12/19/2016 texas medicaid fee schedule - 1 of...
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12/19/2016 1 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
Provider Type:
TOS:
TOS Desc:
Proc Code:
Mod 1:
Mod 2:
Client Age
Frm:
Thru:
Client Age
Units:
Non-
facility/Facility
Total
RVUs/Base
Units:Conversion
Factor:
Medicaid Fee:
Fee Effect
Date:
Adjust %:
Adjusted Fee
for Report
Date:
Note Codes:
Last Pricing
Review Date:
1 2 3 1 2 3
AUDIOLOGIS
T 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
AUDIOLOGIS
T 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
AUDIOLOGIS
T 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
AUDIOLOGIS
T 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
BIRTHING
CENTER 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
CASE
MANAGEMEN
T/HCBS
PROVIDER 1
MEDICAL
SERVICES 90792 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 7/1/2013
CASE
MANAGEMEN
T/HCBS
PROVIDER 1
MEDICAL
SERVICES 90792 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 7/1/2013
CCP
PROVIDER 1
MEDICAL
SERVICES 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
HEALTHY TEXAS WOMEN
Texas Medicaid Fee Schedule Information
Field Descriptions
Classification assigned during provider enrollment and used to determine payable services
One-character type-of-service (TOS) code assigned to each procedure code for system administration.
Non-Facility pricing is for services that are rendered in places of service other than an inpatient hospital or an outpatient hospital. Facility pricing is for services that are rendered in an inpatient hospital (place of service [POS] 3), or an outpatient hospital or ambulatory surgical center (POS 5).
The current relative value units (RVUs) for the procedure code, if the fee is a resource-based fee (RBF). The payable amount for RBFs is calculated by multiplying the total RVUs by the applicable conversion factor. For Anesthesia services only, this column shows the base units instead; and
payment is based on the sum of the base units plus actual face-to-face time units multiplied by the applicable conversion factor.
Description of the TOS.
The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System.
1st Modifier, if required for pricing determination.
2nd Modifier, if required for pricing determination.
The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20
years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations.
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the current year’s Texas Medicaid
Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.
TOS TOS DescProc
Code
Provider
Type
The Texas Medicaid conversion factor that is applicable for determining the amount payable when the rate is calculated by base units for anesthesia services or RVUs for other services.
The Medicaid allowed amount.
Medicaid rates are reviewed every two years or as necessary. This column shows the date on which the most recent review was conducted.
Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation.
A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty. Additional information about rate
changes is available on the TMHP website at www.tmhp.com.
The effective date of service for which the fee is payable.
A percentage reduction has been applied to the allowed fee for this service. This column shows the percent by which the fee was adjusted. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.
The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20 years
of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations.
Medicaid rates are based on the client’s age in days, months or years.
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 2 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 90471 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90472 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90632 21 999 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90636 21 999 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90649 21 26 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90650 19 26 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90651 19 999 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90654 19 999 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90656 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90656 U1 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90670 19 999 Years 0.00 $0.0000 $170.58 10/1/2016 0.00 $170.58 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90707 21 999 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90714 21 999 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90715 21 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90732 21 999 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 3 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 90746 21 999 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97802 0 20 Years 1.00 $28.0672 $28.07 1/1/2015 0.00 $28.07 0.93 $28.0672 $26.10 1/1/2015 0.00 $26.10 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97803 0 20 Years 0.86 $28.0672 $24.14 1/1/2015 0.00 $24.14 0.80 $28.0672 $22.45 1/1/2015 0.00 $22.45 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97804 0 20 Years 0.45 $28.0672 $12.63 1/1/2015 0.00 $12.63 0.43 $28.0672 $12.07 1/1/2015 0.00 $12.07 1/1/2017CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 10022 0 20 Years 0.00 $0.0000 $13.32 1/1/2015 0.00 $13.32 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 10022 21 999 Years 0.00 $0.0000 $12.68 1/1/2015 0.00 $12.68 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 11976 10 55 Years 0.00 $0.0000 $95.36 1/1/2016 0.00 $95.36 0.00 $0.0000 $95.36 1/1/2016 0.00 $95.36 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 11981 0 20 Years 3.98 $28.0672 $102.77 10/1/2016 0.00 $102.77 2.37 $28.0672 $61.20 10/1/2016 0.00 $61.20 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 11981 21 999 Years 3.98 $26.7305 $97.88 10/1/2016 0.00 $97.88 2.37 $26.7305 $58.28 10/1/2016 0.00 $58.28 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 11982 0 20 Years 4.52 $28.0672 $116.71 10/1/2016 0.00 $116.71 2.88 $28.0672 $74.36 10/1/2016 0.00 $74.36 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 11982 21 999 Years 4.52 $26.7305 $111.15 10/1/2016 0.00 $111.15 2.88 $26.7305 $70.82 10/1/2016 0.00 $70.82 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 11983 0 20 Years 6.31 $28.0672 $162.93 10/1/2016 0.00 $162.93 4.99 $28.0672 $128.86 10/1/2016 0.00 $128.86 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 4 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 11983 21 999 Years 6.31 $26.7305 $155.18 10/1/2016 0.00 $155.18 4.99 $26.7305 $122.72 10/1/2016 0.00 $122.72 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 56820 0 20 Years 2.30 $28.6400 $60.60 4/1/2010 -2.00 $59.39 2.30 $28.6400 $60.60 4/1/2010 -2.00 $59.39 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 56820 21 999 Years 2.30 $27.2760 $57.71 4/1/2010 -2.00 $56.56 2.30 $27.2760 $57.71 4/1/2010 -2.00 $56.56 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57170 10 20 Years 1.72 $28.0672 $44.42 1/1/2016 0.00 $44.42 1.38 $28.0672 $35.63 1/1/2016 0.00 $35.63 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57170 21 55 Years 1.72 $26.7305 $42.30 1/1/2016 0.00 $42.30 1.38 $26.7305 $33.94 1/1/2016 0.00 $33.94 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57421 0 20 Years 3.33 $28.6400 $87.74 4/1/2010 -2.00 $85.99 3.33 $28.6400 $87.74 4/1/2010 -2.00 $85.99 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57421 21 999 Years 3.33 $27.2760 $83.56 4/1/2010 -2.00 $81.89 3.33 $27.2760 $83.56 4/1/2010 -2.00 $81.89 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57452 0 20 Years 2.47 $28.6400 $65.08 4/1/2010 -2.00 $63.78 2.47 $28.6400 $65.08 4/1/2010 -2.00 $63.78 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57452 21 999 Years 2.47 $27.2760 $61.98 4/1/2010 -2.00 $60.74 2.47 $27.2760 $61.98 4/1/2010 -2.00 $60.74 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57454 0 20 Years 3.69 $28.6400 $97.23 4/1/2010 -2.00 $95.29 3.69 $28.6400 $97.23 4/1/2010 -2.00 $95.29 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57454 21 999 Years 3.69 $27.2760 $92.60 4/1/2010 -2.00 $90.75 3.69 $27.2760 $92.60 4/1/2010 -2.00 $90.75 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 5 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57455 0 20 Years 3.01 $28.6400 $79.31 4/1/2010 -2.00 $77.72 3.01 $28.6400 $79.31 4/1/2010 -2.00 $77.72 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57455 21 999 Years 3.01 $27.2760 $75.53 4/1/2010 -2.00 $74.02 3.01 $27.2760 $75.53 4/1/2010 -2.00 $74.02 