Charge Code

Effective

to

Gross

Net

Rate Type

Rounding

Revenue Code

HCPCS/CPT Code

Modifier(s)

GL Account

Tiered Rate

Tier 1

Net

Rate Type

Revenue Code

HCPCS/CPT Code

Modifier(s)

Max Minutes

Tier 2

Net

Rate Type

Revenue Code

HCPCS/CPT Code

Modifier(s)