State prevailing rates

State prevailing rates (or state fees), are fees for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for which the Defense Health Agency (DHA) has not established rates or fees.

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


Using the rate tables:

  1. Select the appropriate state from the list to the right (a PDF will open)
  2. Use Ctrl+F to search for the procedure code associated with the claim
  3. If there are multiple rates for one procedure code, narrow your search to the claim's specific provider class and modifier
  4. Refer to the Revision date column - your claim's process date must fall AFTER the rate's revision date
  5. Once you've identified the rate associated with the claim's process date, verify that the claim's date of service falls between that rate's effective date and expiration date

Please refer to the examples below for more guidance.


Example 1: Active rate is applicable

Procedure code: 74300
Provider class: 001
Modifier: 00
Date of service: 8/1/2020
Claim processed date: 10/15/2020


Image of rate table pertaining to example 1


Rate: $441
Explanation: Since the processed date was 10/15/2020 and it must fall AFTER the rate's revision date, we must refer to the row highlighted above. If the claim's date of service falls within this rate's effective date and expiration date, then this is the accurate rate for the claim. 


Example 2: Active rate is NOT applicable

Procedure code: 74300
Provider class: 001
Modifier: 00
Date of service: 8/1/2020
Claim processed date: 8/31/2020


Image of rate table pertaining to example 2 

Rate: $824
Explanation: Since the processed date was 8/31/2020 and it must fall AFTER the rate's revision date, we must refer to the row highlighted above. If the claim's date of service falls within this rate's effective date and expiration date, then this is the accurate rate for the claim.


Example 3: No rates are applicable

Procedure code: 74300
Provider class: 001
Modifier: 00
Date of service: 11/1/2019
Claim processed date: 12/8/2019


Image of rate table pertaining to example 3 

Rate: Billed charge
Explanation: Since the processed date was 12/8/2019 and it must fall AFTER the rate's revision date, we must refer to the row highlighted above. This claim's date of service falls after this rate's expiration date, meaning none of the rates above apply.