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57456 0 20 Years 2.81 $28.6400 $74.04 4/1/2010 -2.00 $72.56 2.81 $28.6400 $74.04 4/1/2010 -2.00 $72.56 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57456 21 999 Years 2.81 $27.2760 $70.52 4/1/2010 -2.00 $69.11 2.81 $27.2760 $70.52 4/1/2010 -2.00 $69.11 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57460 0 20 Years 4.43 $28.6400 $116.73 4/1/2010 -2.00 $114.40 4.43 $28.6400 $116.73 4/1/2010 -2.00 $114.40 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57460 21 999 Years 4.43 $27.2760 $111.16 4/1/2010 -2.00 $108.94 4.43 $27.2760 $111.16 4/1/2010 -2.00 $108.94 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57461 0 20 Years 5.13 $28.6400 $135.17 4/1/2010 -2.00 $132.47 5.13 $28.6400 $135.17 4/1/2010 -2.00 $132.47 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 57461 21 999 Years 5.13 $27.2760 $128.74 4/1/2010 -2.00 $126.17 5.13 $27.2760 $128.74 4/1/2010 -2.00 $126.17 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 58110 0 20 Years 1.13 $28.6400 $29.77 4/1/2010 -2.00 $29.17 1.13 $28.6400 $29.77 4/1/2010 -2.00 $29.17 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 58110 21 999 Years 1.13 $27.2760 $28.35 4/1/2010 -2.00 $27.78 1.13 $27.2760 $28.35 4/1/2010 -2.00 $27.78 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 58300 0 20 Years 0.00 $0.0000 $53.19 1/1/2016 0.00 $53.19 0.00 $0.0000 $53.19 1/1/2016 0.00 $53.19 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 6 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 58300 21 999 Years 0.00 $0.0000 $50.66 1/1/2016 0.00 $50.66 0.00 $0.0000 $50.66 1/1/2016 0.00 $50.66 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 58301 0 20 Years 0.00 $0.0000 $74.11 1/1/2016 0.00 $74.11 0.00 $0.0000 $74.11 1/1/2016 0.00 $74.11 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 58301 21 999 Years 0.00 $0.0000 $70.58 1/1/2016 0.00 $70.58 0.00 $0.0000 $70.58 1/1/2016 0.00 $70.58 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 71010 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 71010 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE T
TECHNICAL
COMPONENT 71010 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE T
TECHNICAL
COMPONENT 71010 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 7 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 71020 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 71020 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE T
TECHNICAL
COMPONENT 71020 0 20 Years 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE T
TECHNICAL
COMPONENT 71020 21 999 Years 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 76830 0 20 Years 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 76830 21 999 Years 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $38.72 4/1/2015 0.00 $38.72 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 8 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
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Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88172 0 20 Years 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 9 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88172 21 999 Years 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88173 0 20 Years 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88173 21 999 Years 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88305 0 20 Years 1.09 $28.0672 $28.14 4/1/2015 0.00 $28.14 1.09 $28.0672 $28.14 4/1/2015 0.00 $28.14 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88305 21 999 Years 1.09 $26.7305 $26.81 4/1/2015 0.00 $26.81 1.09 $26.7305 $26.81 4/1/2015 0.00 $26.81 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $221.55 4/1/2015 0.00 $221.55 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $211.00 4/1/2015 0.00 $211.00 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88307 0 20 Years 2.41 $28.0672 $62.23 4/1/2013 0.00 $62.23 9 4/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE I
PROFESSIONAL
COMPONENT 88307 21 999 Years 2.41 $26.7305 $59.27 4/1/2013 0.00 $59.27 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 10 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90471 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90472 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90632 21 999 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90636 21 999 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 11 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90649 21 26 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90650 19 26 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90651 19 999 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90654 19 999 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90656 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90656 U1 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90670 19 999 Years 0.00 $0.0000 $170.58 10/1/2016 0.00 $170.58 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 12 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90707 21 999 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90714 21 999 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90715 21 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 13 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90732 21 999 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90736 60 999 Years 0.00 $0.0000 $221.88 10/1/2016 0.00 $221.88 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 90746 21 999 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $8.56 10/1/2014 0.00 $8.56 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $20.21 1/1/2013 -2.00 $19.81 0.00 $0.0000 $20.21 1/1/2013 -2.00 $19.81 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $18.23 1/1/2013 -2.00 $17.87 0.00 $0.0000 $18.23 1/1/2013 -2.00 $17.87 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $20.21 1/1/2013 -2.00 $19.81 0.00 $0.0000 $20.21 1/1/2013 -2.00 $19.81 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $18.23 1/1/2013 -2.00 $17.87 0.00 $0.0000 $18.23 1/1/2013 -2.00 $17.87 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 15 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $31.89 1/1/2013 -2.00 $31.25 0.00 $0.0000 $31.89 1/1/2013 -2.00 $31.25 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $28.76 1/1/2013 -2.00 $28.18 0.00 $0.0000 $28.76 1/1/2013 -2.00 $28.18 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $31.89 1/1/2013 -2.00 $31.25 0.00 $0.0000 $31.89 1/1/2013 -2.00 $31.25 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $28.76 1/1/2013 -2.00 $28.18 0.00 $0.0000 $28.76 1/1/2013 -2.00 $28.18 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 16 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 17 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $10.47 1/1/2013 -2.00 $10.26 0.00 $0.0000 $10.47 1/1/2013 -2.00 $10.26 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $9.44 1/1/2013 -2.00 $9.25 0.00 $0.0000 $9.44 1/1/2013 -2.00 $9.25 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 18 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $10.47 1/1/2013 -2.00 $10.26 0.00 $0.0000 $10.47 1/1/2013 -2.00 $10.26 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $9.44 1/1/2013 -2.00 $9.25 0.00 $0.0000 $9.44 1/1/2013 -2.00 $9.25 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $17.53 1/1/2013 -2.00 $17.18 0.00 $0.0000 $17.53 1/1/2013 -2.00 $17.18 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $15.81 1/1/2013 -2.00 $15.49 0.00 $0.0000 $15.81 1/1/2013 -2.00 $15.49 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $17.53 1/1/2013 -2.00 $17.18 0.00 $0.0000 $17.53 1/1/2013 -2.00 $17.18 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 19 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $15.81 1/1/2013 -2.00 $15.49 0.00 $0.0000 $15.81 1/1/2013 -2.00 $15.49 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99213 TH 10 20 Years 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99213 TH 21 55 Years 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99213 10 20 Years 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99213 21 55 Years 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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RVUs/
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Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99214 TH 10 20 Years 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99214 TH 21 55 Years 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99214 10 20 Years 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99214 21 55 Years 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99215 TH 10 20 Years 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99215 TH 21 55 Years 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99215 10 20 Years 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 2 SURGERY 99215 21 55 Years 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99406 10 20 Years 0.41 $28.6400 $10.80 1/1/2012 -2.00 $10.58 0.41 $28.6400 $10.80 1/1/2012 -2.00 $10.58 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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RVUs/
Base Units
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Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99406 21 55 Years 0.41 $27.2760 $10.29 1/1/2012 -2.00 $10.08 0.41 $27.2760 $10.29 1/1/2012 -2.00 $10.08 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99407 10 20 Years 0.80 $28.6400 $21.08 1/1/2012 -2.00 $20.66 0.80 $28.6400 $21.08 1/1/2012 -2.00 $20.66 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 99407 21 55 Years 0.80 $27.2760 $20.07 1/1/2012 -2.00 $19.67 0.80 $27.2760 $20.07 1/1/2012 -2.00 $19.67 1/1/2015CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 9
OTHER MEDICAL
ITEMS OR
SERVICES A4261 0 999 Years 0.00 $0.0000 $46.77 10/1/2010 0.00 $46.77 0.00 $0.0000 $46.77 10/1/2010 0.00 $46.77 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 9
OTHER MEDICAL
ITEMS OR
SERVICES A4266 0 999 Years 0.00 $0.0000 $31.38 10/1/2010 0.00 $31.38 0.00 $0.0000 $31.38 10/1/2010 0.00 $31.38 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES A4267 0 999 Years 0.00 $0.0000 $0.50 10/1/2010 0.00 $0.50 0.00 $0.0000 $0.50 10/1/2010 0.00 $0.50 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES A4268 0 999 Years 0.00 $0.0000 $2.60 10/1/2010 0.00 $2.60 0.00 $0.0000 $2.60 10/1/2010 0.00 $2.60 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES A4269 10 55 Years 0.00 $0.0000 $11.28 10/1/2010 0.00 $11.28 0.00 $0.0000 $11.28 10/1/2010 0.00 $11.28 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES A9150 FP 0 999 Years 0.00 $0.0000 $12.88 10/1/2010 0.00 $12.88 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES H1010 0 20 Years 0.00 $0.0000 $11.88 10/1/2014 0.00 $11.88 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES H1010 21 999 Years 0.00 $0.0000 $11.32 10/1/2014 0.00 $11.32 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Codes Note CodesTotal
RVUs/
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Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J1050 0 999 Years 0.00 $0.0000 $0.19 1/1/2013 0.00 $0.19 9 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J1050 U1 0 999 Years 0.00 $0.0000 $64.98 1/1/2013 0.00 $64.98 9 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7297 10 55 Years 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7297 U8 10 55 Years 0.00 $0.0000 $335.63 1/1/2016 0.00 $335.63 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7298 10 55 Years 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7298 U8 10 55 Years 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7300 0 999 Years 0.00 $0.0000 $693.48 1/1/2016 0.00 $693.48 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7300 FP U8 0 999 Years 0.00 $0.0000 $346.74 1/1/2016 0.00 $346.74 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7300 U8 0 999 Years 0.00 $0.0000 $346.74 1/1/2016 0.00 $346.74 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7301 10 55 Years 0.00 $0.0000 $663.32 1/1/2016 0.00 $663.32 9 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7301 U8 10 55 Years 0.00 $0.0000 $530.66 1/1/2016 0.00 $530.66 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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RVUs/
Base Units
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Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7307 0 999 Years 0.00 $0.0000 $723.99 1/1/2016 0.00 $723.99 1/1/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES J7307 U8 0 999 Years 0.00 $0.0000 $579.20 1/1/2016 0.00 $579.20 1/1/2016
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
(CRNA) GR 7 ANESTHESIA 00400 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
(CRNA) GR 7 ANESTHESIA 00400 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
(CRNA) GR 7 ANESTHESIA 00851 21 999 Years 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 1/1/2016
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
(CRNA) GR 7 ANESTHESIA 00940 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
(CRNA) GR 7 ANESTHESIA 00940 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
/ANES ASST 7 ANESTHESIA 00400 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
/ANES ASST 7 ANESTHESIA 00400 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
/ANES ASST 7 ANESTHESIA 00851 21 999 Years 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 1/1/2016
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
/ANES ASST 7 ANESTHESIA 00940 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CERTIFIED
REGISTERED
NURSE
ANESTHETIST
/ANES ASST 7 ANESTHESIA 00940 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
CLINIC/GROU
P PRACTICE 7 ANESTHESIA 00400 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
CLINIC/GROU
P PRACTICE 7 ANESTHESIA 00400 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
CLINIC/GROU
P PRACTICE 7 ANESTHESIA 00851 21 999 Years 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 1/1/2016
CLINIC/GROU
P PRACTICE 7 ANESTHESIA 00940 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
CLINIC/GROU
P PRACTICE 7 ANESTHESIA 00940 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
CLINIC/GROU
P PRACTICE 2 SURGERY 10022 0 20 Years 3.94 $28.0672 $110.58 1/1/2015 0.00 $110.58 1.88 $28.0672 $52.77 1/1/2015 0.00 $52.77 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 10022 21 999 Years 3.94 $26.7305 $105.32 1/1/2015 0.00 $105.32 1.88 $26.7305 $50.25 1/1/2015 0.00 $50.25 1/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 10022 0 20 Years 0.00 $0.0000 $14.48 1/1/2015 0.00 $14.48 1/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 10022 21 999 Years 0.00 $0.0000 $13.78 1/1/2015 0.00 $13.78 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 11976 10 55 Years 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 11981 0 20 Years 3.98 $28.0672 $111.71 10/1/2016 0.00 $111.71 2.37 $28.0672 $66.52 10/1/2016 0.00 $66.52 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 11981 21 999 Years 3.98 $26.7305 $106.39 10/1/2016 0.00 $106.39 2.37 $26.7305 $63.35 10/1/2016 0.00 $63.35 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 11982 0 20 Years 4.52 $28.0672 $126.86 10/1/2016 0.00 $126.86 2.88 $28.0672 $80.83 10/1/2016 0.00 $80.83 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 11982 21 999 Years 4.52 $26.7305 $120.82 10/1/2016 0.00 $120.82 2.88 $26.7305 $76.98 10/1/2016 0.00 $76.98 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 11983 0 20 Years 6.31 $28.0672 $177.10 10/1/2016 0.00 $177.10 4.99 $28.0672 $140.06 10/1/2016 0.00 $140.06 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 11983 21 999 Years 6.31 $26.7305 $168.67 10/1/2016 0.00 $168.67 4.99 $26.7305 $133.39 10/1/2016 0.00 $133.39 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19000 0 20 Years 3.21 $28.0672 $90.10 10/1/2016 0.00 $90.10 1.26 $28.0672 $35.36 10/1/2014 0.00 $35.36 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19000 21 999 Years 3.21 $26.7305 $85.80 10/1/2016 0.00 $85.80 1.26 $26.7305 $33.68 10/1/2014 0.00 $33.68 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19081 0 20 Years 19.70 $28.0672 $552.92 10/1/2016 0.00 $552.92 4.90 $28.0672 $137.53 10/1/2016 0.00 $137.53 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19081 21 999 Years 19.70 $26.7305 $526.59 10/1/2016 0.00 $526.59 4.90 $26.7305 $130.98 10/1/2016 0.00 $130.98 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 2 SURGERY 19082 0 20 Years 16.28 $28.0672 $456.93 10/1/2016 0.00 $456.93 2.45 $28.0672 $68.76 10/1/2016 0.00 $68.76 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19082 21 999 Years 16.28 $26.7305 $435.17 10/1/2016 0.00 $435.17 2.45 $26.7305 $65.49 10/1/2016 0.00 $65.49 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19083 0 20 Years 19.05 $28.0672 $534.68 10/1/2016 0.00 $534.68 4.59 $28.0672 $128.83 10/1/2016 0.00 $128.83 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19083 21 999 Years 19.05 $26.7305 $509.22 10/1/2016 0.00 $509.22 4.59 $26.7305 $122.69 10/1/2016 0.00 $122.69 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19084 0 20 Years 15.66 $28.0672 $439.53 10/1/2016 0.00 $439.53 2.30 $28.0672 $64.55 10/1/2016 0.00 $64.55 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19084 21 999 Years 15.66 $26.7305 $418.60 10/1/2016 0.00 $418.60 2.30 $26.7305 $61.48 10/1/2016 0.00 $61.48 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19100 0 20 Years 4.28 $28.0672 $120.13 10/1/2016 0.00 $120.13 2.02 $28.0672 $56.70 10/1/2016 0.00 $56.70 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19100 21 999 Years 4.28 $26.7305 $114.41 10/1/2016 0.00 $114.41 2.02 $26.7305 $54.00 10/1/2016 0.00 $54.00 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19101 0 20 Years 9.71 $28.0672 $272.53 10/1/2016 0.00 $272.53 6.37 $28.0672 $178.79 10/1/2016 0.00 $178.79 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19101 21 999 Years 9.71 $26.7305 $259.55 10/1/2016 0.00 $259.55 6.37 $26.7305 $170.27 10/1/2016 0.00 $170.27 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19120 0 20 Years 14.11 $28.0672 $396.03 10/1/2016 0.00 $396.03 11.89 $28.0672 $333.72 10/1/2016 0.00 $333.72 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19120 21 999 Years 14.11 $26.7305 $377.17 10/1/2016 0.00 $377.17 11.89 $26.7305 $317.83 10/1/2016 0.00 $317.83 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19125 0 20 Years 13.22 $28.0672 $371.05 10/1/2016 0.00 $371.05 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19125 21 999 Years 13.22 $26.7305 $353.38 10/1/2016 0.00 $353.38 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19126 0 20 Years 4.68 $28.0672 $131.35 10/1/2016 0.00 $131.35 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19126 21 999 Years 4.68 $26.7305 $125.10 10/1/2016 0.00 $125.10 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19281 0 20 Years 6.80 $28.0672 $190.86 10/1/2016 0.00 $190.86 2.93 $28.0672 $82.24 1/1/2014 0.00 $82.24 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19281 21 999 Years 6.80 $26.7305 $181.77 10/1/2016 0.00 $181.77 2.93 $26.7305 $78.32 1/1/2014 0.00 $78.32 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19282 0 20 Years 4.76 $28.0672 $133.60 1/1/2014 0.00 $133.60 1.47 $28.0672 $41.26 10/1/2016 0.00 $41.26 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19282 21 999 Years 4.76 $26.7305 $127.24 1/1/2014 0.00 $127.24 1.47 $26.7305 $39.29 10/1/2016 0.00 $39.29 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19283 0 20 Years 7.65 $28.0672 $214.71 10/1/2016 0.00 $214.71 2.95 $28.0672 $82.80 10/1/2016 0.00 $82.80 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19283 21 999 Years 7.65 $26.7305 $204.49 10/1/2016 0.00 $204.49 2.95 $26.7305 $78.85 10/1/2016 0.00 $78.85 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 26 of 197TEXAS MEDICAID FEE SCHEDULE -
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CLINIC/GROU
P PRACTICE 2 SURGERY 19284 0 20 Years 5.77 $28.0672 $161.95 10/1/2016 0.00 $161.95 1.49 $28.0672 $41.82 10/1/2016 0.00 $41.82 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19284 21 999 Years 5.77 $26.7305 $154.23 10/1/2016 0.00 $154.23 1.49 $26.7305 $39.83 10/1/2016 0.00 $39.83 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19285 0 20 Years 14.62 $28.0672 $410.34 10/1/2016 0.00 $410.34 2.50 $28.0672 $70.17 10/1/2016 0.00 $70.17 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19285 21 999 Years 14.62 $26.7305 $390.80 10/1/2016 0.00 $390.80 2.50 $26.7305 $66.83 10/1/2016 0.00 $66.83 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19286 0 20 Years 12.84 $28.0672 $360.38 10/1/2016 0.00 $360.38 1.26 $28.0672 $35.36 10/1/2016 0.00 $35.36 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 19286 21 999 Years 12.84 $26.7305 $343.22 10/1/2016 0.00 $343.22 1.26 $26.7305 $33.68 10/1/2016 0.00 $33.68 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56405 0 20 Years 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56405 21 999 Years 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56420 0 20 Years 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56420 21 999 Years 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56501 0 20 Years 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56501 21 999 Years 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56515 0 20 Years 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56515 21 999 Years 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56605 0 20 Years 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56605 21 999 Years 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56606 0 20 Years 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56606 21 999 Years 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56820 0 20 Years 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 56820 21 999 Years 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57023 0 20 Years 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57023 21 999 Years 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 27 of 197TEXAS MEDICAID FEE SCHEDULE -
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Fee for
Report
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CLINIC/GROU
P PRACTICE 2 SURGERY 57061 0 20 Years 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57061 21 999 Years 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57100 0 20 Years 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57100 21 999 Years 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57170 10 20 Years 1.72 $28.0672 $48.28 1/1/2016 0.00 $48.28 1.38 $28.0672 $38.73 1/1/2016 0.00 $38.73 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57170 21 55 Years 1.72 $26.7305 $45.98 1/1/2016 0.00 $45.98 1.38 $26.7305 $36.89 1/1/2016 0.00 $36.89 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57421 0 20 Years 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57421 21 999 Years 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57452 0 20 Years 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57452 21 999 Years 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57454 0 20 Years 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57454 21 999 Years 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57455 0 20 Years 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57455 21 999 Years 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57456 0 20 Years 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57456 21 999 Years 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57460 0 20 Years 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57460 21 999 Years 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57461 0 20 Years 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57461 21 999 Years 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57500 0 20 Years 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57500 21 999 Years 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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CLINIC/GROU
P PRACTICE 2 SURGERY 57505 0 20 Years 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57505 21 999 Years 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57511 0 20 Years 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57511 21 999 Years 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57520 0 20 Years 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57520 21 999 Years 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57522 0 20 Years 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 57522 21 999 Years 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58100 0 20 Years 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58100 21 999 Years 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58110 0 20 Years 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58110 21 999 Years 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58300 0 20 Years 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58300 21 999 Years 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58301 0 20 Years 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58301 21 999 Years 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58340 0 20 Years 3.36 $28.0672 $94.31 1/1/2016 0.00 $94.31 1.66 $28.0672 $46.59 10/1/2014 0.00 $46.59 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58340 21 999 Years 3.36 $26.7305 $89.81 1/1/2016 0.00 $89.81 1.66 $26.7305 $44.37 10/1/2014 0.00 $44.37 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58562 0 20 Years 7.92 $28.6400 $226.83 4/1/2010 -2.00 $222.29 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58562 21 999 Years 7.92 $27.2760 $216.03 4/1/2010 -2.00 $211.71 10/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58565 21 999 Years 0.00 $0.0000 $1,543.15 1/1/2016 0.00 $1,543.15 0.00 $0.0000 $348.03 1/1/2016 0.00 $348.03 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58600 21 999 Years 0.00 $0.0000 $292.70 1/1/2016 0.00 $292.70 10 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Report
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CLINIC/GROU
P PRACTICE 8
ASSISTANT
SURGERY 58600 0 20 Years 1.75 $28.0672 $49.12 9/1/2013 0.00 $49.12 10/1/2014
CLINIC/GROU
P PRACTICE 2 SURGERY 58611 21 55 Years 0.00 $0.0000 $61.75 1/1/2016 0.00 $61.75 10 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58615 21 55 Years 0.00 $0.0000 $195.67 1/1/2016 0.00 $195.67 10 1/1/2016
CLINIC/GROU
P PRACTICE 8
ASSISTANT
SURGERY 58615 0 20 Years 1.17 $28.0672 $32.84 9/1/2013 0.00 $32.84 10/1/2014
CLINIC/GROU
P PRACTICE 2 SURGERY 58670 21 55 Years 10.35 $26.7305 $276.66 1/1/2016 0.00 $276.66 1/1/2016
CLINIC/GROU
P PRACTICE 2 SURGERY 58671 21 55 Years 10.33 $26.7305 $276.13 1/1/2016 0.00 $276.13 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 71010 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 71010 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 71010 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 71010 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 71020 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 71020 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 71020 0 20 Years 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 71020 21 999 Years 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 73060 0 20 Years 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 73060 21 999 Years 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 73060 0 20 Years 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 73060 21 999 Years 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 73060 0 20 Years 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 73060 21 999 Years 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 74000 0 20 Years 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 74000 21 999 Years 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 74000 0 20 Years 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 74000 21 999 Years 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 74000 0 20 Years 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 74000 21 999 Years 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 74010 0 20 Years 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 74010 21 999 Years 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 74010 0 20 Years 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 74010 21 999 Years 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 74010 0 20 Years 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 74010 21 999 Years 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 74740 0 20 Years 2.11 $28.0672 $59.22 1/1/2016 0.00 $59.22 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 74740 21 999 Years 2.11 $26.7305 $56.40 1/1/2016 0.00 $56.40 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 74740 0 20 Years 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 74740 21 999 Years 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 74740 0 20 Years 1.56 $28.0672 $43.78 1/1/2016 0.00 $43.78 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 74740 21 999 Years 1.56 $26.7305 $41.70 1/1/2016 0.00 $41.70 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76098 0 20 Years 0.56 $28.0672 $15.72 1/1/2014 0.00 $15.72 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76098 21 999 Years 0.56 $26.7305 $14.97 1/1/2014 0.00 $14.97 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76098 0 20 Years 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76098 21 999 Years 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76098 0 20 Years 0.33 $28.0672 $9.26 1/1/2014 0.00 $9.26 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76098 21 999 Years 0.33 $26.7305 $8.82 1/1/2014 0.00 $8.82 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76641 0 20 Years 3.06 $28.0672 $85.89 1/1/2015 0.00 $85.89 9 7/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76641 21 999 Years 3.06 $26.7305 $81.80 1/1/2015 0.00 $81.80 9 7/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76641 0 20 Years 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 7/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76641 21 999 Years 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 7/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76641 0 20 Years 2.01 $28.0672 $56.42 1/1/2015 0.00 $56.42 9 7/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76641 21 999 Years 2.01 $26.7305 $53.73 1/1/2015 0.00 $53.73 9 7/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76642 0 20 Years 2.52 $28.0672 $70.73 1/1/2015 0.00 $70.73 9 7/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76642 21 999 Years 2.52 $26.7305 $67.36 1/1/2015 0.00 $67.36 9 7/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76642 0 20 Years 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 7/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76642 21 999 Years 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 7/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76642 0 20 Years 1.54 $28.0672 $43.22 1/1/2015 0.00 $43.22 9 7/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76642 21 999 Years 1.54 $26.7305 $41.16 1/1/2015 0.00 $41.16 9 7/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76700 0 20 Years 4.21 $28.0672 $118.16 1/1/2014 0.00 $118.16 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76700 21 999 Years 4.21 $26.7305 $112.54 1/1/2014 0.00 $112.54 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76700 0 20 Years 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76700 21 999 Years 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76700 0 20 Years 3.06 $28.0672 $85.89 1/1/2014 0.00 $85.89 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76700 21 999 Years 3.06 $26.7305 $81.80 1/1/2014 0.00 $81.80 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76705 0 20 Years 3.24 $28.0672 $90.94 1/1/2014 0.00 $90.94 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76705 21 999 Years 3.24 $26.7305 $86.61 1/1/2014 0.00 $86.61 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76705 0 20 Years 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76705 21 999 Years 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76705 0 20 Years 2.41 $28.0672 $67.64 1/1/2014 0.00 $67.64 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76705 21 999 Years 2.41 $26.7305 $64.42 1/1/2014 0.00 $64.42 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76770 0 20 Years 3.97 $28.0672 $111.43 1/1/2014 0.00 $111.43 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76770 21 999 Years 3.97 $26.7305 $106.12 1/1/2014 0.00 $106.12 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76770 0 20 Years 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76770 21 999 Years 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76770 0 20 Years 2.92 $28.0672 $81.96 1/1/2014 0.00 $81.96 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76770 21 999 Years 2.92 $26.7305 $78.05 1/1/2014 0.00 $78.05 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76830 0 20 Years 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76830 21 999 Years 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76856 0 20 Years 3.10 $28.0672 $87.01 1/1/2016 0.00 $87.01 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76856 21 999 Years 3.10 $26.7305 $82.86 1/1/2016 0.00 $82.86 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76856 0 20 Years 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76856 21 999 Years 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 33 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76856 0 20 Years 2.13 $28.0672 $59.78 1/1/2016 0.00 $59.78 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76856 21 999 Years 2.13 $26.7305 $56.94 1/1/2016 0.00 $56.94 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76857 0 20 Years 1.33 $28.0672 $37.33 1/1/2016 0.00 $37.33 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76857 21 999 Years 1.33 $26.7305 $35.55 1/1/2016 0.00 $35.55 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76857 0 20 Years 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76857 21 999 Years 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76857 0 20 Years 0.64 $28.0672 $17.96 1/1/2016 0.00 $17.96 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76857 21 999 Years 0.64 $26.7305 $17.11 1/1/2016 0.00 $17.11 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76881 0 20 Years 3.29 $28.0672 $92.34 1/1/2016 0.00 $92.34 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76881 21 999 Years 3.29 $26.7305 $87.94 1/1/2016 0.00 $87.94 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76881 0 20 Years 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76881 21 999 Years 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76881 0 20 Years 2.39 $28.0672 $67.08 1/1/2016 0.00 $67.08 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76881 21 999 Years 2.39 $26.7305 $63.89 1/1/2016 0.00 $63.89 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76882 0 20 Years 1.02 $28.0672 $28.63 1/1/2016 0.00 $28.63 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76882 21 999 Years 1.02 $26.7305 $27.27 1/1/2016 0.00 $27.27 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76882 0 20 Years 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 1/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76882 21 999 Years 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 1/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76882 0 20 Years 0.32 $28.0672 $8.98 1/1/2016 0.00 $8.98 10/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76882 21 999 Years 0.32 $26.7305 $8.55 1/1/2016 0.00 $8.55 10/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76942 0 20 Years 6.13 $28.0672 $172.05 1/1/2014 0.00 $172.05 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76942 21 999 Years 6.13 $26.7305 $163.86 1/1/2014 0.00 $163.86 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 34 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76942 0 20 Years 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76942 21 999 Years 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76942 0 20 Years 5.17 $28.0672 $145.11 1/1/2014 0.00 $145.11 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76942 21 999 Years 5.17 $26.7305 $138.20 1/1/2014 0.00 $138.20 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76998 0 20 Years 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 76998 21 999 Years 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76998 0 20 Years 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 76998 21 999 Years 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76998 0 20 Years 0.00 $0.0000 $91.76 1/1/2014 0.00 $91.76 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 76998 21 999 Years 0.00 $0.0000 $87.40 1/1/2014 0.00 $87.40 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77051 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77051 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77051 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77051 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77051 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77051 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77052 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77052 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77052 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77052 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77052 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77052 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77053 0 20 Years 1.76 $28.0672 $49.40 1/1/2014 0.00 $49.40 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77053 21 999 Years 1.76 $26.7305 $47.05 1/1/2014 0.00 $47.05 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77053 0 20 Years 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 1/1/2014
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77053 21 999 Years 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77053 0 20 Years 1.26 $28.0672 $35.36 1/1/2014 0.00 $35.36 9 1/1/2014
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77053 21 999 Years 1.26 $26.7305 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77055 0 20 Years 2.52 $28.0672 $70.73 11/1/2015 0.00 $70.73 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77055 21 999 Years 2.52 $26.7305 $67.36 11/1/2015 0.00 $67.36 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77055 0 20 Years 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77055 21 999 Years 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77055 0 20 Years 1.52 $28.0672 $42.66 11/1/2015 0.00 $42.66 9 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77055 21 999 Years 1.52 $26.7305 $40.63 11/1/2015 0.00 $40.63 9 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77056 0 20 Years 3.24 $28.0672 $90.94 11/1/2015 0.00 $90.94 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77056 21 999 Years 3.24 $26.7305 $86.61 11/1/2015 0.00 $86.61 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77056 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77056 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77056 0 20 Years 2.00 $28.0672 $56.13 11/1/2015 0.00 $56.13 9 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77056 21 999 Years 2.00 $26.7305 $53.46 11/1/2015 0.00 $53.46 9 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77057 0 20 Years 2.31 $28.0672 $64.84 11/1/2015 0.00 $64.84 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77057 21 999 Years 2.31 $26.7305 $61.75 11/1/2015 0.00 $61.75 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77057 0 20 Years 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77057 21 999 Years 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 36 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77057 0 20 Years 1.31 $28.0672 $36.77 11/1/2015 0.00 $36.77 9 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77057 21 999 Years 1.31 $26.7305 $35.02 11/1/2015 0.00 $35.02 9 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77058 0 20 Years 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77058 21 999 Years 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77058 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77058 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77058 0 20 Years 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77058 21 999 Years 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77059 0 20 Years 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 11/1/2015
CLINIC/GROU
P PRACTICE 4 RADIOLOGY 77059 21 999 Years 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77059 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 77059 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77059 0 20 Years 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 11/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 77059 21 999 Years 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 11/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88160 0 20 Years 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 37 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88160 21 999 Years 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 4/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 88160 0 20 Years 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 4/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 88160 21 999 Years 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88161 0 20 Years 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88161 21 999 Years 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 4/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 88161 0 20 Years 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 4/1/2015
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT 88161 21 999 Years 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88172 0 20 Years 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88172 21 999 Years 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88173 0 20 Years 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88173 21 999 Years 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88305 0 20 Years 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88305 21 999 Years 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $240.82 4/1/2015 0.00 $240.82 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 38 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $229.35 4/1/2015 0.00 $229.35 9 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88307 0 20 Years 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 4/1/2015
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT 88307 21 999 Years 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 4/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90471 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90472 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90632 21 999 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90636 21 999 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90649 21 26 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90650 19 26 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90651 19 999 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90654 19 999 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90656 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 39 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90656 U1 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90670 19 999 Years 0.00 $0.0000 $170.58 10/1/2016 0.00 $170.58 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90707 21 999 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90714 21 999 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90715 21 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90732 21 999 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90736 60 999 Years 0.00 $0.0000 $221.88 10/1/2016 0.00 $221.88 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90746 21 999 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 7/1/2013
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 7/1/2013
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90792 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 7/1/2013
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90792 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 7/1/2013
CLINIC/GROU
P PRACTICE 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 94760 0 20 Years 0.09 $28.0672 $2.53 4/1/2015 0.00 $2.53 4/1/2015
CLINIC/GROU
P PRACTICE 5 LABORATORY 94760 21 999 Years 0.09 $26.7305 $2.41 4/1/2015 0.00 $2.41 4/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99078 0 999 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99078 TH 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99078 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99204 FP 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99204 FP 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 42 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99213 TH 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99213 TH 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99213 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99213 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 43 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99214 FP 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99214 FP 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99214 TH 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99214 TH 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99214 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99214 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99215 TH 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99215 TH 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99215 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
CLINIC/GROU
P PRACTICE 2 SURGERY 99215 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
CLINIC/GROU
P PRACTICE 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99385 18 39 Years 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99386 40 64 Years 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 44 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99395 18 39 Years 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99396 40 64 Years 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99406 10 20 Years 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99406 21 55 Years 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99407 10 20 Years 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 1/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 99407 21 55 Years 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 1/1/2015
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES A4261 0 999 Years 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 1/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES A4264 21 999 Years 0.00 $0.0000 $1,560.00 9/1/2013 0.00 $1,560.00 1/1/2016
CLINIC/GROU
P PRACTICE 9
OTHER MEDICAL
ITEMS OR
SERVICES A4266 0 999 Years 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES A4267 0 999 Years 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES A4268 0 999 Years 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES A4269 10 55 Years 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES A9150 FP 0 999 Years 0.00 $0.0000 $14.00 4/1/1995 0.00 $14.00 1/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY G0202 0 20 Years 3.77 $28.0672 $105.81 4/1/2014 0.00 $105.81 4/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY G0202 21 999 Years 3.77 $26.7305 $100.77 4/1/2014 0.00 $100.77 4/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT G0202 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT G0202 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT G0202 0 20 Years 2.78 $28.0672 $78.03 4/1/2014 0.00 $78.03 4/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT G0202 21 999 Years 2.78 $26.7305 $74.31 4/1/2014 0.00 $74.31 4/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY G0204 0 20 Years 4.60 $28.0672 $129.11 4/1/2014 0.00 $129.11 4/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY G0204 21 999 Years 4.60 $26.7305 $122.96 4/1/2014 0.00 $122.96 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 45 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT G0204 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 4/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT G0204 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 4/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT G0204 0 20 Years 3.36 $28.0672 $94.31 4/1/2014 0.00 $94.31 4/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT G0204 21 999 Years 3.36 $26.7305 $89.81 4/1/2014 0.00 $89.81 4/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY G0206 0 20 Years 3.62 $28.0672 $101.60 4/1/2014 0.00 $101.60 4/1/2016
CLINIC/GROU
P PRACTICE 4 RADIOLOGY G0206 21 999 Years 3.62 $26.7305 $96.76 4/1/2014 0.00 $96.76 4/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT G0206 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
CLINIC/GROU
P PRACTICE I
PROFESSIONAL
COMPONENT G0206 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT G0206 0 20 Years 2.63 $28.0672 $73.82 4/1/2014 0.00 $73.82 4/1/2016
CLINIC/GROU
P PRACTICE T
TECHNICAL
COMPONENT G0206 21 999 Years 2.63 $26.7305 $70.30 4/1/2014 0.00 $70.30 4/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES H1010 0 20 Years 0.00 $0.0000 $12.91 10/1/2014 0.00 $12.91 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES H1010 21 999 Years 0.00 $0.0000 $12.30 10/1/2014 0.00 $12.30 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J1050 0 999 Years 0.00 $0.0000 $0.19 1/1/2013 0.00 $0.19 9 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J1050 U1 0 999 Years 0.00 $0.0000 $64.98 1/1/2013 0.00 $64.98 9 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7297 10 55 Years 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7297 U8 10 55 Years 0.00 $0.0000 $335.63 1/1/2016 0.00 $335.63 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 46 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7298 10 55 Years 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7298 U8 10 55 Years 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7300 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7300 FP 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7301 10 55 Years 0.00 $0.0000 $663.32 1/1/2016 0.00 $663.32 9 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7301 U8 10 55 Years 0.00 $0.0000 $530.66 1/1/2016 0.00 $530.66 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7307 0 999 Years 0.00 $0.0000 $786.95 1/1/2016 0.00 $786.95 1/1/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES J7307 U8 0 999 Years 0.00 $0.0000 $629.56 1/1/2016 0.00 $629.56 1/1/2016
COMPREHENS
IVE HEALTH
CENTER
(CHC) 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 10022 0 Y 3.94 $28.0672 $110.58 1/1/2015 0.00 $110.58 1.88 $28.0672 $52.77 1/1/2015 0.00 $52.77 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 10022 21 Y 3.94 $26.7305 $105.32 1/1/2015 0.00 $105.32 1.88 $26.7305 $50.25 1/1/2015 0.00 $50.25 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 5 LABORATORY 88305 0 Y 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
DENTIST
(D.D.S.,
