00 00 ZZZ $12.29

89320 A FP 00 00 00 ZZZ $17.22

89320 C 00 00 00 00 ZZZ $17.22

89320 T 00 00 00 00 ZZZ $17.22

89321 C 00 00 00 00 ZZZ $17.22

89321 T 00 00 00 00 ZZZ $17.22

89322 C 00 00 00 00 ZZZ $22.37

89322 T 00 00 00 00 ZZZ $22.37

89325 C 00 00 00 00 ZZZ $15.24

89325 T 00 00 00 00 ZZZ $15.24

89329 C 00 00 00 00 ZZZ $29.95

89329 T 00 00 00 00 ZZZ $29.95

89330 C 00 00 00 00 ZZZ $14.14

89330 T 00 00 00 00 ZZZ $14.14

89331 C 00 00 00 00 ZZZ $28.28

89331 T 00 00 00 00 ZZZ $28.28

90281 1 00 00 00 00 ZZZ $0.00

90283 1 00 00 00 00 ZZZ $0.00

90284 1 00 00 00 00 ZZZ $0.00

90287 1 00 00 00 00 ZZZ $0.00

90288 1 00 00 00 00 ZZZ $0.00

90291 1 00 00 00 00 ZZZ $0.00

90296 1 00 00 00 00 ZZZ $0.00

90371 1 00 00 00 00 ZZZ $60.48

90371 1 U1 00 00 00 ZZZ $63.60

90375 1 00 00 00 00 ZZZ $281.91

90376 1 00 00 00 00 ZZZ $296.24

90385 1 00 00 00 00 ZZZ $49.61

90386 1 00 00 00 00 ZZZ $0.00

90389 1 00 00 00 00 ZZZ $101.60

90393 1 00 00 00 00 ZZZ $0.00

90396 1 00 00 00 00 ZZZ $126.60

Page 414: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

90399 1 00 00 00 00 ZZZ $0.00

90581 1 00 00 00 00 ZZZ $0.00

90585 1 00 00 00 00 ZZZ $147.50

90586 1 00 00 00 00 ZZZ $12.75

90592 1 00 00 00 00 ZZZ $0.00

90620 1 00 00 00 00 ZZZ $183.11

90620 1 SL 00 00 00 AR1 $9.56

90620 6 EP TJ 00 00 ZZZ $9.56

90621 1 00 00 00 00 ZZZ $131.81

90621 1 SL 00 00 00 AR1 $9.56

90621 6 EP TJ 00 00 ZZZ $9.56

90630 1 00 00 00 00 ZZZ $25.07

90630 1 SL 00 00 00 AR1 $9.56

90630 6 EP TJ 00 00 ZZZ $9.56

90632 1 00 00 00 00 ZZZ $61.05

90633 1 SL 00 00 00 AR1 $9.56

90633 6 EP TJ 00 00 ZZZ $9.56

90634 1 SL 00 00 00 AR1 $9.56

90634 6 EP TJ 00 00 ZZZ $9.56

90636 1 00 00 00 00 ZZZ $91.28

90636 1 SL 00 00 00 AR1 $9.56

90636 6 EP TJ 00 00 ZZZ $9.56

90646 1 SL 00 00 00 AR1 $9.56

90647 1 00 00 00 00 ZZZ $25.09

90647 1 SL 00 00 00 AR1 $9.56

90647 6 EP TJ 00 00 ZZZ $9.56

90648 1 SL 00 00 00 AR1 $9.56

90648 6 EP TJ 00 00 ZZZ $9.56

90649 1 SL 00 00 00 AR1 $9.56

90649 6 EP TJ 00 00 ZZZ $9.56

90650 1 SL 00 00 00 AR1 $9.56

90650 6 EP TJ 00 00 ZZZ $9.56

90651 1 SL 00 00 00 AR1 $9.56

90651 6 EP TJ 00 00 ZZZ $9.56

90654 1 00 00 00 00 ZZZ $10.31

90654 1 SL 00 00 00 AR1 $9.56

90654 6 EP TJ 00 00 ZZZ $9.56

90655 1 SL 00 00 00 AR1 $9.56

90655 6 EP TJ 00 00 ZZZ $9.56

90656 1 00 00 00 00 ZZZ $13.12

Page 415: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

90656 1 SL 00 00 00 AR1 $9.56

90656 6 EP TJ 00 00 ZZZ $9.56

90657 1 SL 00 00 00 AR1 $9.56

90657 6 EP TJ 00 00 ZZZ $9.56

90658 1 00 00 00 00 ZZZ $12.06

90658 1 SL 00 00 00 AR1 $9.56

90658 6 EP TJ 00 00 ZZZ $9.56

90660 1 00 00 00 00 ZZZ $18.40

90660 1 SL 00 00 00 AR1 $9.56

90660 6 EP TJ 00 00 ZZZ $9.56

90662 1 00 00 00 00 ZZZ $13.80

90670 1 SL 00 00 00 AR1 $9.56

90670 6 EP TJ 00 00 ZZZ $9.56

90672 1 00 00 00 00 ZZZ $24.60

90672 1 SL 00 00 00 AR1 $9.56

90672 6 EP TJ 00 00 ZZZ $9.56

90673 1 00 00 00 00 ZZZ $37.19

90673 1 SL 00 00 00 AR1 $9.56

90673 6 EP TJ 00 00 ZZZ $9.56

90674 1 00 00 00 00 ZZZ $22.94

90674 1 SL 00 00 00 AR1 $9.56

90674 6 EP TJ 00 00 ZZZ $9.56

90675 1 00 00 00 00 ZZZ $262.98

90676 1 00 00 00 00 ZZZ $0.00

90680 1 SL 00 00 00 AR1 $9.56

90680 6 EP TJ 00 00 ZZZ $9.56

90681 1 SL 00 00 00 AR1 $9.56

90681 6 EP TJ 00 00 ZZZ $9.56

90685 1 SL 00 00 00 AR1 $9.56

90685 6 EP TJ 00 00 ZZZ $9.56

90686 1 00 00 00 00 ZZZ $16.14

90686 1 SL 00 00 00 AR1 $9.56

90686 6 EP TJ 00 00 ZZZ $9.56

90688 1 00 00 00 00 ZZZ $16.15

90688 1 SL 00 00 00 AR1 $9.56

90688 6 EP TJ 00 00 ZZZ $9.56

90690 1 00 00 00 00 ZZZ $9.71

90691 1 00 00 00 00 ZZZ $42.10

90696 1 SL 00 00 00 AR1 $9.56

90696 6 EP TJ 00 00 ZZZ $9.56

Page 416: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

90698 1 SL 00 00 00 AR1 $9.56

90698 6 EP TJ 00 00 ZZZ $9.56

90700 1 SL 00 00 00 AR1 $9.56

90700 6 EP TJ 00 00 ZZZ $9.56

90702 1 SL 00 00 00 AR1 $9.56

90702 6 EP TJ 00 00 ZZZ $9.56

90707 1 00 00 00 00 ZZZ $34.64

90707 1 SL 00 00 00 AR1 $9.56

90707 1 U1 00 00 00 ZZZ $34.64

90707 6 EP TJ 00 00 ZZZ $9.56

90710 1 00 00 00 00 ZZZ $26.96

90710 1 SL 00 00 00 AR1 $9.56

90710 6 EP TJ 00 00 ZZZ $9.56

90713 1 00 00 00 00 ZZZ $20.84

90713 1 SL 00 00 00 AR1 $9.56

90713 6 EP TJ 00 00 ZZZ $9.56

90714 1 00 00 00 00 ZZZ $14.00

90714 1 SL 00 00 00 AR1 $9.56

90714 6 EP TJ 00 00 ZZZ $9.56

90715 1 00 00 00 00 ZZZ $28.80

90715 1 SL 00 00 00 AR1 $9.56

90715 6 EP TJ 00 00 ZZZ $9.56

90716 1 00 00 00 00 ZZZ $51.53

90716 1 SL 00 00 00 AR1 $9.56

90716 6 EP TJ 00 00 ZZZ $9.56

90717 1 00 00 00 00 ZZZ $0.00

90723 1 SL 00 00 00 AR1 $9.56

90723 6 EP TJ 00 00 ZZZ $9.56

90732 1 00 00 00 00 ZZZ $12.34

90732 1 SL 00 00 00 AR1 $9.56

90732 6 EP TJ 00 00 ZZZ $9.56

90733 1 00 00 00 00 ZZZ $69.85

90734 1 00 00 00 00 ZZZ $65.60

90734 1 SL 00 00 00 AR1 $9.56

90734 6 EP TJ 00 00 ZZZ $9.56

90736 1 00 00 00 00 ZZZ $129.20

90740 1 00 00 00 00 ZZZ $153.14

90743 1 SL 00 00 00 AR1 $9.56

90743 6 EP TJ 00 00 ZZZ $9.56

90744 1 SL 00 00 00 AR1 $9.56

Page 417: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

90744 6 EP TJ 00 00 ZZZ $9.56

90746 1 00 00 00 00 ZZZ $57.58

90747 1 00 00 00 00 ZZZ $110.20

90747 1 SL 00 00 00 AR1 $9.56

90747 6 EP TJ 00 00 ZZZ $9.56

90748 1 00 00 00 00 ZZZ $33.98

90748 1 SL 00 00 00 AR1 $9.56

90748 6 EP TJ 00 00 ZZZ $9.56

90749 1 00 00 00 00 ZZZ $0.00

90791 1 00 00 00 00 ZZZ $182.31

90792 1 00 00 00 00 ZZZ $161.45

90832 1 00 00 00 00 ZZZ $77.22

90833 1 00 00 00 00 ZZZ $53.81

90834 1 00 00 00 00 ZZZ $104.28

90836 1 00 00 00 00 ZZZ $87.49

90837 1 00 00 00 00 ZZZ $153.78

90838 1 00 00 00 00 ZZZ $140.65

90839 1 00 00 00 00 ZZZ $192.23

90840 1 00 00 00 00 ZZZ $96.53

90847 1 00 00 00 00 ZZZ $97.90

90849 1 00 00 00 00 ZZZ $50.00

90853 1 00 00 00 00 ZZZ $50.00

90870 C 00 00 00 00 ZZZ $108.90

90870 P 00 00 00 00 ZZZ $64.90

90870 T 00 00 00 00 ZZZ $44.00

90882 1 00 00 00 00 ZZZ $22.00

90899 1 00 00 00 00 ZZZ $0.00

90935 1 00 00 00 00 ZZZ $81.40

90937 1 00 00 00 00 ZZZ $129.80

90940 C 00 00 00 00 ZZZ $0.00

90940 P 00 00 00 00 ZZZ $0.00

90940 T 00 00 00 00 ZZZ $0.00

90945 1 00 00 00 00 ZZZ $81.40

90947 1 00 00 00 00 ZZZ $129.80

90967 1 00 00 00 00 ZZZ $25.61

90968 1 00 00 00 00 ZZZ $19.92

90969 1 00 00 00 00 ZZZ $19.44

90970 1 00 00 00 00 ZZZ $10.43

90989 1 00 00 00 00 ZZZ $532.00

90993 1 00 00 00 00 ZZZ $18.40

Page 418: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

90997 1 00 00 00 00 ZZZ $156.19

90999 1 00 00 00 00 ZZZ $0.00

91010 C 00 00 00 00 ZZZ $86.90

91010 P 00 00 00 00 ZZZ $79.00

91010 T 00 00 00 00 ZZZ $59.00

91013 C 00 00 00 00 ZZZ $28.51

91013 P 00 00 00 00 ZZZ $12.90

91013 T 00 00 00 00 ZZZ $15.61

91020 C 00 00 00 00 ZZZ $89.96

91020 P 00 00 00 00 ZZZ $53.98

91020 T 00 00 00 00 ZZZ $35.98

91022 C 00 00 00 00 ZZZ $222.52

91022 P 00 00 00 00 ZZZ $95.80

91022 T 00 00 00 00 ZZZ $126.72

91030 1 00 00 00 00 ZZZ $40.39

91034 C 00 00 00 00 ZZZ $218.50

91034 P 00 00 00 00 ZZZ $63.87

91034 T 00 00 00 00 ZZZ $159.60

91035 C 00 00 00 00 ZZZ $425.33

91035 P 00 00 00 00 ZZZ $103.04

91035 T 00 00 00 00 ZZZ $330.48

91037 C 00 00 00 00 ZZZ $144.58

91037 P 00 00 00 00 ZZZ $63.87

91037 T 00 00 00 00 ZZZ $85.68

91038 C 00 00 00 00 ZZZ $127.92

91038 P 00 00 00 00 ZZZ $72.26

91038 T 00 00 00 00 ZZZ $61.36

91040 C 00 00 00 00 ZZZ $406.98

91040 P 00 00 00 00 ZZZ $63.87

91040 T 00 00 00 00 ZZZ $348.08

91065 1 00 00 00 00 ZZZ $40.54

91110 C 00 00 00 00 ZZZ $889.97

91110 P 00 00 00 00 ZZZ $237.60

91110 T 00 00 00 00 ZZZ $672.12

91111 C 00 00 00 00 ZZZ $653.69

91111 P 00 00 00 00 ZZZ $70.66

91111 T 00 00 00 00 ZZZ $583.03

91112 C 00 00 00 00 ZZZ $1,093.08

91112 P 00 00 00 00 ZZZ $135.76

91112 T 00 00 00 00 ZZZ $957.32

Page 419: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

91117 C 00 00 00 00 ZZZ $184.07

91117 P 00 00 00 00 ZZZ $110.45

91117 T 00 00 00 00 ZZZ $73.64

91120 C 00 00 00 00 ZZZ $401.71

91120 P 00 00 00 00 ZZZ $64.34

91120 T 00 00 00 00 ZZZ $342.34

91122 C 00 00 00 00 ZZZ $165.98

91122 P 00 00 00 00 ZZZ $101.98

91122 T 00 00 00 00 ZZZ $64.00

91132 C 00 00 00 00 ZZZ $36.52

91132 T 00 00 00 00 ZZZ $36.52

91133 C 00 00 00 00 ZZZ $47.43

91133 T 00 00 00 00 ZZZ $47.43

91200 C 00 00 00 00 ZZZ $42.10

91200 P 00 00 00 00 ZZZ $19.37

91200 T 00 00 00 00 ZZZ $22.73

91299 1 00 00 00 00 ZZZ $0.00

92002 1 00 00 00 00 ZZZ $45.11

92004 1 00 00 00 00 ZZZ $75.53

92012 1 00 00 00 00 ZZZ $38.29

92014 1 00 00 00 00 ZZZ $55.34

92015 1 00 00 00 00 ZZZ $34.09

92018 1 00 00 00 00 ZZZ $127.05

92019 1 00 00 00 00 ZZZ $64.90

92020 1 00 00 00 00 ZZZ $24.20

92025 C 00 00 00 00 ZZZ $38.41

92025 P 00 00 00 00 ZZZ $22.76

92025 T 00 00 00 00 ZZZ $15.65

92060 1 00 00 00 00 ZZZ $40.91

92071 D 00 00 00 00 ZZZ $0.00

92072 D 00 00 00 00 ZZZ $0.00

92081 1 00 00 00 00 ZZZ $34.09

92082 1 00 00 00 00 ZZZ $38.81

92083 1 00 00 00 00 ZZZ $41.96

92100 1 00 00 00 00 ZZZ $38.55

92132 C 00 00 00 00 ZZZ $45.30

92132 P 00 00 00 00 ZZZ $27.28

92132 T 00 00 00 00 ZZZ $18.02

92133 C 00 00 00 00 ZZZ $56.03

92133 P 00 00 00 00 ZZZ $38.01

Page 420: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

92133 T 00 00 00 00 ZZZ $18.02

92134 C 00 00 00 00 ZZZ $56.03

92134 P 00 00 00 00 ZZZ $38.01

92134 T 00 00 00 00 ZZZ $18.02

92136 C 00 00 00 00 ZZZ $87.23

92136 P 00 00 00 00 ZZZ $31.53

92136 T 00 00 00 00 ZZZ $55.70

92145 C 00 00 00 00 ZZZ $18.61

92145 P 00 00 00 00 ZZZ $11.44

92145 T 00 00 00 00 ZZZ $7.17

92225 1 00 00 00 00 ZZZ $55.00

92226 1 00 00 00 00 ZZZ $39.87

92230 1 00 00 00 00 ZZZ $55.00

92235 C 00 00 00 00 ZZZ $127.60

92235 P 00 00 00 00 ZZZ $70.00

92235 T 00 00 00 00 ZZZ $57.60

92240 C 00 00 00 00 ZZZ $113.96

92240 P 00 00 00 00 ZZZ $70.78

92240 T 00 00 00 00 ZZZ $43.18

92242 C 00 00 00 00 ZZZ $252.06

92242 P 00 00 00 00 ZZZ $65.79

92242 T 00 00 00 00 ZZZ $186.27

92250 C 00 00 00 00 ZZZ $43.53

92250 P 00 00 00 00 ZZZ $26.12

92250 T 00 00 00 00 ZZZ $17.41

92260 C 00 00 00 00 ZZZ $35.00

92260 P 00 00 00 00 ZZZ $21.00

92260 T 00 00 00 00 ZZZ $14.00

92265 C 00 00 00 00 ZZZ $58.30

92265 P 00 00 00 00 ZZZ $35.20

92265 T 00 00 00 00 ZZZ $23.10

92270 C 00 00 00 00 ZZZ $63.80

92270 P 00 00 00 00 ZZZ $38.05

92270 T 00 00 00 00 ZZZ $25.75

92275 C 00 00 00 00 ZZZ $125.00

92275 P 00 00 00 00 ZZZ $75.00

92275 T 00 00 00 00 ZZZ $50.00

92283 1 00 00 00 00 ZZZ $42.54

92284 1 00 00 00 00 ZZZ $55.37

92286 C 00 00 00 00 ZZZ $65.04

Page 421: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

92286 P 00 00 00 00 ZZZ $39.02

92286 T 00 00 00 00 ZZZ $26.02

92287 C 00 00 00 00 ZZZ $99.10

92287 P 00 00 00 00 ZZZ $0.00

92287 T 00 00 00 00 ZZZ $0.00

92326 D 00 00 00 00 ZZZ $0.00

92340 D 00 00 00 00 ZZZ $51.22

92370 D 00 00 00 00 ZZZ $34.51

92499 1 00 00 00 00 ZZZ $0.00

92502 1 00 00 00 00 ZZZ $160.85

92504 1 00 00 00 00 ZZZ $34.00

92511 1 00 00 00 00 ZZZ $63.80

92512 C 00 00 00 00 ZZZ $33.04

92512 P 00 00 00 00 ZZZ $19.52

92512 T 00 00 00 00 ZZZ $13.52

92516 C 00 00 00 00 ZZZ $26.23

92516 P 00 00 00 00 ZZZ $15.58

92516 T 00 00 00 00 ZZZ $10.65

92520 C 00 00 00 00 ZZZ $34.36

92520 P 00 00 00 00 ZZZ $20.30

92520 T 00 00 00 00 ZZZ $14.06

92521 1 UA 00 00 00 ZZZ $49.44

92522 1 UA 00 00 00 ZZZ $49.44

92523 1 UA 00 00 00 ZZZ $49.44

92524 1 UA 00 00 00 ZZZ $49.44

92526 1 00 00 00 00 ZZZ $38.58

92531 1 00 00 00 00 ZZZ $8.80

92532 1 00 00 00 00 ZZZ $8.80

92533 1 00 00 00 00 ZZZ $9.90

92534 1 00 00 00 00 ZZZ $23.00

92537 C 00 00 00 00 ZZZ $40.63

92537 P 00 00 00 00 ZZZ $32.77

92537 T 00 00 00 00 ZZZ $7.86

92538 C 00 00 00 00 ZZZ $20.59

92538 P 00 00 00 00 ZZZ $16.39

92538 T 00 00 00 00 ZZZ $4.20

92540 C 00 00 00 00 ZZZ $124.73

92540 P 00 00 00 00 ZZZ $102.91

92540 T 00 00 00 00 ZZZ $21.82

92541 C 00 00 00 00 ZZZ $47.56

Page 422: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

92541 P 00 00 00 00 ZZZ $29.56

92541 T 00 00 00 00 ZZZ $18.00

92542 C 00 00 00 00 ZZZ $39.60

92542 P 00 00 00 00 ZZZ $23.10

92542 T 00 00 00 00 ZZZ $36.00

92544 C 00 00 00 00 ZZZ $28.60

92544 P 00 00 00 00 ZZZ $17.60

92544 T 00 00 00 00 ZZZ $11.00

92545 C 00 00 00 00 ZZZ $28.60

92545 P 00 00 00 00 ZZZ $17.60

92545 T 00 00 00 00 ZZZ $11.00

92546 C 00 00 00 00 ZZZ $28.60

92546 P 00 00 00 00 ZZZ $17.60

92546 T 00 00 00 00 ZZZ $11.00

92547 C 00 00 00 00 ZZZ $17.60

92547 T 00 00 00 00 ZZZ $17.60

92548 C 00 00 00 00 ZZZ $103.54

92548 P 00 00 00 00 ZZZ $37.13

92548 T 00 00 00 00 ZZZ $66.41

92550 C 00 00 00 00 ZZZ $27.04

92550 T 00 00 00 00 ZZZ $27.04

92551 C 00 00 00 00 ZZZ $9.90

92551 P 00 00 00 00 ZZZ $9.00

92551 T 00 00 00 00 ZZZ $4.00

92552 C 00 00 00 00 ZZZ $19.80

92552 T 00 00 00 00 ZZZ $19.80

92553 C 00 00 00 00 ZZZ $26.40

92553 T 00 00 00 00 ZZZ $26.40

92555 C 00 00 00 00 ZZZ $11.02

92555 T 00 00 00 00 ZZZ $11.02

92556 C 00 00 00 00 ZZZ $16.52

92556 T 00 00 00 00 ZZZ $16.52

92557 C 00 00 00 00 ZZZ $49.50

92557 T 00 00 00 00 ZZZ $49.50

92559 C 00 00 00 00 ZZZ $12.10

92559 T 00 00 00 00 ZZZ $12.10

92560 C 00 00 00 00 ZZZ $9.90

92560 P 00 00 00 00 ZZZ $9.90

92561 C 00 00 00 00 ZZZ $22.00

92561 T 00 00 00 00 ZZZ $22.00

Page 423: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

92562 C 00 00 00 00 ZZZ $13.20

92562 T 00 00 00 00 ZZZ $13.20

92563 C 00 00 00 00 ZZZ $11.02

92563 T 00 00 00 00 ZZZ $11.02

92564 C 00 00 00 00 ZZZ $14.30

92564 T 00 00 00 00 ZZZ $14.30

92565 C 00 00 00 00 ZZZ $11.54

92565 T 00 00 00 00 ZZZ $11.54

92567 C 00 00 00 00 AR1 $16.50

92567 C 00 00 00 00 ZZZ $16.50

92567 T 00 00 00 00 AR1 $16.50

92567 T 00 00 00 00 ZZZ $16.50

92568 C 00 00 00 00 ZZZ $11.02

92568 T 00 00 00 00 ZZZ $11.02

92570 C 00 00 00 00 ZZZ $0.00

92570 T 00 00 00 00 ZZZ $0.00

92571 C 00 00 00 00 ZZZ $11.28

92571 T 00 00 00 00 ZZZ $11.28

92572 C 00 00 00 00 ZZZ $5.83

92572 T 00 00 00 00 ZZZ $5.83

92575 C 00 00 00 00 ZZZ $17.00

92575 T 00 00 00 00 ZZZ $17.00

92576 C 00 00 00 00 ZZZ $19.80

92576 T 00 00 00 00 ZZZ $19.80

92577 C 00 00 00 00 ZZZ $22.00

92577 T 00 00 00 00 ZZZ $22.00

92579 C 00 00 00 00 ZZZ $31.50

92579 T 00 00 00 00 ZZZ $0.00

92582 C 00 00 00 00 ZZZ $29.70

92582 T 00 00 00 00 ZZZ $29.70

92583 C 00 00 00 00 ZZZ $26.40

92583 T 00 00 00 00 ZZZ $26.40

92584 C 00 00 00 00 ZZZ $101.20

92584 T 00 00 00 00 ZZZ $101.20

92585 C 00 00 00 00 ZZZ $105.60

92585 P 00 00 00 00 ZZZ $33.70

92585 T 00 00 00 00 ZZZ $96.00

92586 C 00 00 00 00 ZZZ $80.86

92586 P 00 00 00 00 ZZZ $48.52

92586 T 00 00 00 00 ZZZ $32.34

Page 424: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

92587 C 00 00 00 00 ZZZ $67.24

92587 P 00 00 00 00 ZZZ $10.45

92587 T 00 00 00 00 ZZZ $56.79

92588 C 00 00 00 00 ZZZ $92.73

92588 P 00 00 00 00 ZZZ $28.31

92588 T 00 00 00 00 ZZZ $64.42

92590 1 00 00 00 00 ZZZ $53.00

92591 1 00 00 00 00 ZZZ $66.00

92594 1 00 00 00 00 ZZZ $12.00

92595 1 00 00 00 00 ZZZ $30.00

92601 1 00 00 00 00 ZZZ $146.86

92602 1 00 00 00 00 ZZZ $103.13

92603 1 00 00 00 00 ZZZ $99.01

92604 1 00 00 00 00 ZZZ $67.66

92610 1 00 00 00 00 ZZZ $47.44

92611 C 00 00 00 00 ZZZ $51.56

92611 T 00 00 00 00 ZZZ $51.56

92612 C 00 00 00 00 ZZZ $193.90

92612 T 00 00 00 00 ZZZ $193.90

92613 C 00 00 00 00 ZZZ $53.62

92613 P 00 00 00 00 ZZZ $53.62

92614 C 00 00 00 00 ZZZ $149.75

92614 T 00 00 00 00 ZZZ $149.75

92615 C 00 00 00 00 ZZZ $48.49

92615 P 00 00 00 00 ZZZ $48.49

92616 C 00 00 00 00 ZZZ $205.03

92616 T 00 00 00 00 ZZZ $205.03

92617 C 00 00 00 00 ZZZ $59.68

92617 P 00 00 00 00 ZZZ $59.68

92620 1 00 00 00 00 ZZZ $55.95

92621 1 00 00 00 00 ZZZ $14.46

92625 1 00 00 00 00 ZZZ $55.02

92626 1 00 00 00 00 ZZZ $28.93

92627 1 00 00 00 00 ZZZ $28.93

92630 1 00 00 00 00 ZZZ $78.25

92633 1 00 00 00 00 ZZZ $78.25

92640 C 00 00 00 00 ZZZ $45.27

92640 P 00 00 00 00 ZZZ $45.27

92700 1 00 00 00 00 ZZZ $0.00

92920 1 00 00 00 00 ZZZ $660.86

Page 425: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

92921 1 00 00 00 00 ZZZ $785.14

92924 1 00 00 00 00 ZZZ $785.14

92925 1 00 00 00 00 ZZZ $0.00

92928 1 00 00 00 00 ZZZ $733.64

92929 1 00 00 00 00 ZZZ $0.00

92933 1 00 00 00 00 ZZZ $820.85

92934 1 00 00 00 00 ZZZ $0.00

92937 1 00 00 00 00 ZZZ $733.17

92938 1 00 00 00 00 ZZZ $0.00

92941 1 00 00 00 00 ZZZ $822.42

92943 1 00 00 00 00 ZZZ $822.42

92944 1 00 00 00 00 ZZZ $0.00

92950 1 00 00 00 00 ZZZ $189.20

92953 C 00 00 00 00 ZZZ $23.89

92953 P 00 00 00 00 ZZZ $14.12

92953 T 00 00 00 00 ZZZ $9.76

92960 C 00 00 00 00 ZZZ $204.22

92960 P 00 00 00 00 ZZZ $122.96

92960 T 00 00 00 00 ZZZ $81.26

92961 C 00 00 00 00 ZZZ $265.72

92961 P 00 00 00 00 ZZZ $265.72

92970 1 00 00 00 00 ZZZ $347.00

92971 1 00 00 00 00 ZZZ $163.18

92973 1 00 00 00 00 ZZZ $198.85

92974 1 00 00 00 00 ZZZ $224.42

92975 1 00 00 00 00 ZZZ $568.00

92977 1 00 00 00 00 ZZZ $354.78

92978 C 00 00 00 00 ZZZ $164.35

92978 P 00 00 00 00 ZZZ $60.24

92978 T 00 00 00 00 ZZZ $104.12

92979 C 00 00 00 00 ZZZ $104.90

92979 P 00 00 00 00 ZZZ $104.90

92982 1 00 00 00 00 ZZZ $995.89

92986 1 U1 00 00 00 ZZZ $2,133.05

92986 C 00 00 00 00 ZZZ $1,509.88

92986 P 00 00 00 00 ZZZ $603.95

92986 T 00 00 00 00 ZZZ $905.93

92987 1 U1 00 00 00 ZZZ $1,256.43

92987 C 00 00 00 00 ZZZ $1,564.33

92987 P 00 00 00 00 ZZZ $625.73

Page 426: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

92987 T 00 00 00 00 ZZZ $938.60

92990 1 U1 00 00 00 ZZZ $1,197.90

92990 C 00 00 00 00 ZZZ $1,184.80

92990 P 00 00 00 00 ZZZ $473.92

92990 T 00 00 00 00 ZZZ $710.88

92992 1 00 00 00 00 ZZZ $0.00

92993 1 00 00 00 00 ZZZ $0.00

92997 1 00 00 00 00 ZZZ $1,080.28

92998 1 00 00 00 00 ZZZ $467.18

93000 C 00 00 00 00 ZZZ $28.60

93005 C 00 00 00 00 ZZZ $19.80

93005 T 00 00 00 00 ZZZ $19.80

93010 C 00 00 00 00 ZZZ $14.30

93010 P 00 00 00 00 ZZZ $13.98

93015 C 00 00 00 00 ZZZ $156.20

93016 C 00 00 00 00 ZZZ $37.40

93016 P 00 00 00 00 ZZZ $37.40

93017 C 00 00 00 00 ZZZ $67.10

93017 T 00 00 00 00 ZZZ $67.10

93018 C 00 00 00 00 ZZZ $97.90

93018 P 00 00 00 00 ZZZ $89.00

93024 C 00 00 00 00 ZZZ $123.20

93024 P 00 00 00 00 ZZZ $73.70

93024 T 00 00 00 00 ZZZ $49.50

93025 C 00 00 00 00 ZZZ $300.32

93025 P 00 00 00 00 ZZZ $120.13

93025 T 00 00 00 00 ZZZ $180.19

93040 C 00 00 00 00 ZZZ $13.20

93041 C 00 00 00 00 ZZZ $6.60

93041 T 00 00 00 00 ZZZ $6.60

93042 C 00 00 00 00 ZZZ $6.60

93042 P 00 00 00 00 ZZZ $6.60

93201 C 00 00 00 00 ZZZ $44.00

93224 C 00 00 00 00 ZZZ $195.80

93225 C 00 00 00 00 ZZZ $48.40

93225 T 00 00 00 00 ZZZ $48.40

93226 C 00 00 00 00 ZZZ $91.30

93226 T 00 00 00 00 ZZZ $91.30

93227 C 00 00 00 00 ZZZ $56.10

93227 P 00 00 00 00 ZZZ $51.00

Page 427: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93228 C 00 00 00 00 ZZZ $33.67

93228 P 00 00 00 00 ZZZ $33.67

93229 C 00 00 00 00 ZZZ $0.00

93229 T 00 00 00 00 ZZZ $0.00

93260 C 00 00 00 00 ZZZ $80.01

93260 P 00 00 00 00 ZZZ $57.66

93260 T 00 00 00 00 ZZZ $22.35

93261 C 00 00 00 00 ZZZ $72.64

93261 P 00 00 00 00 ZZZ $50.29

93261 T 00 00 00 00 ZZZ $22.35

93268 C 00 00 00 00 ZZZ $194.30

93268 P 00 00 00 00 ZZZ $105.98

93268 T 00 00 00 00 ZZZ $88.32

93270 C 00 00 00 00 ZZZ $53.09

93271 C 00 00 00 00 ZZZ $103.35

93272 C 00 00 00 00 ZZZ $35.07

93272 P 00 00 00 00 ZZZ $21.04

93272 T 00 00 00 00 ZZZ $14.03

93278 C 00 00 00 00 ZZZ $80.66

93278 P 00 00 00 00 ZZZ $45.00

93278 T 00 00 00 00 ZZZ $35.66

93279 C 00 00 00 00 ZZZ $73.51

93279 P 00 00 00 00 ZZZ $47.42

93279 T 00 00 00 00 ZZZ $26.08

93280 C 00 00 00 00 ZZZ $86.79

93280 P 00 00 00 00 ZZZ $56.91

93280 T 00 00 00 00 ZZZ $29.88

93281 C 00 00 00 00 ZZZ $101.49

93281 P 00 00 00 00 ZZZ $66.39

93281 T 00 00 00 00 ZZZ $35.09

93282 C 00 00 00 00 ZZZ $93.90

93282 P 00 00 00 00 ZZZ $62.13

93282 T 00 00 00 00 ZZZ $31.77

93283 C 00 00 00 00 ZZZ $114.29

93283 P 00 00 00 00 ZZZ $78.25

93283 T 00 00 00 00 ZZZ $36.04

93284 C 00 00 00 00 ZZZ $133.74

93284 P 00 00 00 00 ZZZ $92.95

93284 T 00 00 00 00 ZZZ $40.78

93285 C 00 00 00 00 ZZZ $63.55

Page 428: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93285 P 00 00 00 00 ZZZ $38.89

93285 T 00 00 00 00 ZZZ $24.66

93286 C 00 00 00 00 ZZZ $36.04

93286 P 00 00 00 00 ZZZ $19.92

93286 T 00 00 00 00 ZZZ $16.12

93287 C 00 00 00 00 ZZZ $47.42

93287 P 00 00 00 00 ZZZ $28.93

93287 T 00 00 00 00 ZZZ $18.50

93288 C 00 00 00 00 ZZZ $56.91

93288 P 00 00 00 00 ZZZ $31.77

93288 T 00 00 00 00 ZZZ $25.13

93289 C 00 00 00 00 ZZZ $87.26

93289 P 00 00 00 00 ZZZ $57.38

93289 T 00 00 00 00 ZZZ $29.88

93290 C 00 00 00 00 ZZZ $42.21

93290 P 00 00 00 00 ZZZ $27.98

93290 T 00 00 00 00 ZZZ $14.23

93291 C 00 00 00 00 ZZZ $54.54

93291 P 00 00 00 00 ZZZ $32.25

93291 T 00 00 00 00 ZZZ $22.29

93292 C 00 00 00 00 ZZZ $49.32

93292 P 00 00 00 00 ZZZ $31.77

93292 T 00 00 00 00 ZZZ $17.55

93293 C 00 00 00 00 ZZZ $78.72

93293 P 00 00 00 00 ZZZ $22.29

93293 T 00 00 00 00 ZZZ $56.43

93294 C 00 00 00 00 ZZZ $48.37

93294 P 00 00 00 00 ZZZ $19.35

93294 T 00 00 00 00 ZZZ $29.02

93295 C 00 00 00 00 ZZZ $87.26

93295 P 00 00 00 00 ZZZ $34.90

93295 T 00 00 00 00 ZZZ $52.36

93296 C 00 00 00 00 ZZZ $47.90

93296 P 00 00 00 00 ZZZ $19.16

93296 T 00 00 00 00 ZZZ $28.74

93297 C 00 00 00 00 ZZZ $33.67

93297 P 00 00 00 00 ZZZ $13.47

93297 T 00 00 00 00 ZZZ $20.20

93298 C 00 00 00 00 ZZZ $38.89

93298 P 00 00 00 00 ZZZ $15.56

Page 429: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93298 T 00 00 00 00 ZZZ $23.33

93299 C 00 00 00 00 ZZZ $32.00

93299 P 00 00 00 00 ZZZ $32.00

93303 C 00 00 00 00 ZZZ $261.91

93303 P 00 00 00 00 ZZZ $98.84

93303 T 00 00 00 00 ZZZ $163.07

93304 C 00 00 00 00 ZZZ $142.99

93304 P 00 00 00 00 ZZZ $60.14

93304 T 00 00 00 00 ZZZ $82.85

93306 C 00 00 00 00 ZZZ $351.89

93306 P 00 00 00 00 ZZZ $94.37

93306 T 00 00 00 00 ZZZ $257.51

93307 C 00 00 00 00 ZZZ $195.80

93307 P 00 00 00 00 ZZZ $102.00

93307 T 00 00 00 00 ZZZ $93.80

93308 C 00 00 00 00 ZZZ $142.67

93308 P 00 00 00 00 ZZZ $83.00

93308 T 00 00 00 00 ZZZ $59.67

93312 C 00 00 00 00 ZZZ $282.70

93312 P 00 00 00 00 ZZZ $191.00

93312 T 00 00 00 00 ZZZ $91.70

93313 C 00 00 00 00 ZZZ $99.14

93313 P 00 00 00 00 ZZZ $59.48

93313 T 00 00 00 00 ZZZ $39.66

93314 C 00 00 00 00 ZZZ $247.93

93314 P 00 00 00 00 ZZZ $78.38

93314 T 00 00 00 00 ZZZ $169.55

93315 C 00 00 00 00 ZZZ $337.65

93315 P 00 00 00 00 ZZZ $175.55

93315 T 00 00 00 00 ZZZ $162.10

93316 C 00 00 00 00 ZZZ $69.37

93316 P 00 00 00 00 ZZZ $69.37

93317 C 00 00 00 00 ZZZ $267.56

93317 P 00 00 00 00 ZZZ $122.62

93317 T 00 00 00 00 ZZZ $144.94

93318 C 00 00 00 00 ZZZ $306.95

93318 P 00 00 00 00 ZZZ $159.59

93318 T 00 00 00 00 ZZZ $147.36

93320 C 00 00 00 00 ZZZ $129.00

93320 P 00 00 00 00 ZZZ $79.00

Page 430: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93320 T 00 00 00 00 ZZZ $50.00

93321 C 00 00 00 00 ZZZ $86.84

93321 P 00 00 00 00 ZZZ $48.84

93321 T 00 00 00 00 ZZZ $38.00

93325 C 00 00 00 00 ZZZ $36.00

93325 P 00 00 00 00 ZZZ $36.00

93325 T 00 00 00 00 ZZZ $16.00

93350 C 00 00 00 00 ZZZ $194.66

93350 P 00 00 00 00 ZZZ $83.34

93350 T 00 00 00 00 ZZZ $111.31

93351 C 00 00 00 00 ZZZ $364.22

93351 P 00 00 00 00 ZZZ $145.69

93351 T 00 00 00 00 ZZZ $218.53

93352 C 00 00 00 00 ZZZ $50.74

93352 P 00 00 00 00 ZZZ $50.74

93355 C 00 00 00 00 ZZZ $218.70

93355 P 00 00 00 00 ZZZ $87.48

93355 T 00 00 00 00 ZZZ $131.22

93451 C 00 00 00 00 ZZZ $192.22

93451 P 00 00 00 00 ZZZ $192.22

93452 C 00 00 00 00 ZZZ $336.62

93452 P 00 00 00 00 ZZZ $336.62

93453 C 00 00 00 00 ZZZ $441.75

93453 P 00 00 00 00 ZZZ $441.75

93454 C 00 00 00 00 ZZZ $339.67

93454 P 00 00 00 00 ZZZ $339.67

93455 C 00 00 00 00 ZZZ $391.78

93455 P 00 00 00 00 ZZZ $391.78

93456 C 00 00 00 00 ZZZ $435.23

93456 P 00 00 00 00 ZZZ $435.23

93457 C 00 00 00 00 ZZZ $487.21

93457 P 00 00 00 00 ZZZ $487.21

93458 C 00 00 00 00 ZZZ $414.09

93458 P 00 00 00 00 ZZZ $414.09

93459 C 00 00 00 00 ZZZ $466.54

93459 P 00 00 00 00 ZZZ $466.54

93460 C 00 00 00 00 ZZZ $519.74

93460 P 00 00 00 00 ZZZ $519.74

93461 C 00 00 00 00 ZZZ $573.24

93461 P 00 00 00 00 ZZZ $573.24

Page 431: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93462 1 00 00 00 00 ZZZ $264.26

93463 1 00 00 00 00 ZZZ $140.19

93464 C 00 00 00 00 ZZZ $309.96

93464 P 00 00 00 00 ZZZ $123.69

93464 T 00 00 00 00 ZZZ $186.27

93503 C 00 00 00 00 ZZZ $229.86

93503 P 00 00 00 00 ZZZ $218.00

93503 T 00 00 00 00 ZZZ $145.00

93505 C 00 00 00 00 ZZZ $350.14

93505 P 00 00 00 00 ZZZ $333.00

93505 T 00 00 00 00 ZZZ $222.00

93530 C 00 00 00 00 ZZZ $441.18

93530 P 00 00 00 00 ZZZ $441.18

93531 C 00 00 00 00 ZZZ $825.24

93531 P 00 00 00 00 ZZZ $825.24

93532 C 00 00 00 00 ZZZ $1,004.75

93532 P 00 00 00 00 ZZZ $1,004.75

93533 C 00 00 00 00 ZZZ $604.95

93533 P 00 00 00 00 ZZZ $604.95

93561 C 00 00 00 00 ZZZ $53.03

93561 P 00 00 00 00 ZZZ $32.04

93561 T 00 00 00 00 ZZZ $21.00

93562 C 00 00 00 00 ZZZ $17.48

93562 P 00 00 00 00 ZZZ $10.88

93562 T 00 00 00 00 ZZZ $6.60

93563 1 00 00 00 00 ZZZ $73.80

93564 1 00 00 00 00 ZZZ $75.15

93565 1 00 00 00 00 ZZZ $57.23

93566 1 00 00 00 00 ZZZ $206.26

93567 1 00 00 00 00 ZZZ $172.47

93568 1 00 00 00 00 ZZZ $187.48

93571 1 00 00 00 00 ZZZ $149.20

93572 1 00 00 00 00 ZZZ $118.89

93580 C 00 00 00 00 ZZZ $1,234.60

93580 P 00 00 00 00 ZZZ $993.08

93581 C 00 00 00 00 ZZZ $1,650.95

93581 P 00 00 00 00 ZZZ $1,327.98

93582 1 00 00 00 00 ZZZ $910.59

93583 1 00 00 00 00 ZZZ $0.00

93590 C 00 00 00 00 ZZZ $1,086.97

Page 432: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93590 P 00 00 00 00 ZZZ $1,086.97

93591 C 00 00 00 00 ZZZ $900.33

93591 P 00 00 00 00 ZZZ $900.33

93592 C 00 00 00 00 ZZZ $900.33

93592 P 00 00 00 00 ZZZ $400.93

93600 C 00 00 00 00 ZZZ $182.60

93600 P 00 00 00 00 ZZZ $110.00

93600 T 00 00 00 00 ZZZ $72.60

93602 C 00 00 00 00 ZZZ $151.80

93602 P 00 00 00 00 ZZZ $95.85

93602 T 00 00 00 00 ZZZ $55.95

93603 C 00 00 00 00 ZZZ $254.10

93603 P 00 00 00 00 ZZZ $161.10

93603 T 00 00 00 00 ZZZ $93.00

93609 C 00 00 00 00 ZZZ $458.96

93609 P 00 00 00 00 ZZZ $323.29

93609 T 00 00 00 00 ZZZ $135.67

93610 C 00 00 00 00 ZZZ $254.10

93610 P 00 00 00 00 ZZZ $161.10

93610 T 00 00 00 00 ZZZ $93.00

93612 C 00 00 00 00 ZZZ $254.10

93612 P 00 00 00 00 ZZZ $161.10

93612 T 00 00 00 00 ZZZ $93.00

93613 C 00 00 00 00 ZZZ $708.87

93613 P 00 00 00 00 ZZZ $425.33

93613 T 00 00 00 00 ZZZ $283.54

93615 C 00 00 00 00 ZZZ $231.00

93615 P 00 00 00 00 ZZZ $139.00

93615 T 00 00 00 00 ZZZ $93.00

93616 C 00 00 00 00 ZZZ $231.00

93616 P 00 00 00 00 ZZZ $138.00

93616 T 00 00 00 00 ZZZ $93.00

93618 C 00 00 00 00 ZZZ $316.81

93618 P 00 00 00 00 ZZZ $190.79

93618 T 00 00 00 00 ZZZ $126.02

93619 C 00 00 00 00 ZZZ $1,012.67

93619 P 00 00 00 00 ZZZ $627.56

93619 T 00 00 00 00 ZZZ $385.11

93620 C 00 00 00 00 ZZZ $1,438.35

93620 P 00 00 00 00 ZZZ $910.15

Page 433: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93620 T 00 00 00 00 ZZZ $528.20

93621 C 00 00 00 00 ZZZ $1,287.00

93621 P 00 00 00 00 ZZZ $775.42

93621 T 00 00 00 00 ZZZ $511.58

93622 C 00 00 00 00 ZZZ $1,287.00

93622 P 00 00 00 00 ZZZ $775.42

93622 T 00 00 00 00 ZZZ $511.58

93623 C 00 00 00 00 ZZZ $254.00

93623 P 00 00 00 00 ZZZ $153.00

93623 T 00 00 00 00 ZZZ $102.00

93624 C 00 00 00 00 ZZZ $279.40

93624 P 00 00 00 00 ZZZ $177.40

93624 T 00 00 00 00 ZZZ $102.00

93631 C 00 00 00 00 ZZZ $653.40

93631 P 00 00 00 00 ZZZ $391.60

93631 T 00 00 00 00 ZZZ $261.80

93640 C 00 00 00 00 ZZZ $371.10

93640 P 00 00 00 00 ZZZ $223.50

93640 T 00 00 00 00 ZZZ $147.60

93641 C 00 00 00 00 ZZZ $487.28

93641 P 00 00 00 00 ZZZ $291.97

93641 T 00 00 00 00 ZZZ $195.31

93642 C 00 00 00 00 ZZZ $436.14

93642 P 00 00 00 00 ZZZ $261.68

93642 T 00 00 00 00 ZZZ $174.46

93644 C 00 00 00 00 ZZZ $274.53

93644 P 00 00 00 00 ZZZ $183.32

93644 T 00 00 00 00 ZZZ $91.21

93650 C 00 00 00 00 ZZZ $797.60

93650 P 00 00 00 00 ZZZ $319.04

93650 T 00 00 00 00 ZZZ $478.56

93653 C 00 00 00 00 ZZZ $994.44

93653 P 00 00 00 00 ZZZ $596.66

93653 T 00 00 00 00 ZZZ $397.78

93654 C 00 00 00 00 ZZZ $1,326.73

93654 P 00 00 00 00 ZZZ $796.04

93654 T 00 00 00 00 ZZZ $530.69

93655 C 00 00 00 00 ZZZ $497.22

93655 P 00 00 00 00 ZZZ $298.33

93655 T 00 00 00 00 ZZZ $198.89

Page 434: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93656 C 00 00 00 00 ZZZ $1,327.38

93656 P 00 00 00 00 ZZZ $796.43

93656 T 00 00 00 00 ZZZ $530.95

93657 C 00 00 00 00 ZZZ $408.28

93657 P 00 00 00 00 ZZZ $244.97

93657 T 00 00 00 00 ZZZ $163.31

93660 C 00 00 00 00 ZZZ $198.85

93660 P 00 00 00 00 ZZZ $129.13

93660 T 00 00 00 00 ZZZ $69.72

93662 C 00 00 00 00 ZZZ $337.87

93662 P 00 00 00 00 ZZZ $170.38

93662 T 00 00 00 00 ZZZ $167.49

93702 C 00 00 00 00 ZZZ $121.80

93724 C 00 00 00 00 ZZZ $490.50

93724 P 00 00 00 00 ZZZ $315.17

93724 T 00 00 00 00 ZZZ $175.33

93740 C 00 00 00 00 ZZZ $58.00

93740 P 00 00 00 00 ZZZ $34.00

93740 T 00 00 00 00 ZZZ $23.00

93745 C 00 00 00 00 ZZZ $0.00

93745 P 00 00 00 00 ZZZ $0.00

93745 T 00 00 00 00 ZZZ $0.00

93750 C 00 00 00 00 ZZZ $68.76

93750 T 00 00 00 00 ZZZ $68.76

93770 C 00 00 00 00 ZZZ $8.65

93770 P 00 00 00 00 ZZZ $8.65

93784 C 00 00 00 00 ZZZ $91.38

93786 C 00 00 00 00 ZZZ $42.90

93786 T 00 00 00 00 ZZZ $42.90

93788 C 00 00 00 00 ZZZ $24.25

93788 T 00 00 00 00 ZZZ $24.25

93790 C 00 00 00 00 ZZZ $24.25

93790 P 00 00 00 00 ZZZ $24.25

93799 C 00 00 00 00 ZZZ $0.00

93799 P 00 00 00 00 ZZZ $0.00

93799 T 00 00 00 00 ZZZ $0.00

93880 C 00 00 00 00 ZZZ $189.20

93880 P 00 00 00 00 ZZZ $112.00

93880 T 00 00 00 00 ZZZ $77.20

93882 C 00 00 00 00 ZZZ $141.90

Page 435: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93882 P 00 00 00 00 ZZZ $86.00

93882 T 00 00 00 00 ZZZ $55.90

93886 C 00 00 00 00 ZZZ $187.00

93886 P 00 00 00 00 ZZZ $99.00

93886 T 00 00 00 00 ZZZ $88.00

93888 C 00 00 00 00 ZZZ $187.00

93888 P 00 00 00 00 ZZZ $99.00

93888 T 00 00 00 00 ZZZ $88.00

93890 C 00 00 00 00 ZZZ $296.00

93890 P 00 00 00 00 ZZZ $68.07

93890 T 00 00 00 00 ZZZ $227.99

93892 C 00 00 00 00 ZZZ $315.18

93892 P 00 00 00 00 ZZZ $77.86

93892 T 00 00 00 00 ZZZ $237.32

93893 C 00 00 00 00 ZZZ $309.12

93893 P 00 00 00 00 ZZZ $77.86

93893 T 00 00 00 00 ZZZ $231.26

93895 C 00 00 00 00 ZZZ $0.00

93895 P 00 00 00 00 ZZZ $0.00

93895 T 00 00 00 00 ZZZ $0.00

93922 C 00 00 00 00 ZZZ $102.57

93922 P 00 00 00 00 ZZZ $61.18

93922 T 00 00 00 00 ZZZ $41.40

93923 C 00 00 00 00 ZZZ $176.00

93923 P 00 00 00 00 ZZZ $103.00

93923 T 00 00 00 00 ZZZ $73.00

93924 C 00 00 00 00 ZZZ $153.46

93924 P 00 00 00 00 ZZZ $83.71

93924 T 00 00 00 00 ZZZ $69.75

93925 C 00 00 00 00 ZZZ $189.20

93925 P 00 00 00 00 ZZZ $102.00

93925 T 00 00 00 00 ZZZ $87.20

93926 C 00 00 00 00 ZZZ $134.20

93926 P 00 00 00 00 ZZZ $83.00

93926 T 00 00 00 00 ZZZ $51.20

93930 C 00 00 00 00 ZZZ $135.06

93930 P 00 00 00 00 ZZZ $51.00

93930 T 00 00 00 00 ZZZ $84.06

93931 C 00 00 00 00 ZZZ $91.30

93931 P 00 00 00 00 ZZZ $54.00

Page 436: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

93931 T 00 00 00 00 ZZZ $37.30

93970 C 00 00 00 00 ZZZ $147.13

93970 P 00 00 00 00 ZZZ $79.00

93970 T 00 00 00 00 ZZZ $68.13

93971 C 00 00 00 00 ZZZ $97.82

93971 P 00 00 00 00 ZZZ $54.00

93971 T 00 00 00 00 ZZZ $43.90

93975 C 00 00 00 00 ZZZ $242.00

93975 P 00 00 00 00 ZZZ $129.00

93975 T 00 00 00 00 ZZZ $113.00

93976 C 00 00 00 00 ZZZ $141.90

93976 P 00 00 00 00 ZZZ $86.00

93976 T 00 00 00 00 ZZZ $55.90

93978 C 00 00 00 00 ZZZ $195.80

93978 P 00 00 00 00 ZZZ $109.00

93978 T 00 00 00 00 ZZZ $86.80

93979 C 00 00 00 00 ZZZ $134.20

93979 P 00 00 00 00 ZZZ $83.00

93979 T 00 00 00 00 ZZZ $51.20

93980 C 00 00 00 00 ZZZ $152.90

93980 P 00 00 00 00 ZZZ $92.28

93980 T 00 00 00 00 ZZZ $60.62

93981 C 00 00 00 00 ZZZ $113.30

93981 P 00 00 00 00 ZZZ $58.00

93981 T 00 00 00 00 ZZZ $55.30

93990 C 00 00 00 00 ZZZ $129.54

93990 P 00 00 00 00 ZZZ $19.11

93990 T 00 00 00 00 ZZZ $110.43

93998 C 00 00 00 00 ZZZ $0.00

93998 P 00 00 00 00 ZZZ $0.00

93998 T 00 00 00 00 ZZZ $0.00

94010 C 00 00 00 00 ZZZ $37.77

94010 P 00 00 00 00 ZZZ $36.00

94010 T 00 00 00 00 ZZZ $24.00

94011 C 00 00 00 00 ZZZ $126.62

94011 T 00 00 00 00 ZZZ $126.62

94012 C 00 00 00 00 ZZZ $194.91

94012 T 00 00 00 00 ZZZ $194.91

94013 C 00 00 00 00 ZZZ $41.26

94013 T 00 00 00 00 ZZZ $41.26

Page 437: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

94014 C 00 00 00 00 ZZZ $48.27

94014 P 00 00 00 00 ZZZ $19.21

94014 T 00 00 00 00 ZZZ $29.06

94015 T 00 00 00 00 ZZZ $28.46

94016 C 00 00 00 00 ZZZ $30.53

94016 P 00 00 00 00 ZZZ $30.53

94060 C 00 00 00 00 ZZZ $63.80

94060 P 00 00 00 00 ZZZ $58.00

94060 T 00 00 00 00 ZZZ $39.00

94070 C 00 00 00 00 ZZZ $83.60

94070 P 00 00 00 00 ZZZ $76.00

94070 T 00 00 00 00 ZZZ $51.00

94150 C 00 00 00 00 ZZZ $11.00

94150 P 00 00 00 00 ZZZ $10.00

94150 T 00 00 00 00 ZZZ $7.00

94200 C 00 00 00 00 ZZZ $24.00

94200 P 00 00 00 00 ZZZ $24.00

94200 T 00 00 00 00 ZZZ $16.00

94250 C 00 00 00 00 ZZZ $12.10

94250 P 00 00 00 00 ZZZ $11.00

94250 T 00 00 00 00 ZZZ $7.00

94375 C 00 00 00 00 ZZZ $26.23

94375 P 00 00 00 00 ZZZ $22.00

94375 T 00 00 00 00 ZZZ $13.00

94400 C 00 00 00 00 ZZZ $29.37

94400 P 00 00 00 00 ZZZ $17.62

94400 T 00 00 00 00 ZZZ $11.75

94450 C 00 00 00 00 ZZZ $27.01

94450 P 00 00 00 00 ZZZ $16.21

94450 T 00 00 00 00 ZZZ $10.80

94610 1 00 00 00 00 ZZZ $83.94

94620 C 00 00 00 00 ZZZ $108.90

94620 P 00 00 00 00 ZZZ $99.00

94620 T 00 00 00 00 ZZZ $66.00

94621 C 00 00 00 00 ZZZ $113.04

94621 P 00 00 00 00 ZZZ $67.83

94621 T 00 00 00 00 ZZZ $45.21

94640 1 00 00 00 00 ZZZ $14.16

94642 1 00 00 00 00 ZZZ $5.60

94644 1 00 00 00 00 ZZZ $46.65

Page 438: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

94645 1 00 00 00 00 ZZZ $17.07

94664 1 00 00 00 00 ZZZ $13.90

94680 C 00 00 00 00 ZZZ $48.49

94680 P 00 00 00 00 ZZZ $45.00

94680 T 00 00 00 00 ZZZ $30.00

94681 C 00 00 00 00 ZZZ $92.00

94681 P 00 00 00 00 ZZZ $92.00

94681 T 00 00 00 00 ZZZ $61.00

94690 C 00 00 00 00 ZZZ $18.09

94690 P 00 00 00 00 ZZZ $15.00

94690 T 00 00 00 00 ZZZ $10.00

94726 C 00 00 00 00 ZZZ $60.17

94726 P 00 00 00 00 ZZZ $15.95

94726 T 00 00 00 00 ZZZ $44.22

94727 C 00 00 00 00 ZZZ $47.85

94727 P 00 00 00 00 ZZZ $15.95

94727 T 00 00 00 00 ZZZ $31.89

94728 C 00 00 00 00 ZZZ $47.85

94728 P 00 00 00 00 ZZZ $15.95

94728 T 00 00 00 00 ZZZ $31.89

94729 C 00 00 00 00 ZZZ $58.80

94729 P 00 00 00 00 ZZZ $10.60

94729 T 00 00 00 00 ZZZ $48.20

94750 C 00 00 00 00 ZZZ $27.01

94750 P 00 00 00 00 ZZZ $16.21

94750 T 00 00 00 00 ZZZ $10.80

94760 C 00 00 00 00 ZZZ $14.30

94760 P 00 00 00 00 ZZZ $4.40

94760 T 00 00 00 00 ZZZ $9.90

94761 C 00 00 00 00 ZZZ $30.80

94761 T 00 00 00 00 ZZZ $30.80

94770 C 00 00 00 00 ZZZ $29.00

94770 P 00 00 00 00 ZZZ $29.00

94770 T 00 00 00 00 ZZZ $19.00

94772 C 00 00 00 00 ZZZ $94.60

94772 P 00 00 00 00 ZZZ $52.00

94772 T 00 00 00 00 ZZZ $42.60

94799 1 00 00 00 00 ZZZ $0.00

95004 1 00 00 00 00 ZZZ $2.88

95024 1 00 00 00 00 ZZZ $4.19

Page 439: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95027 1 00 00 00 00 ZZZ $4.19

95028 1 00 00 00 00 ZZZ $6.56

95044 1 00 00 00 00 ZZZ $5.77

95052 1 00 00 00 00 ZZZ $7.08

95056 1 00 00 00 00 ZZZ $4.98

95060 1 00 00 00 00 ZZZ $11.00

95065 1 00 00 00 00 ZZZ $5.77

95070 C 00 00 00 00 ZZZ $83.60

95070 T 00 00 00 00 ZZZ $83.60

95071 C 00 00 00 00 ZZZ $78.68

95071 P 00 00 00 00 ZZZ $47.21

95071 T 00 00 00 00 ZZZ $31.47

95076 1 00 00 00 00 ZZZ $129.32

95079 1 00 00 00 00 ZZZ $96.70

95115 1 00 00 00 00 ZZZ $11.02

95117 1 00 00 00 00 ZZZ $14.16

95120 1 00 00 00 00 ZZZ $6.00

95125 1 00 00 00 00 ZZZ $8.00

95130 1 00 00 00 00 ZZZ $14.30

95131 1 00 00 00 00 ZZZ $28.60

95132 1 00 00 00 00 ZZZ $44.00

95133 1 00 00 00 00 ZZZ $50.60

95134 1 00 00 00 00 ZZZ $0.00

95144 1 00 00 00 00 ZZZ $6.82

95145 1 00 00 00 00 ZZZ $12.85

95146 1 00 00 00 00 ZZZ $18.62

95147 1 00 00 00 00 ZZZ $24.92

95148 1 00 00 00 00 ZZZ $25.18

95149 1 00 00 00 00 ZZZ $25.97

95165 1 00 00 00 00 ZZZ $6.56

95170 1 00 00 00 00 ZZZ $9.97

95180 1 00 00 00 00 ZZZ $76.58

95199 1 00 00 00 00 ZZZ $0.00

95782 C 00 00 00 00 ZZZ $833.69

95782 P 00 00 00 00 ZZZ $158.30

95782 T 00 00 00 00 ZZZ $675.41

95783 C 00 00 00 00 ZZZ $882.49

95783 P 00 00 00 00 ZZZ $172.21

95783 T 00 00 00 00 ZZZ $709.94

95805 C 00 00 00 00 ZZZ $278.30

Page 440: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95805 P 00 00 00 00 ZZZ $152.00

95805 T 00 00 00 00 ZZZ $152.00

95807 C 00 00 00 00 ZZZ $259.64

95807 P 00 00 00 00 ZZZ $138.47

95807 T 00 00 00 00 ZZZ $121.17

95808 C 00 00 00 00 ZZZ $334.40

95808 P 00 00 00 00 ZZZ $200.20

95808 T 00 00 00 00 ZZZ $134.20

95810 C 00 00 00 00 ZZZ $438.24

95810 P 00 00 00 00 ZZZ $258.76

95810 T 00 00 00 00 ZZZ $179.48

95811 C 00 00 00 00 ZZZ $564.76

95811 P 00 00 00 00 ZZZ $308.05

95811 T 00 00 00 00 ZZZ $256.71

95812 C 00 00 00 00 ZZZ $153.87

95812 P 00 00 00 00 ZZZ $66.42

95812 T 00 00 00 00 ZZZ $87.45

95813 C 00 00 00 00 ZZZ $213.28

95813 P 00 00 00 00 ZZZ $99.42

95813 T 00 00 00 00 ZZZ $113.86

95816 C 00 00 00 00 ZZZ $94.94

95816 P 00 00 00 00 ZZZ $56.76

95816 T 00 00 00 00 ZZZ $38.18

95819 C 00 00 00 00 ZZZ $105.60

95819 P 00 00 00 00 ZZZ $96.00

95819 T 00 00 00 00 ZZZ $64.00

95822 C 00 00 00 00 ZZZ $116.60

95822 P 00 00 00 00 ZZZ $106.00

95822 T 00 00 00 00 ZZZ $71.00

95824 C 00 00 00 00 ZZZ $70.40

95824 P 00 00 00 00 ZZZ $42.24

95824 T 00 00 00 00 ZZZ $28.16

95827 C 00 00 00 00 ZZZ $111.46

95827 P 00 00 00 00 ZZZ $67.08

95827 T 00 00 00 00 ZZZ $44.38

95829 C 00 00 00 00 ZZZ $264.88

95829 P 00 00 00 00 ZZZ $238.00

95829 T 00 00 00 00 ZZZ $159.00

95830 C 00 00 00 00 ZZZ $105.19

95830 P 00 00 00 00 ZZZ $105.19

Page 441: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95831 1 00 00 00 00 ZZZ $24.20

95832 1 00 00 00 00 ZZZ $30.00

95833 1 00 00 00 00 ZZZ $55.37

95851 1 00 00 00 00 ZZZ $24.25

95852 1 00 00 00 00 ZZZ $22.15

95857 C 00 00 00 00 ZZZ $49.50

95857 P 00 00 00 00 ZZZ $45.00

95857 T 00 00 00 00 ZZZ $30.00

95860 C 00 00 00 00 ZZZ $72.60

95860 P 00 00 00 00 ZZZ $62.70

95860 T 00 00 00 00 ZZZ $9.90

95861 C 00 00 00 00 ZZZ $101.20

95861 P 00 00 00 00 ZZZ $93.58

95861 T 00 00 00 00 ZZZ $7.62

95863 C 00 00 00 00 ZZZ $141.90

95863 P 00 00 00 00 ZZZ $123.20

95863 T 00 00 00 00 ZZZ $18.70

95864 C 00 00 00 00 ZZZ $170.50

95864 P 00 00 00 00 ZZZ $148.50

95864 T 00 00 00 00 ZZZ $22.00

95865 C 00 00 00 00 ZZZ $148.44

95865 P 00 00 00 00 ZZZ $114.77

95865 T 00 00 00 00 ZZZ $33.67

95866 C 00 00 00 00 ZZZ $100.06

95866 P 00 00 00 00 ZZZ $89.16

95866 T 00 00 00 00 ZZZ $10.91

95867 C 00 00 00 00 ZZZ $72.60

95867 P 00 00 00 00 ZZZ $61.08

95867 T 00 00 00 00 ZZZ $11.52

95868 C 00 00 00 00 ZZZ $101.20

95868 P 00 00 00 00 ZZZ $93.58

95868 T 00 00 00 00 ZZZ $7.62

95869 C 00 00 00 00 ZZZ $44.00

95869 P 00 00 00 00 ZZZ $39.00

95869 T 00 00 00 00 ZZZ $5.00

95870 C 00 00 00 00 ZZZ $39.19

95870 P 00 00 00 00 ZZZ $29.84

95870 T 00 00 00 00 ZZZ $9.35

95872 C 00 00 00 00 ZZZ $77.00

95872 P 00 00 00 00 ZZZ $46.30

Page 442: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95872 T 00 00 00 00 ZZZ $30.30

95873 C 00 00 00 00 ZZZ $36.52

95873 P 00 00 00 00 ZZZ $26.08

95873 T 00 00 00 00 ZZZ $10.43

95874 C 00 00 00 00 ZZZ $36.99

95874 P 00 00 00 00 ZZZ $26.56

95874 T 00 00 00 00 ZZZ $10.43

95875 C 00 00 00 00 ZZZ $102.30

95875 P 00 00 00 00 ZZZ $65.30

95875 T 00 00 00 00 ZZZ $37.00

95885 C 00 00 00 00 ZZZ $63.35

95885 P 00 00 00 00 ZZZ $22.76

95885 T 00 00 00 00 ZZZ $40.59

95886 C 00 00 00 00 ZZZ $103.42

95886 P 00 00 00 00 ZZZ $60.66

95886 T 00 00 00 00 ZZZ $42.76

95887 C 00 00 00 00 ZZZ $91.15

95887 P 00 00 00 00 ZZZ $47.66

95887 T 00 00 00 00 ZZZ $43.49

95905 C 00 00 00 00 ZZZ $100.06

95905 P 00 00 00 00 ZZZ $3.79

95905 T 00 00 00 00 ZZZ $96.27

95907 C 00 00 00 00 ZZZ $101.39

95907 P 00 00 00 00 ZZZ $63.21

95907 T 00 00 00 00 ZZZ $38.18

95908 C 00 00 00 00 ZZZ $125.37

95908 P 00 00 00 00 ZZZ $79.32

95908 T 00 00 00 00 ZZZ $46.04

95909 C 00 00 00 00 ZZZ $150.26

95909 P 00 00 00 00 ZZZ $94.81

95909 T 00 00 00 00 ZZZ $55.46

95910 C 00 00 00 00 ZZZ $198.24

95910 P 00 00 00 00 ZZZ $126.73

95910 T 00 00 00 00 ZZZ $71.51

95911 C 00 00 00 00 ZZZ $241.06

95911 P 00 00 00 00 ZZZ $158.02

95911 T 00 00 00 00 ZZZ $83.05

95912 C 00 00 00 00 ZZZ $283.90

95912 P 00 00 00 00 ZZZ $189.94

95912 T 00 00 00 00 ZZZ $93.96

Page 443: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95913 C 00 00 00 00 ZZZ $330.18

95913 P 00 00 00 00 ZZZ $224.98

95913 T 00 00 00 00 ZZZ $105.19

95921 C 00 00 00 00 ZZZ $48.68

95921 P 00 00 00 00 ZZZ $37.13

95921 T 00 00 00 00 ZZZ $11.55

95922 C 00 00 00 00 ZZZ $51.15

95922 P 00 00 00 00 ZZZ $39.60

95922 T 00 00 00 00 ZZZ $11.55

95923 C 00 00 00 00 ZZZ $138.00

95923 P 00 00 00 00 ZZZ $63.08

95923 T 00 00 00 00 ZZZ $74.93

95924 C 00 00 00 00 ZZZ $160.87

95924 P 00 00 00 00 ZZZ $106.70

95924 T 00 00 00 00 ZZZ $54.18

95925 C 00 00 00 00 ZZZ $116.56

95925 P 00 00 00 00 ZZZ $59.45

95925 T 00 00 00 00 ZZZ $57.00

95926 C 00 00 00 00 ZZZ $80.70

95926 P 00 00 00 00 ZZZ $73.36

95926 T 00 00 00 00 ZZZ $31.85

95927 C 00 00 00 00 ZZZ $80.70

95927 P 00 00 00 00 ZZZ $45.66

95927 T 00 00 00 00 ZZZ $35.04

95928 C 00 00 00 00 ZZZ $214.94

95928 P 00 00 00 00 ZZZ $103.04

95928 T 00 00 00 00 ZZZ $111.90

95929 C 00 00 00 00 ZZZ $223.79

95929 P 00 00 00 00 ZZZ $103.04

95929 T 00 00 00 00 ZZZ $120.76

95930 C 00 00 00 00 ZZZ $45.66

95930 P 00 00 00 00 ZZZ $34.97

95930 T 00 00 00 00 ZZZ $10.69

95933 C 00 00 00 00 ZZZ $48.26

95933 P 00 00 00 00 ZZZ $29.28

95933 T 00 00 00 00 ZZZ $18.98

95937 C 00 00 00 00 ZZZ $66.21

95937 P 00 00 00 00 ZZZ $52.97

95937 T 00 00 00 00 ZZZ $13.24

95938 C 00 00 00 00 ZZZ $324.54

Page 444: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95938 P 00 00 00 00 ZZZ $56.01

95938 T 00 00 00 00 ZZZ $268.54

95939 C 00 00 00 00 ZZZ $518.03

95939 P 00 00 00 00 ZZZ $147.30

95939 T 00 00 00 00 ZZZ $370.74

95940 C 00 00 00 00 ZZZ $38.50

95940 P 00 00 00 00 ZZZ $23.10

95943 C 00 00 00 00 ZZZ $84.85

95943 P 00 00 00 00 ZZZ $45.35

95943 T 00 00 00 00 ZZZ $39.51

95950 C 00 00 00 00 ZZZ $330.00

95950 P 00 00 00 00 ZZZ $86.00

95950 T 00 00 00 00 ZZZ $244.00

95951 C 00 00 00 00 ZZZ $479.15

95951 P 00 00 00 00 ZZZ $287.49

95951 T 00 00 00 00 ZZZ $191.66

95953 C 00 00 00 00 ZZZ $330.00

95953 P 00 00 00 00 ZZZ $63.80

95953 T 00 00 00 00 ZZZ $266.20

95954 C 00 00 00 00 ZZZ $232.67

95954 P 00 00 00 00 ZZZ $167.90

95954 T 00 00 00 00 ZZZ $64.77

95955 C 00 00 00 00 ZZZ $162.54

95955 P 00 00 00 00 ZZZ $74.25

95956 C 00 00 00 00 ZZZ $519.27

95956 P 00 00 00 00 ZZZ $100.75

95956 T 00 00 00 00 ZZZ $418.52

95957 C 00 00 00 00 ZZZ $121.95

95957 P 00 00 00 00 ZZZ $73.52

95957 T 00 00 00 00 ZZZ $48.43

95958 C 00 00 00 00 ZZZ $398.51

95958 P 00 00 00 00 ZZZ $324.26

95958 T 00 00 00 00 ZZZ $74.25

95961 C 00 00 00 00 ZZZ $274.62

95961 P 00 00 00 00 ZZZ $209.81

95961 T 00 00 00 00 ZZZ $64.81

95962 C 00 00 00 00 ZZZ $288.14

95962 P 00 00 00 00 ZZZ $223.33

95962 T 00 00 00 00 ZZZ $64.81

95965 C 00 00 00 00 ZZZ $927.40

Page 445: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95965 P 00 00 00 00 ZZZ $556.40

