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:

Select the appropriate state from the list to the right (a PDF will open)
Use Ctrl+F to search for the procedure code associated with the claim
If there are multiple rates for one procedure code, narrow your search to the claim's specific provider class and modifier
Refer to the Revision date column - your claim's process date must fall AFTER the rate's revision date
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.

See table column definitions

Procedure code

The CPT/HCPCS code

State

The state for which the rate is calculated

Provider class

The provider’s level of education or type of certification (i.e. M.D., D.O., LPN etc.)

Modifier

CPT modifiers (also referred to as Level I modifiers) are used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician; code modifiers help further describe a procedure code without changing its definition

Effective date

The beginning date of service applicable to the record

Expiration date

The through date of service applicable to the record

Revision date

The date the state prevailing rate was last reviewed or revised

Rate

The fee per unit for the CPT/HCPCS code

Active

A "Y" value indicates that the rate is active; "N" value indicates the record is not currently active
See state prevailing rates FAQs

Why are there multiple rows for one procedure code?

The state prevailing rate table provides the current rate as well as historical rates. Lines may also be added for multiple provider classes and/or modifiers.

Policy updates

Provider handbook

Join the TRICARE East network

State prevailing rates

Using the rate tables:

View rates by state: