includes all Modifiers Modifier Description accessories, CG Policy Criteria Applied components SC Medical Add On and HQ Setting electronics, QC Remote Support-Monitor Only not otherwise GT Remote Support-Interactive Support classified) S5150 Respite $3.31 per ¼ UN Two Members Served Services- ¼ hour UP Three Members Served hour UQ Four Members Served S5151 Respite $110.21 per UR Five Members Served Services- Per diem US Six Members Served Diem
includes all accessories, components and electronics, not otherwise classified) S5150 Respite Services- ¼ hour $3.31 per ¼ hour S5151 Respite Services- Per Diem $110.21 per diem Modifiers Modifier Description CG Policy Criteria Applied SC Medical Add On HQ Setting QC Remote Support-Monitor Only GT Remote Support-Interactive Support UN Two Members Served UP Three Members Served UQ Four Members Served UR Five Members Served US Six Members Served
c3s029.docx