95965 T 00 00 00 00 ZZZ $371.00

95966 C 00 00 00 00 ZZZ $465.40

95966 P 00 00 00 00 ZZZ $279.20

95966 T 00 00 00 00 ZZZ $186.20

95967 C 00 00 00 00 ZZZ $0.00

95967 P 00 00 00 00 ZZZ $232.18

95967 T 00 00 00 00 ZZZ $0.00

95970 C 00 00 00 00 ZZZ $27.23

95970 P 00 00 00 00 ZZZ $16.34

95970 T 00 00 00 00 ZZZ $10.89

95971 C 00 00 00 00 ZZZ $61.37

95971 P 00 00 00 00 ZZZ $36.82

95971 T 00 00 00 00 ZZZ $24.55

95972 C 00 00 00 00 ZZZ $82.09

95972 P 00 00 00 00 ZZZ $49.26

95972 T 00 00 00 00 ZZZ $37.11

95974 C 00 00 00 00 ZZZ $167.08

95974 P 00 00 00 00 ZZZ $100.24

95974 T 00 00 00 00 ZZZ $66.84

95975 C 00 00 00 00 ZZZ $99.42

95975 P 00 00 00 00 ZZZ $59.65

95975 T 00 00 00 00 ZZZ $39.77

95978 C 00 00 00 00 ZZZ $261.56

95978 P 00 00 00 00 ZZZ $156.94

95978 T 00 00 00 00 ZZZ $104.62

95979 C 00 00 00 00 ZZZ $120.76

95979 P 00 00 00 00 ZZZ $72.46

95979 T 00 00 00 00 ZZZ $48.30

95980 C 00 00 00 00 ZZZ $49.34

95980 P 00 00 00 00 ZZZ $29.60

95980 T 00 00 00 00 ZZZ $19.73

95981 C 00 00 00 00 ZZZ $29.26

95981 P 00 00 00 00 ZZZ $17.55

95981 T 00 00 00 00 ZZZ $11.70

95982 C 00 00 00 00 ZZZ $41.91

95982 P 00 00 00 00 ZZZ $25.15

95982 T 00 00 00 00 ZZZ $16.76

95990 1 00 00 00 00 ZZZ $63.53

95991 1 00 00 00 00 ZZZ $93.24

Page 446: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

95992 1 00 00 00 00 ZZZ $53.59

95999 1 00 00 00 00 ZZZ $0.00

96105 1 00 00 00 00 ZZZ $69.72

96111 1 00 00 00 00 ZZZ $69.72

96365 1 00 00 00 00 ZZZ $90.58

96366 1 00 00 00 00 ZZZ $28.93

96367 1 00 00 00 00 ZZZ $45.53

96368 1 00 00 00 00 ZZZ $27.03

96369 1 00 00 00 00 ZZZ $196.81

96370 1 00 00 00 00 ZZZ $20.87

96371 1 00 00 00 00 ZZZ $95.32

96374 1 00 00 00 00 ZZZ $71.61

96375 1 00 00 00 00 ZZZ $31.30

96377 1 00 00 00 00 ZZZ $0.00

96379 1 00 00 00 00 ZZZ $0.00

96401 1 00 00 00 00 ZZZ $82.99

96402 1 00 00 00 00 ZZZ $44.58

96405 1 00 00 00 00 ZZZ $41.96

96406 1 00 00 00 00 ZZZ $57.70

96409 1 00 00 00 00 ZZZ $153.18

96411 1 00 00 00 00 ZZZ $88.68

96413 1 00 00 00 00 ZZZ $216.25

96415 1 00 00 00 00 ZZZ $48.85

96416 1 00 00 00 00 ZZZ $232.38

96417 1 00 00 00 00 ZZZ $105.75

96420 1 00 00 00 00 ZZZ $73.00

96422 1 00 00 00 00 ZZZ $76.93

96423 1 00 00 00 00 ZZZ $30.31

96425 1 00 00 00 00 ZZZ $89.17

96440 1 00 00 00 00 ZZZ $168.89

96446 1 00 00 00 00 ZZZ $152.93

96450 1 00 00 00 00 ZZZ $141.90

96521 1 00 00 00 00 ZZZ $191.59

96522 1 00 00 00 00 ZZZ $138.48

96523 1 00 00 00 00 ZZZ $35.10

96542 1 00 00 00 00 ZZZ $99.14

96549 1 00 00 00 00 ZZZ $0.00

96567 C 00 00 00 00 ZZZ $77.39

96567 P 00 00 00 00 ZZZ $0.00

96567 T 00 00 00 00 ZZZ $0.00

Page 447: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

96570 C 00 00 00 00 ZZZ $86.22

96570 P 00 00 00 00 ZZZ $49.37

96570 T 00 00 00 00 ZZZ $36.85

96571 C 00 00 00 00 ZZZ $47.03

96571 P 00 00 00 00 ZZZ $28.22

96571 T 00 00 00 00 ZZZ $18.81

96900 C 00 00 00 00 ZZZ $14.16

96902 1 00 00 00 00 ZZZ $29.70

96904 1 00 00 00 00 ZZZ $59.35

96910 C 00 00 00 00 ZZZ $16.26

96910 T 00 00 00 00 ZZZ $16.26

96912 C 00 00 00 00 ZZZ $18.62

96912 T 00 00 00 00 ZZZ $18.62

96913 1 00 00 00 00 ZZZ $68.07

96920 1 00 00 00 00 ZZZ $169.96

96921 1 00 00 00 00 ZZZ $174.09

96922 1 00 00 00 00 ZZZ $240.06

96999 1 00 00 00 00 ZZZ $0.00

97001 1 00 00 00 00 AR1 $49.44

97001 1 00 00 00 00 ZZZ $49.44

97110 1 00 00 00 00 AR1 $21.76

97110 1 00 00 00 00 ZZZ $21.76

97110 1 UB 00 00 00 AR1 $17.40

97110 1 UB 00 00 00 ZZZ $17.40

97150 1 00 00 00 00 AR1 $5.94

97150 1 00 00 00 00 ZZZ $5.94

97150 1 UB 00 00 00 AR1 $4.75

97150 1 UB 00 00 00 ZZZ $4.75

97597 1 00 00 00 00 ZZZ $60.14

97598 1 00 00 00 00 ZZZ $76.46

97602 1 00 00 00 00 ZZZ $67.65

97605 1 00 00 00 00 ZZZ $30.44

97606 1 00 00 00 00 ZZZ $49.24

97607 1 00 00 00 00 ZZZ $0.00

97608 1 00 00 00 00 ZZZ $0.00

97750 C 00 00 00 00 ZZZ $27.77

97750 P 00 00 00 00 ZZZ $11.11

97750 T 00 00 00 00 ZZZ $16.66

97762 1 00 00 00 00 ZZZ $27.54

97799 1 00 00 00 00 ZZZ $0.00

Page 448: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

98925 1 00 00 00 00 ZZZ $20.46

98926 1 00 00 00 00 ZZZ $28.59

98927 1 00 00 00 00 ZZZ $35.67

98928 1 00 00 00 00 ZZZ $41.18

98929 1 00 00 00 00 ZZZ $46.16

99070 1 00 00 00 00 AR1 $11.00

99070 1 U1 00 00 00 ZZZ $0.00

99070 6 EP 00 00 00 ZZZ $11.00

99082 1 00 00 00 00 ZZZ $0.00

99082 1 UB 00 00 00 ZZZ $0.88

99100 1 00 00 00 00 ZZZ $0.00

99116 1 00 00 00 00 ZZZ $0.00

99135 1 00 00 00 00 ZZZ $0.00

99140 1 00 00 00 00 ZZZ $0.00

99151 1 00 00 00 00 ZZZ $86.32

99152 1 00 00 00 00 ZZZ $57.12

99153 1 00 00 00 00 ZZZ $11.82

99155 1 00 00 00 00 ZZZ $88.47

99156 1 00 00 00 00 ZZZ $76.89

99157 1 00 00 00 00 ZZZ $58.16

99170 1 00 00 00 00 ZZZ $171.58

99172 1 00 00 00 00 ZZZ $22.10

99173 1 00 00 00 00 ZZZ $22.10

99173 6 EP 00 00 00 ZZZ $14.08

99173 D UB 00 00 00 ZZZ $13.20

99175 1 00 00 00 00 ZZZ $39.34

99183 1 00 00 00 00 ZZZ $101.20

99184 1 00 00 00 00 ZZZ $290.79

99188 1 00 00 00 00 ZZZ $19.95

99190 1 00 00 00 00 ZZZ $265.10

99191 1 00 00 00 00 ZZZ $119.00

99192 1 00 00 00 00 ZZZ $80.00

99195 1 00 00 00 00 ZZZ $16.50

99199 1 00 00 00 00 ZZZ $0.00

99201 1 00 00 00 00 ZZZ $29.70

99201 1 UB 00 00 00 ZZZ $137.50

99202 1 00 00 00 00 ZZZ $45.10

99203 1 00 00 00 00 ZZZ $64.90

99204 1 00 00 00 00 ZZZ $88.00

99205 1 00 00 00 00 ZZZ $137.50

Page 449: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

99205 1 U2 00 00 00 ZZZ $137.50

99211 1 00 00 00 00 ZZZ $14.30

99211 V U7 00 00 00 ZZZ $14.30

99212 1 00 00 00 00 ZZZ $27.50

99212 V U7 00 00 00 ZZZ $27.50

99213 1 00 00 00 00 ZZZ $36.30

99213 V U7 00 00 00 ZZZ $38.40

99214 1 00 00 00 00 ZZZ $70.05

99214 V U7 00 00 00 ZZZ $70.05

99215 1 00 00 00 00 ZZZ $106.00

99215 A FP UB 00 00 ZZZ $55.00

99215 V U7 00 00 00 ZZZ $106.00

99217 1 00 00 00 00 ZZZ $46.73

99218 1 00 00 00 00 ZZZ $52.80

99219 1 00 00 00 00 ZZZ $75.90

99220 1 00 00 00 00 ZZZ $116.60

99221 1 00 00 00 00 ZZZ $64.90

99221 1 U1 00 00 00 ZZZ $28.60

99221 1 UB 00 00 00 ZZZ $22.00

99222 1 00 00 00 00 ZZZ $92.40

99223 1 00 00 00 00 ZZZ $141.90

99231 1 00 00 00 00 ZZZ $34.50

99231 1 U1 00 00 00 ZZZ $28.60

99231 1 UB 00 00 00 ZZZ $22.00

99231 V U7 00 00 00 ZZZ $34.50

99232 1 00 00 00 00 ZZZ $50.60

99232 V U7 00 00 00 ZZZ $50.60

99233 1 00 00 00 00 ZZZ $68.20

99233 V U7 00 00 00 ZZZ $68.20

99234 1 00 00 00 00 ZZZ $68.71

99235 1 00 00 00 00 ZZZ $92.86

99236 1 00 00 00 00 ZZZ $116.08

99238 1 00 00 00 00 ZZZ $52.80

99241 1 00 00 00 00 ZZZ $53.50

99241 1 UA UB 00 00 ZZZ $42.36

99242 1 00 00 00 00 ZZZ $72.60

99242 1 UA UB 00 00 ZZZ $66.97

99243 1 00 00 00 00 ZZZ $101.20

99243 1 UA UB 00 00 ZZZ $86.90

99244 1 00 00 00 00 ZZZ $119.90

Page 450: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

99244 1 U1 00 00 00 ZZZ $122.09

99244 1 UA U1 00 00 ZZZ $122.09

99245 1 00 00 00 00 ZZZ $123.20

99245 1 UA U1 00 00 ZZZ $164.45

99251 1 00 00 00 00 ZZZ $53.00

99252 1 00 00 00 00 ZZZ $72.60

99253 1 00 00 00 00 ZZZ $98.56

99254 1 00 00 00 00 ZZZ $119.90

99255 1 00 00 00 00 ZZZ $123.20

99281 1 00 00 00 00 ZZZ $22.00

99281 V U7 00 00 00 ZZZ $22.00

99282 1 00 00 00 00 ZZZ $35.00

99282 V U7 00 00 00 ZZZ $35.00

99283 1 00 00 00 00 ZZZ $53.90

99283 V U7 00 00 00 ZZZ $53.90

99284 1 00 00 00 00 ZZZ $71.50

99284 V U7 00 00 00 ZZZ $71.50

99285 1 00 00 00 00 ZZZ $83.75

99285 V U7 00 00 00 ZZZ $83.75

99288 1 00 00 00 00 ZZZ $53.09

99291 1 00 00 00 00 ZZZ $167.20

99292 1 00 00 00 00 ZZZ $83.60

99304 1 00 00 00 00 ZZZ $62.64

99305 1 00 00 00 00 ZZZ $83.16

99306 1 00 00 00 00 ZZZ $102.60

99307 1 00 00 00 00 ZZZ $32.40

99308 1 00 00 00 00 ZZZ $53.64

99309 1 00 00 00 00 ZZZ $75.60

99310 1 00 00 00 00 ZZZ $94.68

99318 1 00 00 00 00 ZZZ $62.64

99341 1 00 00 00 00 ZZZ $56.32

99342 1 00 00 00 00 ZZZ $71.50

99343 1 00 00 00 00 ZZZ $93.50

99347 1 00 00 00 00 ZZZ $38.93

99348 1 00 00 00 00 ZZZ $56.99

99349 1 00 00 00 00 ZZZ $83.47

99354 1 00 00 00 00 ZZZ $106.00

99355 1 00 00 00 00 ZZZ $55.64

99356 1 00 00 00 00 ZZZ $106.00

99357 1 00 00 00 00 ZZZ $55.00

Page 451: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

99360 1 00 00 00 00 ZZZ $48.00

99381 1 00 00 00 00 AR1 $56.41

99381 1 00 00 00 00 ZZZ $56.41

99381 6 EP H9 00 00 ZZZ $56.41

99381 6 EP U1 00 00 ZZZ $56.41

99382 1 00 00 00 00 AR1 $56.41

99382 6 EP H9 00 00 ZZZ $56.41

99382 6 EP U1 00 00 ZZZ $56.41

99383 1 00 00 00 00 AR1 $56.41

99383 6 EP H9 00 00 ZZZ $56.41

99383 6 EP U1 00 00 ZZZ $56.41

99384 1 00 00 00 00 AR1 $56.41

99384 6 EP H9 00 00 ZZZ $56.41

99384 6 EP U1 00 00 ZZZ $56.41

99385 1 00 00 00 00 AR1 $56.41

99385 6 EP H9 00 00 ZZZ $56.41

99385 6 EP U1 00 00 ZZZ $56.41

99391 1 00 00 00 00 AR1 $56.41

99391 6 EP H9 00 00 ZZZ $56.41

99391 6 EP U2 00 00 ZZZ $56.41

99392 1 00 00 00 00 AR1 $56.41

99392 6 EP H9 00 00 ZZZ $56.41

99392 6 EP U2 00 00 ZZZ $56.41

99393 1 00 00 00 00 AR1 $56.41

99393 6 EP H9 00 00 ZZZ $56.41

99393 6 EP U2 00 00 ZZZ $56.41

99394 1 00 00 00 00 AR1 $56.41

99394 6 EP H9 00 00 ZZZ $56.41

99394 6 EP U2 00 00 ZZZ $56.41

99395 1 00 00 00 00 AR1 $56.41

99395 6 EP H9 00 00 ZZZ $56.41

99395 6 EP U2 00 00 ZZZ $56.41

99401 6 EP 00 00 00 ZZZ $11.29

99401 A FP UA U1 00 ZZZ $50.00

99401 A FP UA UB 00 ZZZ $27.50

99401 J FP UA U6 00 ZZZ $16.50

99401 J U6 00 00 00 ZZZ $15.00

99401 J UA U6 00 00 ZZZ $16.50

99402 1 U2 00 00 00 ZZZ $16.63

99402 1 UA 00 00 00 ZZZ $10.85

Page 452: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

99402 1 UA U1 00 00 ZZZ $14.40

99402 1 UA U2 00 00 ZZZ $16.63

99402 1 UA U3 00 00 ZZZ $20.90

99402 1 UA U4 00 00 ZZZ $19.20

99402 1 UA U5 00 00 ZZZ $38.40

99402 A FP 00 00 00 ZZZ $70.40

99402 A FP UA 00 00 ZZZ $70.00

99402 A FP UA U1 00 ZZZ $16.63

99402 A FP UA UB 00 ZZZ $70.40

99402 A UA U1 00 00 ZZZ $16.63

99402 J FP UA U6 00 ZZZ $41.80

99402 J U6 00 00 00 ZZZ $41.80

99406 1 SE 00 00 00 ZZZ $20.00

99407 1 SE 00 00 00 ZZZ $25.00

99415 1 00 00 00 00 ZZZ $9.18

99416 1 00 00 00 00 ZZZ $0.75

99460 1 UA 00 00 00 AR1 $108.16

99460 6 EP UA 00 00 ZZZ $108.16

99461 1 UA 00 00 00 AR1 $108.16

99461 6 EP UA 00 00 ZZZ $108.16

