State prevailing rates

Please note that the CHAMPUS Maximum Allowable Charges (CMAC) take precedence over the state prevailing rates listed below.

Latest update: 08-01-2018
CPT code State Provider class Modifier Current pricing Effective date Past pricing Past effective date
0359T DC 01 00 $500.00 02/04/16
0359T DC 04 00 $500.00 02/04/16
0360T DC 04 00 $62.50 02/04/16
0360T DC 01 00 $62.50 02/04/16
0361T DC 04 00 $62.50 02/04/16
0361T DC 01 00 $62.50 02/04/16
0365T DC 01 00 $62.50 02/04/16
0365T DC 04 00 $62.50 02/04/16
0368T DC 01 00 $62.50 02/04/16
0368T DC 04 00 $62.50 02/04/16
0369T DC 04 00 $62.50 02/04/16
0369T DC 01 00 $62.50 02/04/16
0370T DC 01 00 $125.00 02/04/16
0370T DC 04 00 $125.00 02/04/16
89250 DC 04 00 $2,700.00 02/04/16
89250 DC 01 00 $2,700.00 02/04/16
89254 DC 04 00 $2,850.00 02/04/16
89254 DC 01 00 $2,850.00 02/04/16
90736 DC 04 00 $254.35 07/20/17
90736 DC 01 00 $254.35 07/20/17
A0431 DC 01 00 $1,786.83 04/09/18 $2,102.15 12/07/16
A0431 DC 04 00 $2,473.12 12/10/15
A0431 DC 04 00 $1,786.83 04/09/18 $2,102.15 12/07/16
A0431 DC 01 00 $2,473.12 12/10/15
E0246 DC 01 RR $10.27 02/04/16
E0246 DC 04 RR $10.27 02/04/16
E0246 DC 04 00 $123.19 02/04/16
E0246 DC 01 00 $123.19 02/04/16
H0015 DC 01 00 $268.00 02/24/16
H0015 DC 04 00 $268.00 02/24/16
H0015 DC 04 00 $282.00 09/18/17 $268.00 02/24/16
H0015 DC 01 00 $282.00 09/18/17 $268.00 02/24/16
H0035 DC 04 00 $282.00 09/18/17 $268.00 09/22/15
H0035 DC 01 00 $282.00 09/18/17 $268.00 09/22/15
H0035 DC 01 00 $268.00 09/22/15 $254.00 01/03/14
H0035 DC 04 00 $268.00 09/22/15 $254.00 01/03/14
H0037 DC 01 00 $377.00 09/18/17 $357.00 09/22/15
H0037 DC 04 00 $377.00 09/18/17 $357.00 09/22/15
H0037 DC 01 00 $357.00 09/22/15 $339.00 01/03/14
H0037 DC 04 00 $357.00 09/22/15 $339.00 01/03/14
K0739 DC 01 00 $14.87 12/01/15 $14.55 12/19/13
K0739 DC 04 00 $15.26 01/24/18 $15.02 12/29/16
K0739 DC 01 00 $15.26 01/24/18 $15.02 12/29/16
K0739 DC 04 00 $14.87 12/01/15 $14.55 12/19/13
L3215 DC 04 00 $88.00 02/04/16
L3215 DC 04 RR $7.33 02/04/16
L3215 DC 01 00 $88.00 02/04/16
L3215 DC 01 RR $7.33 02/04/16
L3216 DC 04 RR $10.16 02/04/16
L3216 DC 01 RR $10.16 02/04/16
L3216 DC 04 00 $122.00 02/04/16
L3216 DC 01 00 $122.00 02/04/16
L3217 DC 04 00 $95.00 02/04/16
L3217 DC 01 00 $95.00 02/04/16
L3217 DC 04 RR $7.92 02/04/16
L3217 DC 01 RR $7.92 02/04/16
L3219 DC 01 00 $88.16 02/04/16
L3219 DC 04 00 $88.16 02/04/16
L3219 DC 04 RR $7.35 02/04/16
L3219 DC 01 RR $7.35 02/04/16
L3221 DC 04 RR $13.00 02/04/16
L3221 DC 01 RR $13.00 02/04/16
L3221 DC 01 00 $156.00 02/04/16
L3221 DC 04 00 $156.00 02/04/16
L3222 DC 04 00 $127.40 02/04/16
L3222 DC 01 00 $127.40 02/04/16
L3222 DC 01 RR $10.62 02/04/16
L3222 DC 04 RR $10.62 02/04/16
L3230 DC 01 00 $497.00 02/04/16
L3230 DC 04 00 $497.00 02/04/16
L3230 DC 04 RR $41.42 02/04/16
L3230 DC 01 RR $41.42 02/04/16
L3250 DC 04 RR $19.31 02/04/16
L3250 DC 04 00 $231.77 02/04/16
L3250 DC 01 00 $231.77 02/04/16
L3250 DC 01 RR $19.31 02/04/16
L3251 DC 04 RR $24.00 02/04/16
L3251 DC 04 00 $288.00 02/04/16
L3251 DC 01 00 $288.00 02/04/16
L3251 DC 01 RR $24.00 02/04/16
L3252 DC 04 RR $15.60 02/04/16
L3252 DC 04 00 $187.20 02/04/16
L3252 DC 01 RR $15.60 02/04/16
L3252 DC 01 00 $187.20 02/04/16
L3253 DC 01 00 $89.00 02/04/16
L3253 DC 04 00 $89.00 02/04/16
L3253 DC 01 RR $7.42 02/04/16
L3253 DC 04 RR $7.42 02/04/16
L3265 DC 04 00 $98.00 02/04/16
L3265 DC 01 00 $98.00 02/04/16
L3265 DC 04 RR $8.16 02/04/16
L3265 DC 01 RR $8.16 02/04/16
L4205 DC 01 00 $22.71 01/24/18 $22.35 12/29/16
L4205 DC 04 00 $22.13 12/01/15 $21.66 12/19/13
L4205 DC 01 00 $22.13 12/01/15 $21.66 12/19/13
L4205 DC 04 00 $22.71 01/24/18 $22.35 12/29/16
L7520 DC 01 00 $30.08 12/01/15 $29.43 12/19/13
L7520 DC 04 00 $30.87 01/24/18 $30.38 12/29/16
L7520 DC 01 00 $30.87 01/24/18 $30.38 12/29/16
L7520 DC 04 00 $30.08 12/01/15 $29.43 12/19/13
S9480 DC 01 00 $282.00 09/18/17 $268.00 02/24/16
S9480 DC 04 00 $268.00 02/24/16
S9480 DC 04 00 $282.00 09/18/17 $268.00 02/24/16
S9480 DC 01 00 $268.00 02/24/16