Reimbursement listing only — fee maxima provided; no authorization or documentation rules

This file is a Medicaid FFS fee schedule listing procedure codes, short descriptions, and Maximum/Allowable Charge values; it contains only fee maxima and does not specify prior authorization, documentation, step therapy, or denial rules for the listed codes. Providers should bill using the listed CPT/U/T codes and claim no more than the stated Maximum/Allowable Charge for each code. Codes with a Maximum = $0.00 indicate no payable allowance in this excerpt.

• Fee schedule entries present per-code Maximum or Allowable Charge (e.g., 0426U Maximum = $7,582.20 [[chunk 108]]).
• Many entries show Maximum = $0.00 indicating no payment for those codes in this extract (e.g., multiple T- and U-codes [[chunk 144]][[chunk 162]]).
• Providers should use the listed code and the stated Maximum/Allowable Charge when submitting Medicaid FFS claims (fee-only listing; no coverage criteria included [[chunk 0]]).

Fee schedule lines — no prior authorization or documentation instructions present

The excerpt lists procedure codes with their Maximum/Allowable Charge values but does not include any prior authorization instructions, documentation requirements, denial criteria, or step therapy conditions. Billing should follow the code and maximum shown on the schedule.

• Anesthesia and other series show recurring fixed maxima (e.g., many anesthesia lines with Maximum = $22.80) but contain no authorizations or documentation guidance [[chunk 18]][[chunk 54]].
• U/T-series genomic and specialty test codes are listed with maxima (e.g., 0334U Maximum = $3,500.00) without accompanying coverage rules [[chunk 90]].

Fee schedule excerpt — provider billing reference (codes with maxima only)

This section functions as a provider billing reference: it lists procedure codes, short descriptions, and the Maximum/Allowable Charge for Medicaid FFS but does not specify prior authorization, documentation, denial risk, or step-therapy requirements.

• Example code/value: 0101U Gene sequence analysis panel — Maximum = $1,743.95 [[chunk 36]].
• High-value genomic examples (e.g., 0426U Genome ultra-rapid sequence analysis — Maximum = $7,582.20) are listed with maxima but no clinical or authorization text [[chunk 108]].

Fee schedule lines — maxima listed; no authorization or provider-action text

The excerpt lists procedure codes with associated Maximum/Allowable Charge amounts and includes no prior authorization, documentation, denial, or step therapy rules; providers must bill the specific code and corresponding maximum shown.

• Example: anesthesia-related T-codes and other procedure lines are shown with Maximum values but no accompanying authorization instructions (e.g., repeated $22.80 anesthesia maxima) [[chunk 54]].
• Several codes in this segment show Maximum = $0.00, indicating no payable amount for those codes in this extract [[chunk 72]].

Fee schedule entries and allowable charges — billing maxima only; no authorization rules

This fee schedule excerpt presents U-series, T-series, and other procedure codes alongside their Maximum/Allowable Charges; it does not provide prior authorization, documentation, denial, or step therapy instructions. Providers should reference the listed Maximum when billing.

• Multiple U/T codes are listed with Maximum = $0.00 while others have specific dollar maxima (e.g., 0600U Maximum = $0.00) [[chunk 144]].
• T-code examples include items with specified maxima and many with $0.00; no authorization language is provided in these chunks [[chunk 162]].

Billing reference — fee schedule maxima only; no documentation or authorization instructions

Providers should bill using the CPT/U/T code and the Maximum/Allowable Charge shown on the schedule; the excerpt provides only fee maxima and does not include prior authorization, documentation, denial, or step therapy requirements.

• Sample entries include genomic test maxima (e.g., 0334U Maximum = $3,500.00) and surgical procedure maxima (e.g., 11307 Maximum = $60.32) but no coverage or authorization text [[chunk 90]][[chunk 198]].
• Where multiple values or 'Allowable Charge' appear, use the value listed as the Maximum/Allowable Charge for billing [[chunk 198]].

Fee schedule listing (U/T series) — maxima shown; no authorization or documentation rules

This fee schedule excerpt lists U/T-series procedure codes with their Maximum/Allowable Charges and contains no prior authorization, documentation, denial, or step therapy guidance; billers should submit claims using the specific code and its listed maximum.

• Examples of high maxima appear in genomic lines (e.g., 0426U Maximum = $7,582.20) while some entries show $0.00 — the schedule provides only these maxima, not coverage criteria [[chunk 108]][[chunk 36]].
• Entries labeled 'Allowable Charge' should be interpreted as the Maximum payable amount listed for that code [[chunk 108]].

Fee schedule entries only — Maximum Allowable Charges listed; no provider action rules

The document segment is a fee schedule listing CPT procedure codes and Maximum Allowable Charges; it does not include prior authorization, documentation, step therapy, or denial-policy text. Providers must reference the listed Maximum when submitting claims.

• Sample entries show 'Maximum Allowable Charge' values (e.g., 0516U Maximum Allowable Charge = $416.78) but no provider action requirements are given [[chunk 126]].
• Surgical/repair/graft codes in this area list maxima (e.g., 15841 Maximum = $1,014.06) without accompanying coverage rules [[chunk 234]].

Fee schedule listing — providers must use listed codes and maxima; many codes show $0.00

The excerpt provides procedure codes and Maximum/Allowable Charge values; providers should bill using the listed code and maximum. The excerpt shows many codes with Maximum = $0.00 and does not provide authorization, documentation, denial, or step therapy instructions.

• T-code examples include many $0.00 maxima (e.g., 0785T Maximum = $0.00; 0930T–0934T show $0.00) indicating no payable allowance in this extract [[chunk 162]][[chunk 180]].
• Where nonzero maxima are present (e.g., 0795T Maximum = $465.19), they are presented as fee maxima only without clinical or authorization context [[chunk 162]].

Billing reference — fee maxima only; no denial or step therapy guidance

This fee schedule excerpt lists procedure codes and their Maximum/Allowable Charges (including many zero-dollar maxima) and does not specify prior authorization, documentation, denial, or step therapy requirements. Billers should use the code and maximum shown on the schedule.

• Examples of surgical/dermatology maxima are provided (e.g., 11307 Maximum = $60.32; 14000 Maximum Allowable Charge = $799.24) without policy text about authorization or documentation [[chunk 198]][[chunk 216]].
• Some entries present paired or multiple values; use the Maximum/Allowable Charge listed for claims submission [[chunk 216]].

Fee schedule — no authorization, documentation, or step therapy rules in excerpt

The excerpt is a fee-schedule listing of CPT procedure codes and Maximum Allowable Charges for Medicaid FFS; it contains no prior authorization, step therapy, documentation, or denial policy language. Providers should bill the exact code and the stated Maximum/Allowable Charge.

• Examples include tissue graft and related codes with explicit maxima (e.g., 15842 Maximum = $2,680.00) and a broad surgical code range with maxima (20100–21195) shown in this segment [[chunk 234]][[chunk 252]].
• Where 'Allowable Charge' appears, interpret it as the listed Maximum for billing purposes [[chunk 234]].