99463 1 UA 00 00 00 AR1 $108.16

99463 6 EP UA 00 00 ZZZ $108.16

99464 1 00 00 00 00 ZZZ $70.56

99465 1 00 00 00 00 ZZZ $144.72

99466 1 00 00 00 00 ZZZ $231.48

99467 1 00 00 00 00 ZZZ $115.56

99468 1 00 00 00 00 ZZZ $869.04

99469 1 00 00 00 00 ZZZ $378.72

99471 1 00 00 00 00 ZZZ $776.52

99472 1 00 00 00 00 ZZZ $383.40

99475 1 00 00 00 00 ZZZ $535.32

99476 1 00 00 00 00 ZZZ $317.88

99477 1 00 00 00 00 ZZZ $418.50

99478 1 00 00 00 00 ZZZ $137.88

99479 1 00 00 00 00 ZZZ $121.32

99480 1 00 00 00 00 ZZZ $116.64

A0434 1 UA 00 00 00 ZZZ $0.00

A4641 1 00 00 00 00 ZZZ $0.00

A4642 1 00 00 00 00 ZZZ $1,340.00

A4648 1 00 00 00 00 ZZZ $24.00

Page 453: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

A9500 1 00 00 00 00 ZZZ $70.66

A9502 1 00 00 00 00 ZZZ $160.00

A9503 1 00 00 00 00 ZZZ $64.00

A9504 1 00 00 00 00 ZZZ $400.00

A9505 1 00 00 00 00 ZZZ $16.88

A9507 1 00 00 00 00 ZZZ $1,647.18

A9508 1 00 00 00 00 ZZZ $14.30

A9510 1 00 00 00 00 ZZZ $48.00

A9512 1 00 00 00 00 ZZZ $0.20

A9515 1 00 00 00 00 ZZZ $5,700.00

A9516 1 00 00 00 00 ZZZ $20.45

A9517 1 00 00 00 00 ZZZ $28.60

A9520 1 00 00 00 00 ZZZ $258.12

A9520 G 00 00 00 00 ZZZ $258.12

A9521 1 00 00 00 00 ZZZ $347.61

A9524 1 00 00 00 00 ZZZ $44.96

A9526 1 00 00 00 00 ZZZ $0.00

A9527 1 00 00 00 00 ZZZ $0.00

A9528 1 00 00 00 00 ZZZ $12.04

A9529 1 00 00 00 00 ZZZ $7.32

A9530 1 00 00 00 00 ZZZ $7.32

A9531 1 00 00 00 00 ZZZ $7.32

A9532 1 00 00 00 00 ZZZ $2,102.40

A9536 1 00 00 00 00 ZZZ $640.00

A9537 1 00 00 00 00 ZZZ $38.20

A9538 1 00 00 00 00 ZZZ $20.80

A9539 1 00 00 00 00 ZZZ $13.68

A9540 1 00 00 00 00 ZZZ $18.14

A9541 1 00 00 00 00 ZZZ $52.88

A9542 1 00 00 00 00 ZZZ $1,808.00

A9543 1 00 00 00 00 ZZZ $0.00

A9547 1 00 00 00 00 ZZZ $409.28

A9548 1 00 00 00 00 ZZZ $191.04

A9550 1 00 00 00 00 ZZZ $0.00

A9551 1 00 00 00 00 ZZZ $88.87

A9552 1 00 00 00 00 ZZZ $0.00

A9553 1 00 00 00 00 ZZZ $451.20

A9554 1 00 00 00 00 ZZZ $414.00

A9555 1 00 00 00 00 ZZZ $0.00

A9556 1 00 00 00 00 ZZZ $14.68

Page 454: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

A9557 1 00 00 00 00 ZZZ $32.00

A9558 1 00 00 00 00 ZZZ $25.60

A9559 1 00 00 00 00 ZZZ $0.00

A9560 1 00 00 00 00 ZZZ $53.92

A9561 1 00 00 00 00 ZZZ $23.04

A9562 1 00 00 00 00 ZZZ $31.27

A9563 1 00 00 00 00 ZZZ $80.77

A9564 1 00 00 00 00 ZZZ $181.98

A9567 1 00 00 00 00 ZZZ $13.68

A9572 1 00 00 00 00 ZZZ $128.00

A9575 1 00 00 00 00 ZZZ $0.54

A9576 1 00 00 00 00 ZZZ $2.46

A9577 1 00 00 00 00 ZZZ $2.85

A9578 1 00 00 00 00 ZZZ $2.68

A9579 1 00 00 00 00 ZZZ $2.55

A9580 1 00 00 00 00 ZZZ $0.00

A9581 1 00 00 00 00 ZZZ $13.50

A9582 1 00 00 00 00 ZZZ $0.00

A9585 1 00 00 00 00 ZZZ $0.00

A9586 1 00 00 00 00 ZZZ $0.00

A9587 1 00 00 00 00 ZZZ $71.78

A9588 1 00 00 00 00 ZZZ $418.95

A9597 1 00 00 00 00 ZZZ $0.00

A9598 1 00 00 00 00 ZZZ $0.00

A9600 1 00 00 00 00 ZZZ $811.30

A9604 1 00 00 00 00 ZZZ $0.00

A9699 1 00 00 00 00 ZZZ $0.00

A9999 6 EP 00 00 00 ZZZ $0.00

C8931 C 00 00 00 00 ZZZ $0.00

C8931 P 00 00 00 00 ZZZ $0.00

C8931 T 00 00 00 00 ZZZ $0.00

C8932 C 00 00 00 00 ZZZ $0.00

C8932 P 00 00 00 00 ZZZ $0.00

C8932 T 00 00 00 00 ZZZ $0.00

C8934 C 00 00 00 00 ZZZ $0.00

C8934 P 00 00 00 00 ZZZ $0.00

C8934 T 00 00 00 00 ZZZ $0.00

C8935 C 00 00 00 00 ZZZ $0.00

C8935 P 00 00 00 00 ZZZ $0.00

C8935 T 00 00 00 00 ZZZ $0.00

Page 455: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

C8936 C 00 00 00 00 ZZZ $0.00

C8936 P 00 00 00 00 ZZZ $0.00

C8936 T 00 00 00 00 ZZZ $0.00

C9132 1 00 00 00 00 ZZZ $2.06

C9140 1 00 00 00 00 ZZZ $1.88

C9254 1 00 00 00 00 ZZZ $0.00

C9257 1 00 00 00 00 ZZZ $0.00

C9363 1 00 00 00 00 ZZZ $0.00

C9460 1 00 00 00 00 ZZZ $17.08

C9483 1 00 00 00 00 ZZZ $81.89

C9600 1 00 00 00 00 ZZZ $0.00

C9601 1 00 00 00 00 ZZZ $0.00

C9602 1 00 00 00 00 ZZZ $0.00

C9603 1 00 00 00 00 ZZZ $0.00

C9604 1 00 00 00 00 ZZZ $0.00

C9605 1 00 00 00 00 ZZZ $0.00

C9606 1 00 00 00 00 ZZZ $0.00

C9607 1 00 00 00 00 ZZZ $0.00

C9608 1 00 00 00 00 ZZZ $0.00

C9733 C 00 00 00 00 ZZZ $0.00

C9733 P 00 00 00 00 ZZZ $0.00

C9733 T 00 00 00 00 ZZZ $0.00

C9734 C 00 00 00 00 ZZZ $0.00

C9734 P 00 00 00 00 ZZZ $0.00

C9734 T 00 00 00 00 ZZZ $0.00

C9739 2 00 00 00 00 ZZZ $0.00

C9739 8 00 00 00 00 ZZZ $0.00

C9740 2 00 00 00 00 ZZZ $0.00

C9740 8 00 00 00 00 ZZZ $0.00

C9744 T 00 00 00 00 ZZZ $0.00

D0190 K 00 00 00 00 ZZZ $7.98

D1206 1 00 00 00 00 ZZZ $19.95

E0779 1 RR 00 00 00 ZZZ $7.48

G0130 C 00 00 00 00 ZZZ $54.08

G0130 P 00 00 00 00 ZZZ $13.98

G0130 T 00 00 00 00 ZZZ $40.10

G0166 C 00 00 00 00 ZZZ $170.64

G0166 P 00 00 00 00 ZZZ $102.38

G0166 T 00 00 00 00 ZZZ $68.26

G0186 2 00 00 00 00 ZZZ $0.00

Page 456: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

G0186 8 00 00 00 00 ZZZ $0.00

G0202 C 00 00 00 00 ZZZ $116.26

G0202 P 00 00 00 00 ZZZ $34.34

G0202 T 00 00 00 00 ZZZ $81.92

G0204 C 00 00 00 00 ZZZ $123.19

G0204 P 00 00 00 00 ZZZ $42.54

G0204 T 00 00 00 00 ZZZ $80.65

G0206 C 00 00 00 00 ZZZ $99.56

G0206 P 00 00 00 00 ZZZ $34.34

G0206 T 00 00 00 00 ZZZ $65.22

G0255 C 00 00 00 00 ZZZ $0.00

G0255 P 00 00 00 00 ZZZ $0.00

G0255 T 00 00 00 00 ZZZ $0.00

G0278 C 00 00 00 00 ZZZ $12.82

G0278 P 00 00 00 00 ZZZ $12.82

G0328 C 00 00 00 00 ZZZ $22.96

G0328 G 00 00 00 00 ZZZ $21.72

G0328 T 00 00 00 00 ZZZ $22.96

G0329 1 00 00 00 00 ZZZ $9.96

G0364 2 00 00 00 00 ZZZ $16.13

G0364 8 00 00 00 00 ZZZ $3.23

G0365 C 00 00 00 00 ZZZ $212.94

G0365 P 00 00 00 00 ZZZ $127.77

G0365 T 00 00 00 00 ZZZ $85.15

G0413 2 00 00 00 00 ZZZ $0.00

G0413 8 00 00 00 00 ZZZ $0.00

G0414 2 00 00 00 00 ZZZ $0.00

G0414 8 00 00 00 00 ZZZ $0.00

G0416 C 00 00 00 00 ZZZ $703.60

G0416 P 00 00 00 00 ZZZ $206.00

G0416 T 00 00 00 00 ZZZ $497.60

G0452 C 00 00 00 00 ZZZ $0.00

G0452 P 00 00 00 00 ZZZ $0.00

G6015 C 00 00 00 00 ZZZ $0.00

G6015 T 00 00 00 00 ZZZ $0.00

J0120 1 00 00 00 00 ZZZ $13.77

J0129 1 00 00 00 00 ZZZ $18.70

J0133 1 00 00 00 00 ZZZ $0.02

J0153 1 00 00 00 00 ZZZ $0.85

J0171 1 00 00 00 00 ZZZ $1.64

Page 457: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J0178 1 00 00 00 00 ZZZ $980.50

J0180 1 00 00 00 00 ZZZ $121.11

J0202 1 00 00 00 00 ZZZ $1,743.82

J0207 1 00 00 00 00 ZZZ $306.77

J0210 1 00 00 00 00 ZZZ $12.88

J0220 1 00 00 00 00 ZZZ $127.20

J0221 1 00 00 00 00 ZZZ $153.60

J0256 1 00 00 00 00 ZZZ $2.09

J0257 1 00 00 00 00 ZZZ $3.92

J0278 1 00 00 00 00 ZZZ $1.30

J0280 1 00 00 00 00 ZZZ $14.64

J0285 1 00 00 00 00 ZZZ $173.33

J0287 1 00 00 00 00 ZZZ $19.55

J0289 1 00 00 00 00 ZZZ $32.03

J0290 1 00 00 00 00 ZZZ $5.76

J0295 1 00 00 00 00 ZZZ $8.70

J0300 1 00 00 00 00 ZZZ $3.49

J0330 1 00 00 00 00 ZZZ $2.39

J0348 1 00 00 00 00 ZZZ $1.91

J0360 1 00 00 00 00 ZZZ $7.01

J0364 1 00 00 00 00 ZZZ $3.10

J0380 1 00 00 00 00 ZZZ $14.24

J0400 1 00 00 00 00 ZZZ $0.29

J0401 1 00 00 00 00 ZZZ $3.63

J0456 1 00 00 00 00 ZZZ $24.32

J0461 1 00 00 00 00 ZZZ $0.03

J0470 1 00 00 00 00 ZZZ $21.60

J0475 1 00 00 00 00 ZZZ $205.85

J0476 1 00 00 00 00 ZZZ $71.40

J0480 1 00 00 00 00 ZZZ $1,410.89

J0485 1 00 00 00 00 ZZZ $3.81

J0490 1 00 00 00 00 ZZZ $38.42

J0500 1 00 00 00 00 ZZZ $12.12

J0515 1 00 00 00 00 ZZZ $7.81

J0558 1 00 00 00 00 ZZZ $4.82

J0561 1 00 00 00 00 ZZZ $5.66

J0585 1 00 00 00 00 ZZZ $4.66

J0586 1 00 00 00 00 ZZZ $8.08

J0588 1 00 00 00 00 ZZZ $3.47

J0592 1 00 00 00 00 ZZZ $0.92

Page 458: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J0594 1 00 00 00 00 ZZZ $8.89

J0595 1 00 00 00 00 ZZZ $3.94

J0596 1 00 00 00 00 ZZZ $30.99

J0600 1 00 00 00 00 ZZZ $21.00

J0610 1 00 00 00 00 ZZZ $2.48

J0620 1 00 00 00 00 ZZZ $28.65

J0630 1 00 00 00 00 ZZZ $40.46

J0636 1 00 00 00 00 ZZZ $1.38

J0637 1 00 00 00 00 ZZZ $29.48

J0638 1 00 00 00 00 ZZZ $90.77

J0640 1 00 00 00 00 ZZZ $66.01

J0641 1 00 00 00 00 ZZZ $1.05

J0670 1 00 00 00 00 ZZZ $8.25

J0690 1 00 00 00 00 ZZZ $4.55

J0692 1 00 00 00 00 ZZZ $7.28

J0694 1 00 00 00 00 ZZZ $10.88

J0695 1 00 00 00 00 ZZZ $4.96

J0696 1 00 00 00 00 ZZZ $11.84

J0697 1 00 00 00 00 ZZZ $8.84

J0698 1 00 00 00 00 ZZZ $13.05

J0702 1 00 00 00 00 ZZZ $3.45

J0706 1 00 00 00 00 ZZZ $3.07

J0712 1 00 00 00 00 ZZZ $0.74

J0713 1 00 00 00 00 ZZZ $6.07

J0714 1 00 00 00 00 ZZZ $81.23

J0716 1 00 00 00 00 ZZZ $0.00

J0717 1 00 00 00 00 ZZZ $5.13

J0720 1 00 00 00 00 ZZZ $5.75

J0725 1 00 00 00 00 ZZZ $3.33

J0735 1 00 00 00 00 ZZZ $6.45

J0740 1 00 00 00 00 ZZZ $692.34

J0743 1 00 00 00 00 ZZZ $15.22

J0744 1 00 00 00 00 ZZZ $12.25

J0745 1 00 00 00 00 ZZZ $2.20

J0770 1 00 00 00 00 ZZZ $23.37

J0780 1 00 00 00 00 ZZZ $3.28

J0795 1 00 00 00 00 ZZZ $4.06

J0800 1 00 00 00 00 ZZZ $21.10

J0833 1 00 00 00 00 ZZZ $65.42

J0834 1 00 00 00 00 ZZZ $91.20

Page 459: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J0850 1 00 00 00 00 ZZZ $464.34

J0875 1 00 00 00 00 ZZZ $14.58

J0881 1 00 00 00 00 ZZZ $4.59

J0882 1 00 00 00 00 ZZZ $4.59

J0883 1 00 00 00 00 ZZZ $5.18

J0884 1 00 00 00 00 ZZZ $5.18

J0885 1 00 00 00 00 ZZZ $11.70

J0887 1 00 00 00 00 ZZZ $2.05

J0888 1 00 00 00 00 ZZZ $2.05

J0894 1 00 00 00 00 ZZZ $26.48

J0895 1 00 00 00 00 ZZZ $10.28

J0895 6 EP 00 00 00 ZZZ $8.68

J0897 1 00 00 00 00 ZZZ $14.43

J0945 1 00 00 00 00 ZZZ $7.60

J1000 1 00 00 00 00 ZZZ $4.56

J1020 1 00 00 00 00 ZZZ $3.66

J1030 1 00 00 00 00 ZZZ $5.36

J1040 1 00 00 00 00 ZZZ $8.44

J1050 1 00 00 00 00 ZZZ $0.47

J1050 A FP 00 00 00 ZZZ $0.47

J1071 1 00 00 00 00 ZZZ $0.03

J1100 1 00 00 00 00 ZZZ $7.40

J1110 1 00 00 00 00 ZZZ $9.97

J1120 1 00 00 00 00 ZZZ $28.82

J1130 1 00 00 00 00 ZZZ $0.24

J1160 1 00 00 00 00 ZZZ $3.47

J1165 1 00 00 00 00 ZZZ $2.44

J1170 1 00 00 00 00 ZZZ $2.67

J1180 1 00 00 00 00 ZZZ $13.98

J1190 1 00 00 00 00 ZZZ $146.37

J1200 1 00 00 00 00 ZZZ $3.12

J1205 1 00 00 00 00 ZZZ $10.66

J1212 1 00 00 00 00 ZZZ $2.14

J1230 1 00 00 00 00 ZZZ $3.57

J1240 1 00 00 00 00 ZZZ $2.10

J1245 1 00 00 00 00 ZZZ $24.82

J1250 1 00 00 00 00 ZZZ $21.55

J1260 1 00 00 00 00 ZZZ $14.81

J1267 1 00 00 00 00 ZZZ $0.65

J1270 1 00 00 00 00 ZZZ $4.92

Page 460: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J1300 1 00 00 00 00 ZZZ $176.38

J1322 1 00 00 00 00 ZZZ $243.50

J1324 1 00 00 00 00 ZZZ $0.00

J1325 1 00 00 00 00 ZZZ $17.03

J1330 1 00 00 00 00 ZZZ $3.71

J1335 1 00 00 00 00 ZZZ $21.24

J1364 1 00 00 00 00 ZZZ $7.54

J1380 1 00 00 00 00 ZZZ $2.08

J1410 1 00 00 00 00 ZZZ $3.68

J1435 1 00 00 00 00 ZZZ $2.23

J1439 1 00 00 00 00 ZZZ $1.06

J1442 1 00 00 00 00 ZZZ $0.99

J1443 1 00 00 00 00 ZZZ $0.03

J1447 1 00 00 00 00 ZZZ $0.77

J1450 1 00 00 00 00 ZZZ $85.83

J1453 1 00 00 00 00 ZZZ $1.57

J1455 1 00 00 00 00 ZZZ $13.20

J1458 1 00 00 00 00 ZZZ $302.80

J1459 1 00 00 00 00 ZZZ $34.15

J1460 1 00 00 00 00 ZZZ $3.28

J1556 1 00 00 00 00 ZZZ $36.63

J1557 1 00 00 00 00 ZZZ $37.29

J1559 1 00 00 00 00 ZZZ $8.88

J1560 1 00 00 00 00 ZZZ $23.28

J1561 1 00 00 00 00 ZZZ $32.88

J1562 1 00 00 00 00 ZZZ $0.00

J1566 1 00 00 00 00 ZZZ $22.22

J1568 1 00 00 00 00 ZZZ $33.81

J1569 1 00 00 00 00 ZZZ $31.65

J1570 1 00 00 00 00 ZZZ $34.66

J1571 1 00 00 00 00 ZZZ $59.25

J1572 1 00 00 00 00 ZZZ $32.61

J1573 1 00 00 00 00 ZZZ $59.25

J1575 1 00 00 00 00 ZZZ $10.83

J1580 1 00 00 00 00 ZZZ $5.05

J1599 1 00 00 00 00 ZZZ $0.00

J1600 1 00 00 00 00 ZZZ $11.65

J1602 1 00 00 00 00 ZZZ $27.28

J1610 1 00 00 00 00 ZZZ $38.55

J1626 1 00 00 00 00 ZZZ $18.45

Page 461: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J1630 1 00 00 00 00 ZZZ $6.78

J1631 1 00 00 00 00 ZZZ $29.55

J1640 1 00 00 00 00 ZZZ $6.63

J1642 1 00 00 00 00 ZZZ $1.01

J1644 1 00 00 00 00 ZZZ $2.32

J1645 1 00 00 00 00 ZZZ $67.86

J1650 1 00 00 00 00 ZZZ $17.66

J1652 1 00 00 00 00 ZZZ $7.40

J1670 1 00 00 00 00 ZZZ $11.42

J1720 1 00 00 00 00 ZZZ $4.94

J1725 1 00 00 00 00 ZZZ $3.14

J1740 1 00 00 00 00 ZZZ $138.85

J1741 1 00 00 00 00 ZZZ $0.00

J1742 1 00 00 00 00 ZZZ $18.77

J1743 1 00 00 00 00 ZZZ $455.03

J1745 1 00 00 00 00 ZZZ $65.70

J1750 1 00 00 00 00 ZZZ $12.25

J1756 1 00 00 00 00 ZZZ $0.28

J1786 1 00 00 00 00 ZZZ $43.59

J1790 1 00 00 00 00 ZZZ $7.60

J1800 1 00 00 00 00 ZZZ $5.77

J1815 1 00 00 00 00 ZZZ $3.23

J1830 1 00 00 00 00 ZZZ $68.40

J1833 1 00 00 00 00 ZZZ $0.73

J1840 1 00 00 00 00 ZZZ $12.64

J1850 1 00 00 00 00 ZZZ $6.90

J1885 1 00 00 00 00 ZZZ $9.74

J1930 1 00 00 00 00 ZZZ $29.31

J1931 1 00 00 00 00 ZZZ $22.74

J1940 1 00 00 00 00 ZZZ $3.67

J1942 1 00 00 00 00 ZZZ $2.80

J1950 1 00 00 00 00 ZZZ $397.04

J1953 1 00 00 00 00 ZZZ $0.43

J1955 1 00 00 00 00 ZZZ $35.80

J1956 1 00 00 00 00 ZZZ $18.62

J1980 1 00 00 00 00 ZZZ $24.90

J2001 1 00 00 00 00 ZZZ $0.88

J2010 1 00 00 00 00 ZZZ $4.16

J2020 1 00 00 00 00 ZZZ $32.93

J2060 1 00 00 00 00 ZZZ $4.64

Page 462: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J2150 1 00 00 00 00 ZZZ $6.09

J2175 1 00 00 00 00 ZZZ $2.19

J2182 1 00 00 00 00 ZZZ $30.53

J2185 1 00 00 00 00 ZZZ $4.40

J2210 1 00 00 00 00 ZZZ $3.76

J2248 1 00 00 00 00 ZZZ $1.78

J2250 1 00 00 00 00 ZZZ $3.89

J2260 1 00 00 00 00 ZZZ $31.26

J2270 1 00 00 00 00 ZZZ $2.12

J2274 1 00 00 00 00 ZZZ $9.28

J2278 1 00 00 00 00 ZZZ $6.17

J2280 1 00 00 00 00 ZZZ $9.30

J2300 1 00 00 00 00 ZZZ $2.85

J2310 1 00 00 00 00 ZZZ $4.84

J2320 1 00 00 00 00 ZZZ $3.58

J2323 1 00 00 00 00 ZZZ $0.00

J2353 1 00 00 00 00 ZZZ $71.09

J2354 1 00 00 00 00 ZZZ $3.81

J2355 1 00 00 00 00 ZZZ $239.67

J2358 1 00 00 00 00 ZZZ $4.35

J2360 1 00 00 00 00 ZZZ $6.48

J2370 1 00 00 00 00 ZZZ $4.85

J2400 1 00 00 00 00 ZZZ $15.70

J2405 1 00 00 00 00 ZZZ $6.79

J2407 1 00 00 00 00 ZZZ $25.62

J2410 1 00 00 00 00 ZZZ $4.91

J2425 1 00 00 00 00 ZZZ $11.47

J2426 1 00 00 00 00 ZZZ $7.24

J2430 1 00 00 00 00 ZZZ $254.81

J2440 1 00 00 00 00 ZZZ $5.01

J2469 1 00 00 00 00 ZZZ $18.01

J2501 1 00 00 00 00 ZZZ $4.49

J2502 1 00 00 00 00 ZZZ $319.20

J2503 1 00 00 00 00 ZZZ $1,054.70

J2504 1 00 00 00 00 ZZZ $167.67

J2505 1 00 00 00 00 ZZZ $2,507.50

J2507 1 00 00 00 00 ZZZ $302.13

J2510 1 00 00 00 00 ZZZ $4.04

J2513 1 00 00 00 00 ZZZ $12.72

J2515 1 00 00 00 00 ZZZ $3.39

Page 463: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J2540 1 00 00 00 00 ZZZ $2.40

J2543 1 00 00 00 00 ZZZ $4.36

J2547 1 00 00 00 00 ZZZ $1.81

J2550 1 00 00 00 00 ZZZ $5.44

J2560 1 00 00 00 00 ZZZ $4.20

J2562 1 00 00 00 00 ZZZ $268.72

J2590 1 00 00 00 00 ZZZ $2.55

J2597 1 00 00 00 00 ZZZ $22.51

J2675 1 00 00 00 00 ZZZ $8.45

J2680 1 00 00 00 00 ZZZ $20.51

J2690 1 00 00 00 00 ZZZ $32.26

J2700 1 00 00 00 00 ZZZ $4.77

J2710 1 00 00 00 00 ZZZ $3.22

J2720 1 00 00 00 00 ZZZ $5.66

J2724 1 00 00 00 00 ZZZ $12.19

J2730 1 00 00 00 00 ZZZ $28.07

J2760 1 00 00 00 00 ZZZ $27.37

J2765 1 00 00 00 00 ZZZ $3.95

J2770 1 00 00 00 00 ZZZ $102.52

J2778 1 00 00 00 00 ZZZ $405.89

J2780 1 00 00 00 00 ZZZ $1.29

J2783 1 00 00 00 00 ZZZ $105.54

J2788 1 00 00 00 00 ZZZ $45.10

J2790 1 00 00 00 00 ZZZ $120.60

J2791 1 00 00 00 00 ZZZ $5.33

J2792 1 00 00 00 00 ZZZ $18.39

J2796 1 00 00 00 00 ZZZ $43.60

J2800 1 00 00 00 00 ZZZ $6.33

J2820 1 00 00 00 00 ZZZ $23.98

J2840 1 00 00 00 00 ZZZ $570.00

J2860 1 00 00 00 00 ZZZ $97.81

J2916 1 00 00 00 00 ZZZ $8.17

J2920 1 00 00 00 00 ZZZ $5.05

J2930 1 00 00 00 00 ZZZ $10.85

J2941 1 00 00 00 00 ZZZ $41.09

J2993 1 00 00 00 00 ZZZ $1,168.75

J2997 1 00 00 00 00 ZZZ $35.63

J3000 1 00 00 00 00 ZZZ $1.99

J3010 1 00 00 00 00 ZZZ $3.66

J3030 1 00 00 00 00 ZZZ $30.02

Page 464: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J3060 1 00 00 00 00 ZZZ $30.94

J3070 1 00 00 00 00 ZZZ $4.64

J3090 1 00 00 00 00 ZZZ $1.21

J3095 1 00 00 00 00 ZZZ $3.53

J3105 1 00 00 00 00 ZZZ $3.60

J3121 1 00 00 00 00 ZZZ $0.06

J3145 1 00 00 00 00 ZZZ $1.25

J3230 1 00 00 00 00 ZZZ $10.33

J3240 1 00 00 00 00 ZZZ $495.60

J3243 1 00 00 00 00 ZZZ $765.20

J3250 1 00 00 00 00 ZZZ $3.76

J3260 1 00 00 00 00 ZZZ $8.42

J3262 1 00 00 00 00 ZZZ $5.07

J3300 1 00 00 00 00 ZZZ $3.24

J3301 1 00 00 00 00 ZZZ $2.02

J3303 1 00 00 00 00 ZZZ $11.87

J3315 1 00 00 00 00 ZZZ $356.66

J3357 1 00 00 00 00 ZZZ $113.40

J3360 1 00 00 00 00 ZZZ $6.15

J3370 1 00 00 00 00 ZZZ $9.40

J3380 1 00 00 00 00 ZZZ $17.03

J3385 1 00 00 00 00 ZZZ $352.19

J3396 1 00 00 00 00 ZZZ $8.99

J3410 1 00 00 00 00 ZZZ $2.19

J3420 1 00 00 00 00 ZZZ $2.23

J3430 1 00 00 00 00 ZZZ $4.18

J3465 1 00 00 00 00 ZZZ $4.51

J3470 1 00 00 00 00 ZZZ $34.62

J3473 1 00 00 00 00 ZZZ $0.40

J3475 1 00 00 00 00 ZZZ $1.91

J3480 1 00 00 00 00 ZZZ $1.62

J3485 1 00 00 00 00 ZZZ $0.96

J3489 1 00 00 00 00 ZZZ $105.42

J3490 1 00 00 00 00 ZZZ $0.00

J3490 1 U9 00 00 00 ZZZ $21.60

J3590 1 00 00 00 00 ZZZ $0.00

J7121 1 00 00 00 00 ZZZ $1.12

J7175 1 00 00 00 00 ZZZ $9.27

J7178 1 00 00 00 00 ZZZ $0.00

J7179 1 00 00 00 00 ZZZ $2.26

Page 465: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J7180 1 00 00 00 00 ZZZ $0.00

J7181 1 00 00 00 00 ZZZ $15.16

J7183 1 00 00 00 00 ZZZ $0.88

J7185 1 00 00 00 00 ZZZ $1.08

J7186 1 00 00 00 00 ZZZ $0.86

J7187 1 00 00 00 00 ZZZ $0.89

J7188 1 00 00 00 00 ZZZ $5.88

J7190 1 00 00 00 00 ZZZ $0.86

J7192 1 00 00 00 00 ZZZ $1.12

J7193 1 00 00 00 00 ZZZ $1.12

J7194 1 00 00 00 00 ZZZ $1.96

J7195 1 00 00 00 00 ZZZ $0.95

J7196 1 00 00 00 00 ZZZ $0.00

J7197 1 00 00 00 00 ZZZ $2.42

J7198 1 00 00 00 00 ZZZ $1.43

J7199 1 00 00 00 00 ZZZ $0.00

J7201 1 00 00 00 00 ZZZ $2.82

J7202 1 00 00 00 00 ZZZ $4.85

J7205 1 00 00 00 00 ZZZ $1.89

J7207 1 00 00 00 00 ZZZ $2.26

J7209 1 00 00 00 00 ZZZ $1.93

J7297 A FP 00 00 00 ZZZ $625.00

J7298 1 00 00 00 00 ZZZ $772.65

J7298 A FP 00 00 00 ZZZ $772.65

J7300 A FP 00 00 00 ZZZ $598.00

J7301 A FP 00 00 00 ZZZ $650.32

J7303 A FP 00 00 00 ZZZ $37.70

J7307 A FP 00 00 00 ZZZ $771.32

J7308 1 00 00 00 00 ZZZ $111.47

J7310 1 00 00 00 00 ZZZ $4,751.60

J7312 1 00 00 00 00 ZZZ $197.58

J7313 1 00 00 00 00 ZZZ $490.95

J7316 1 00 00 00 00 ZZZ $1,046.75

J7320 1 00 00 00 00 ZZZ $8.00

J7321 1 00 00 00 00 ZZZ $102.06

J7322 1 00 00 00 00 ZZZ $19.00

J7323 1 00 00 00 00 ZZZ $110.87

J7324 1 00 00 00 00 ZZZ $171.37

J7325 1 00 00 00 00 ZZZ $11.74

J7327 1 00 00 00 00 ZZZ $988.38

Page 466: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J7328 1 00 00 00 00 ZZZ $0.00

J7330 1 00 00 00 00 ZZZ $16,585.69

J7501 1 00 00 00 00 ZZZ $77.52

J7502 1 00 00 00 00 ZZZ $4.68

J7504 1 00 00 00 00 ZZZ $262.24

J7505 1 00 00 00 00 ZZZ $661.20

J7507 1 00 00 00 00 ZZZ $2.66

J7508 1 00 00 00 00 ZZZ $1.72

J7509 1 00 00 00 00 ZZZ $0.49

J7510 1 00 00 00 00 ZZZ $0.04

J7511 1 00 00 00 00 ZZZ $319.94

J7513 1 00 00 00 00 ZZZ $380.36

J7515 1 00 00 00 00 ZZZ $1.17

J7516 1 00 00 00 00 ZZZ $20.59

J7517 1 00 00 00 00 ZZZ $2.55

J7518 1 00 00 00 00 ZZZ $2.42

J7520 1 00 00 00 00 ZZZ $6.38

J7525 1 00 00 00 00 ZZZ $106.29

J7527 1 00 00 00 00 ZZZ $6.18

J7599 1 00 00 00 00 ZZZ $0.00

J8530 1 00 00 00 00 ZZZ $1.82

J8650 1 00 00 00 00 ZZZ $0.00

J8705 1 00 00 00 00 ZZZ $69.89

J9000 1 00 00 00 00 ZZZ $42.18

J9015 1 00 00 00 00 ZZZ $447.21

J9017 1 00 00 00 00 ZZZ $32.94

J9019 1 00 00 00 00 ZZZ $334.32

J9025 1 00 00 00 00 ZZZ $5.65

J9031 1 00 00 00 00 ZZZ $147.50

J9032 1 00 00 00 00 ZZZ $32.50

J9033 1 00 00 00 00 ZZZ $18.61

J9034 1 00 00 00 00 ZZZ $23.69

J9035 1 00 00 00 00 ZZZ $69.61

J9039 1 00 00 00 00 ZZZ $108.60

J9040 1 00 00 00 00 ZZZ $256.19

J9041 1 00 00 00 00 ZZZ $28.38

J9042 1 00 00 00 00 ZZZ $106.86

J9043 1 00 00 00 00 ZZZ $135.20

J9045 1 00 00 00 00 ZZZ $114.45

J9047 1 00 00 00 00 ZZZ $29.29

Page 467: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J9050 1 00 00 00 00 ZZZ $40.00

J9055 1 00 00 00 00 ZZZ $53.57

J9060 1 00 00 00 00 ZZZ $28.06

J9065 1 00 00 00 00 ZZZ $47.20

J9070 1 00 00 00 00 ZZZ $50.13

J9098 1 00 00 00 00 ZZZ $332.05

J9100 1 00 00 00 00 ZZZ $6.25

J9120 1 00 00 00 00 ZZZ $10.54

J9130 1 00 00 00 00 ZZZ $7.88

J9145 1 00 00 00 00 ZZZ $46.92

J9150 1 00 00 00 00 ZZZ $125.65

J9151 1 00 00 00 00 ZZZ $57.80

J9155 1 00 00 00 00 ZZZ $2.87

J9160 1 00 00 00 00 ZZZ $0.00

J9171 1 00 00 00 00 ZZZ $17.62

J9176 1 00 00 00 00 ZZZ $6.23

J9178 1 00 00 00 00 ZZZ $24.73

J9179 1 00 00 00 00 ZZZ $90.05

J9181 1 00 00 00 00 ZZZ $13.15

J9185 1 00 00 00 00 ZZZ $285.41

J9190 1 00 00 00 00 ZZZ $1.62

J9200 1 00 00 00 00 ZZZ $87.50

J9201 1 00 00 00 00 ZZZ $106.72

J9202 1 00 00 00 00 ZZZ $318.75

J9205 1 00 00 00 00 ZZZ $39.51

J9206 1 00 00 00 00 ZZZ $134.25

J9207 1 00 00 00 00 ZZZ $63.74

J9208 1 00 00 00 00 ZZZ $127.45

J9209 1 00 00 00 00 ZZZ $36.48

J9211 1 00 00 00 00 ZZZ $258.84

J9213 1 00 00 00 00 ZZZ $32.24

J9214 1 00 00 00 00 ZZZ $11.59

J9216 1 00 00 00 00 ZZZ $133.00

J9217 1 00 00 00 00 ZZZ $525.18

J9218 1 00 00 00 00 ZZZ $11.60

J9219 1 00 00 00 00 ZZZ $5,399.80

J9225 1 00 00 00 00 ZZZ $2,524.19

J9226 1 00 00 00 00 ZZZ $14,834.06

J9228 1 00 00 00 00 ZZZ $125.05

J9230 1 00 00 00 00 ZZZ $10.36

Page 468: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J9245 1 00 00 00 00 ZZZ $308.78

J9250 1 00 00 00 00 ZZZ $5.52

J9260 1 00 00 00 00 ZZZ $13.63

J9261 1 00 00 00 00 ZZZ $82.94

J9262 1 00 00 00 00 ZZZ $238.57

J9263 1 00 00 00 00 ZZZ $8.45

J9264 1 00 00 00 00 ZZZ $9.84

J9266 1 00 00 00 00 ZZZ $254.16

J9267 1 00 00 00 00 ZZZ $0.16

J9268 1 00 00 00 00 ZZZ $1,562.75

J9271 1 00 00 00 00 ZZZ $45.70

J9280 1 00 00 00 00 ZZZ $110.36

J9293 1 00 00 00 00 ZZZ $193.20

J9295 1 00 00 00 00 ZZZ $5.25

J9299 1 00 00 00 00 ZZZ $25.37

J9301 1 00 00 00 00 ZZZ $54.24

J9302 1 00 00 00 00 ZZZ $50.61

J9303 1 00 00 00 00 ZZZ $82.87

J9305 1 00 00 00 00 ZZZ $40.54

J9306 1 00 00 00 00 ZZZ $10.16

J9307 1 00 00 00 00 ZZZ $165.62

J9308 1 00 00 00 00 ZZZ $54.02

J9310 1 00 00 00 00 ZZZ $747.57

J9315 1 00 00 00 00 ZZZ $219.30

J9320 1 00 00 00 00 ZZZ $54.25

J9325 1 00 00 00 00 ZZZ $46.13

J9328 1 00 00 00 00 ZZZ $0.00

J9330 1 00 00 00 00 ZZZ $47.91

J9340 1 00 00 00 00 ZZZ $54.71

J9351 1 00 00 00 00 ZZZ $27.35

J9352 1 00 00 00 00 ZZZ $283.34

J9354 1 00 00 00 00 ZZZ $29.17

J9355 1 00 00 00 00 ZZZ $89.51

J9357 1 00 00 00 00 ZZZ $471.24

J9360 1 00 00 00 00 ZZZ $3.52

J9370 1 00 00 00 00 ZZZ $34.62

J9371 1 00 00 00 00 ZZZ $15.02

J9390 1 00 00 00 00 ZZZ $90.72

J9395 1 00 00 00 00 ZZZ $80.66

J9400 1 00 00 00 00 ZZZ $9.37

Page 469: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

J9600 1 00 00 00 00 ZZZ $2,444.76

J9999 1 00 00 00 00 ZZZ $0.00

L8499 6 EP 00 00 00 ZZZ $0.00

L8614 6 EP 00 00 00 ZZZ $0.00

L8615 6 EP 00 00 00 ZZZ $410.95

L8616 6 EP 00 00 00 ZZZ $95.71

L8617 6 EP 00 00 00 ZZZ $83.61

L8618 6 EP 00 00 00 ZZZ $23.88

L8619 6 EP 00 00 00 ZZZ $7,487.15

L8621 6 EP 00 00 00 ZZZ $0.59

L8622 6 EP 00 00 00 ZZZ $0.31

L8623 6 EP 00 00 00 ZZZ $58.94

L8624 6 EP 00 00 00 ZZZ $155.45

L8627 6 EP 00 00 00 ZZZ $6,359.97

L8628 6 EP 00 00 00 ZZZ $1,127.17

L8629 6 EP 00 00 00 ZZZ $163.15

L8693 6 EP 00 00 00 ZZZ $0.00

P2033 C 00 00 00 00 ZZZ $0.00

P2033 P 00 00 00 00 ZZZ $0.00

P2033 T 00 00 00 00 ZZZ $0.00

P9041 1 00 00 00 00 ZZZ $27.32

P9045 1 00 00 00 00 ZZZ $54.68

P9046 1 00 00 00 00 ZZZ $25.59

P9047 1 00 00 00 00 ZZZ $51.20

P9612 1 00 00 00 00 ZZZ $3.00

P9615 1 00 00 00 00 ZZZ $3.00

Q0111 A FP 00 00 00 ZZZ $5.90

Q0111 C 00 00 00 00 ZZZ $5.90

Q0111 P 00 00 00 00 ZZZ $5.90

Q0112 C 00 00 00 00 ZZZ $4.78

Q0112 P 00 00 00 00 ZZZ $4.78

Q0113 C 00 00 00 00 ZZZ $7.47

Q0113 P 00 00 00 00 ZZZ $7.47

Q0114 C 00 00 00 00 ZZZ $9.88

Q0114 P 00 00 00 00 ZZZ $9.88

Q0115 C 00 00 00 00 ZZZ $13.68

Q0115 P 00 00 00 00 ZZZ $13.68

Q0139 1 00 00 00 00 ZZZ $0.82

Q0162 1 UB 00 00 00 ZZZ $0.08

Q0166 1 UB 00 00 00 ZZZ $39.38

Page 470: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

Q2009 1 00 00 00 00 ZZZ $5.44

Q2017 1 00 00 00 00 ZZZ $263.67

Q2034 1 00 00 00 00 ZZZ $15.75

Q2043 1 00 00 00 00 ZZZ $32,860.00

Q2049 1 00 00 00 00 ZZZ $498.26

Q2050 1 00 00 00 00 ZZZ $3,513.48

Q3027 1 00 00 00 00 ZZZ $32.83

Q3031 1 00 00 00 00 ZZZ $0.00

Q4081 1 00 00 00 00 ZZZ $0.96

Q4101 1 00 00 00 00 ZZZ $31.38

Q4102 1 00 00 00 00 ZZZ $4.35

Q4104 1 00 00 00 00 ZZZ $11.87

Q4105 1 00 00 00 00 ZZZ $11.87

Q4106 1 00 00 00 00 ZZZ $38.45

Q4107 1 00 00 00 00 ZZZ $88.97

Q4108 1 00 00 00 00 ZZZ $18.85

Q4121 1 00 00 00 00 ZZZ $23.13

Q4124 1 00 00 00 00 ZZZ $0.00

Q4141 1 00 00 00 00 ZZZ $0.00

Q4145 1 00 00 00 00 ZZZ $0.00

Q4150 1 00 00 00 00 ZZZ $0.00

Q4152 1 00 00 00 00 ZZZ $0.00

Q4157 1 00 00 00 00 ZZZ $0.00

Q4160 1 00 00 00 00 ZZZ $0.00

Q5101 1 00 00 00 00 ZZZ $0.97

Q5102 1 00 00 00 00 ZZZ $100.31

Q9969 1 00 00 00 00 ZZZ $0.00

S0017 1 00 00 00 00 ZZZ $0.00

S0021 1 00 00 00 00 ZZZ $0.00

S0023 1 00 00 00 00 ZZZ $3.00

S0028 1 00 00 00 00 ZZZ $1.03

S0030 1 00 00 00 00 ZZZ $0.00

S0032 1 00 00 00 00 ZZZ $0.00

S0034 1 00 00 00 00 ZZZ $0.00

S0039 1 00 00 00 00 ZZZ $0.00

S0040 1 00 00 00 00 ZZZ $0.00

S0073 1 00 00 00 00 ZZZ $0.00

S0074 1 00 00 00 00 ZZZ $0.00

S0077 1 00 00 00 00 ZZZ $0.00

S0080 1 00 00 00 00 ZZZ $0.00

Page 471: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

S0081 1 00 00 00 00 ZZZ $0.00

S0092 1 00 00 00 00 ZZZ $0.00

S0093 1 00 00 00 00 ZZZ $0.00

S0108 1 00 00 00 00 ZZZ $2.06

S0119 1 00 00 00 00 ZZZ $0.00

S0145 1 00 00 00 00 ZZZ $0.00

S0164 1 00 00 00 00 ZZZ $3.79

S0177 1 00 00 00 00 ZZZ $5.40

S0179 1 00 00 00 00 ZZZ $0.65

S0187 1 00 00 00 00 ZZZ $1.39

S0500 D 00 00 00 00 ZZZ $300.00

S0512 D 00 00 00 00 ZZZ $300.00

S0518 D 00 00 00 00 ZZZ $0.00

S0592 D 00 00 00 00 ZZZ $61.00

S0610 1 00 00 00 00 ZZZ $88.00

S0612 1 00 00 00 00 ZZZ $36.30

S0620 D 00 00 00 00 ZZZ $60.23

S0621 D 00 00 00 00 ZZZ $60.23

S2066 2 00 00 00 00 ZZZ $0.00

S2066 8 00 00 00 00 ZZZ $0.00

S2067 2 00 00 00 00 ZZZ $0.00

S2067 8 00 00 00 00 ZZZ $0.00

S2112 2 00 00 00 00 ZZZ $0.00

S2112 8 00 00 00 00 ZZZ $0.00

S2115 2 00 00 00 00 ZZZ $0.00

S2115 8 00 00 00 00 ZZZ $0.00

S2118 2 00 00 00 00 ZZZ $0.00

S2118 8 00 00 00 00 ZZZ $0.00

S2202 1 00 00 00 00 ZZZ $0.00

S2342 2 00 00 00 00 ZZZ $0.00

S2342 8 00 00 00 00 ZZZ $0.00

S2348 2 00 00 00 00 ZZZ $0.00

S2348 8 00 00 00 00 ZZZ $0.00

S2350 2 00 00 00 00 ZZZ $0.00

S2350 8 00 00 00 00 ZZZ $0.00

S2351 2 00 00 00 00 ZZZ $0.00

S2351 8 00 00 00 00 ZZZ $0.00

S2400 2 00 00 00 00 ZZZ $0.00

S2400 8 00 00 00 00 ZZZ $0.00

S2401 2 00 00 00 00 ZZZ $0.00

Page 472: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

S2401 8 00 00 00 00 ZZZ $0.00

S2402 2 00 00 00 00 ZZZ $0.00

S2402 8 00 00 00 00 ZZZ $0.00

S2403 2 00 00 00 00 ZZZ $0.00

S2403 8 00 00 00 00 ZZZ $0.00

S2404 2 00 00 00 00 ZZZ $0.00

S2404 8 00 00 00 00 ZZZ $0.00

S2405 2 00 00 00 00 ZZZ $0.00

S2405 8 00 00 00 00 ZZZ $0.00

S2409 2 00 00 00 00 ZZZ $0.00

S2409 8 00 00 00 00 ZZZ $0.00

S2411 2 00 00 00 00 ZZZ $0.00

S2411 8 00 00 00 00 ZZZ $0.00

S3800 C 00 00 00 00 ZZZ $0.00

S3800 P 00 00 00 00 ZZZ $0.00

S3800 T 00 00 00 00 ZZZ $0.00

S3840 C 00 00 00 00 ZZZ $0.00

S3840 T 00 00 00 00 ZZZ $0.00

S3842 C 00 00 00 00 ZZZ $0.00

S3842 T 00 00 00 00 ZZZ $0.00

S3844 C 00 00 00 00 ZZZ $0.00

S3844 T 00 00 00 00 ZZZ $0.00

S3846 C 00 00 00 00 ZZZ $0.00

S3846 T 00 00 00 00 ZZZ $0.00

S3849 C 00 00 00 00 ZZZ $0.00

S3849 T 00 00 00 00 ZZZ $0.00

S3850 C 00 00 00 00 ZZZ $0.00

S3850 T 00 00 00 00 ZZZ $0.00

S3853 C 00 00 00 00 ZZZ $0.00

S3853 T 00 00 00 00 ZZZ $0.00

S3861 C 00 00 00 00 ZZZ $0.00

S3861 P 00 00 00 00 ZZZ $0.00

S3861 T 00 00 00 00 ZZZ $0.00

S3904 C 00 00 00 00 ZZZ $0.00

S3904 P 00 00 00 00 ZZZ $0.00

S3904 T 00 00 00 00 ZZZ $0.00

S8030 2 00 00 00 00 ZZZ $0.00

S8030 8 00 00 00 00 ZZZ $0.00

S8037 C 00 00 00 00 ZZZ $0.00

S8037 P 00 00 00 00 ZZZ $0.00

Page 473: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

S8037 T 00 00 00 00 ZZZ $0.00

S8110 C 00 00 00 00 ZZZ $0.00

S8110 P 00 00 00 00 ZZZ $0.00

S8110 T 00 00 00 00 ZZZ $0.00

S9024 C 00 00 00 00 ZZZ $0.00

S9024 P 00 00 00 00 ZZZ $0.00

S9024 T 00 00 00 00 ZZZ $0.00

T1015 1 00 00 00 00 ZZZ $24.20

T1015 1 U1 00 00 00 ZZZ $31.90

T1015 1 U2 00 00 00 ZZZ $31.90

T1015 V U2 00 00 00 ZZZ $31.90

T1015 Z U1 00 00 00 ZZZ $31.90

T1502 1 00 00 00 00 ZZZ $1.60

T1502 6 EP 00 00 00 ZZZ $1.60

V2501 D U1 00 00 00 ZZZ $72.00

V2501 D UA 00 00 00 ZZZ $300.00

V2623 D 00 00 00 00 ZZZ $959.84

V2624 D 00 00 00 00 ZZZ $64.05

V2625 D 00 00 00 00 ZZZ $307.63

V2626 D 00 00 00 00 ZZZ $213.33

V2629 D 00 00 00 00 ZZZ $0.00

V2630 1 00 00 00 00 ZZZ $220.00

V2785 1 00 00 00 00 ZZZ $0.00

V2799 D 00 00 00 00 ZZZ $0.00

V5008 6 EP 00 00 00 ZZZ $12.02

V5014 9 00 00 00 00 ZZZ $0.00

V5030 9 00 00 00 00 ZZZ $0.00

V5040 9 00 00 00 00 ZZZ $0.00

V5050 9 00 00 00 00 ZZZ $0.00

V5060 9 00 00 00 00 ZZZ $0.00

V5120 9 00 00 00 00 ZZZ $0.00

V5130 9 00 00 00 00 ZZZ $0.00

V5140 9 00 00 00 00 ZZZ $0.00

V5170 9 00 00 00 00 ZZZ $0.00

V5180 9 00 00 00 00 ZZZ $0.00

V5210 9 00 00 00 00 ZZZ $0.00

V5220 9 00 00 00 00 ZZZ $0.00

V5267 9 00 00 00 00 ZZZ $0.00

V5273 6 EP 00 00 00 ZZZ $344.75

V5299 9 00 00 00 00 ZZZ $0.00

Page 474: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

Z0663 2 00 00 00 00 ZZZ $1,007.00

Z0663 8 00 00 00 00 ZZZ $201.00

Z1729 1 00 00 00 00 ZZZ $22.75

Z1847 1 00 00 00 00 ZZZ $0.44

Z1930 2 00 00 00 00 ZZZ $912.00

Z1930 8 00 00 00 00 ZZZ $182.40

Z1933 1 00 00 00 00 ZZZ $3.00

Z3041 1 00 00 00 00 ZZZ $7.00

Z3042 1 00 00 00 00 ZZZ $3.00

Z9940 7 00 00 00 00 ZZZ $0.00

Z9950 7 00 00 00 00 ZZZ $0.00

Procedure

Code

Type of

Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code

Medicaid

Maximum

Allowed

Amount

32851 2 00 00 00 00 ZZZ $0.00

32851 8 00 00 00 00 ZZZ $0.00

32852 2 00 00 00 00 ZZZ $0.00

32852 8 00 00 00 00 ZZZ $0.00

32853 2 00 00 00 00 ZZZ $0.00

32853 8 00 00 00 00 ZZZ $0.00

32854 2 00 00 00 00 ZZZ $0.00

32854 8 00 00 00 00 ZZZ $0.00

33935 2 00 00 00 00 ZZZ $0.00

33935 8 00 00 00 00 ZZZ $0.00

33940 2 00 00 00 00 ZZZ $0.00

33940 8 00 00 00 00 ZZZ $0.00

33945 2 00 00 00 00 ZZZ $0.00

33945 8 00 00 00 00 ZZZ $0.00

38240 2 00 00 00 00 ZZZ $0.00

38240 8 00 00 00 00 ZZZ $0.00

38241 2 00 00 00 00 ZZZ $0.00

38241 8 00 00 00 00 ZZZ $0.00

38243 2 00 00 00 00 ZZZ $0.00

38243 8 00 00 00 00 ZZZ $0.00

47135 2 00 00 00 00 ZZZ $0.00

47135 8 00 00 00 00 ZZZ $0.00

ARKANSAS MEDICAID TRANSPLANT PROCEDURE CODES

Page 475: Physician Fee Schedule - medicaid.mmis.arkansas.gov · Procedure Code Type of Service Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount 00100 7 00 00 00 00 ZZZ $0.00

47141 2 00 00 00 00 ZZZ $0.00

47141 8 00 00 00 00 ZZZ $0.00

47142 2 00 00 00 00 ZZZ $0.00

47142 8 00 00 00 00 ZZZ $0.00

47146 2 00 00 00 00 ZZZ $0.00

47146 8 00 00 00 00 ZZZ $0.00

47147 2 00 00 00 00 ZZZ $0.00

47147 8 00 00 00 00 ZZZ $0.00

47147 2 00 00 00 00 ZZZ $0.00

47147 8 00 00 00 00 ZZZ $0.00