D.M.D.) 5 LABORATORY 88305 21 Y 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 96372 0 Y 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 96372 21 Y 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99201 0 Y 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99201 21 Y 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99201 TH 10 Y 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99201 TH 21 Y 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99201 10 Y 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99201 21 Y 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 47 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99202 0 Y 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99202 21 Y 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99202 TH 10 Y 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99202 TH 21 Y 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99202 10 Y 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99202 21 Y 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99203 0 Y 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99203 21 Y 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99203 TH 10 Y 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99203 TH 21 Y 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99203 10 Y 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99203 21 Y 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99204 0 Y 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99204 21 Y 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99204 TH 10 Y 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99204 TH 21 Y 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99204 10 Y 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99204 21 Y 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99205 0 Y 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99205 21 Y 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99205 TH 10 Y 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99205 TH 21 Y 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 48 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99205 10 Y 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 2 SURGERY 99205 21 Y 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99211 0 Y 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99211 21 Y 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99212 0 Y 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99212 21 Y 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99213 0 Y 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99213 21 Y 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99214 0 Y 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99214 21 Y 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99215 0 Y 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES 99215 21 Y 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99241 0 Y 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99241 21 Y 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99242 0 Y 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99242 21 Y 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99243 0 Y 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99243 21 Y 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99244 0 Y 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 3 CONSULTATION 99244 21 Y 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES J0558 0 Y 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES J0561 0 Y 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 49 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES J0690 0 Y 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES J0696 0 Y 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES J2010 0 Y 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
DENTIST
(D.D.S.,
D.M.D.) 1
MEDICAL
SERVICES J3490 0 Y 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
DENTISTRY
GROUP 2 SURGERY 10022 0 20 Years 3.94 $28.0672 $110.58 1/1/2015 0.00 $110.58 1.88 $28.0672 $52.77 1/1/2015 0.00 $52.77 1/1/2015
DENTISTRY
GROUP 2 SURGERY 10022 21 999 Years 3.94 $26.7305 $105.32 1/1/2015 0.00 $105.32 1.88 $26.7305 $50.25 1/1/2015 0.00 $50.25 1/1/2015
DENTISTRY
GROUP 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
DENTISTRY
GROUP 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
DENTISTRY
GROUP 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 50 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
DENTISTRY
GROUP 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
DENTISTRY
GROUP 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
DENTISTRY
GROUP 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
DENTISTRY
GROUP 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
DENTISTRY
GROUP 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
DENTISTRY
GROUP 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
DENTISTRY
GROUP 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
DENTISTRY
GROUP 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 51 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
FAMILY
PLANNING
CLINIC 7 ANESTHESIA 00851 21 999 Years 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11976 10 20 Years 4.05 $26.7305 $108.26 1/1/2016 0.00 $108.26 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11976 21 55 Years 4.05 $26.7305 $108.26 1/1/2016 0.00 $108.26 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11981 0 20 Years 3.98 $28.0672 $111.71 10/1/2016 0.00 $111.71 2.37 $28.0672 $66.52 10/1/2016 0.00 $66.52 10/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11981 21 999 Years 3.98 $26.7305 $106.39 10/1/2016 0.00 $106.39 2.37 $26.7305 $63.35 10/1/2016 0.00 $63.35 10/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11982 0 20 Years 4.52 $28.0672 $126.86 10/1/2016 0.00 $126.86 10/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11982 21 999 Years 4.52 $26.7305 $120.82 10/1/2016 0.00 $120.82 10/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11983 0 20 Years 6.31 $28.0672 $177.10 10/1/2016 0.00 $177.10 10/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 11983 21 999 Years 6.31 $26.7305 $168.67 10/1/2016 0.00 $168.67 10/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 57170 10 20 Years 1.72 $28.0672 $48.28 1/1/2016 0.00 $48.28 1.38 $28.0672 $38.73 1/1/2016 0.00 $38.73 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 57170 21 55 Years 1.72 $26.7305 $45.98 1/1/2016 0.00 $45.98 1.38 $26.7305 $36.89 1/1/2016 0.00 $36.89 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58300 0 20 Years 1.98 $28.0672 $55.57 1/1/2016 0.00 $55.57 1.98 $28.0672 $55.57 1/1/2016 0.00 $55.57 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58300 21 999 Years 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58301 0 999 Years 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58340 0 20 Years 3.36 $28.0672 $94.31 1/1/2016 0.00 $94.31 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58340 21 999 Years 3.36 $26.7305 $89.81 1/1/2016 0.00 $89.81 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58565 21 999 Years 0.00 $0.0000 $1,543.15 1/1/2016 0.00 $1,543.15 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58670 21 55 Years 10.35 $26.7305 $276.66 1/1/2016 0.00 $276.66 1/1/2016
FAMILY
PLANNING
CLINIC 2 SURGERY 58671 21 55 Years 10.33 $26.7305 $276.13 1/1/2016 0.00 $276.13 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 74000 0 20 Years 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 74000 21 999 Years 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 74010 0 20 Years 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 52 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 74010 21 999 Years 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 74740 0 20 Years 2.11 $28.0672 $59.22 1/1/2016 0.00 $59.22 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 74740 21 999 Years 2.11 $26.7305 $56.40 1/1/2016 0.00 $56.40 1/1/2016
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 74740 0 20 Years 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 1/1/2016
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 74740 21 999 Years 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 74740 0 20 Years 1.56 $28.0672 $43.78 1/1/2016 0.00 $43.78 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 74740 21 999 Years 1.56 $26.7305 $41.70 1/1/2016 0.00 $41.70 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 76830 0 20 Years 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 76830 21 999 Years 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 76856 0 20 Years 3.10 $28.0672 $87.01 1/1/2016 0.00 $87.01 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 76856 21 999 Years 3.10 $26.7305 $82.86 1/1/2016 0.00 $82.86 1/1/2016
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 76856 0 20 Years 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 1/1/2016
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 76856 21 999 Years 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 76856 0 20 Years 2.13 $28.0672 $59.78 1/1/2016 0.00 $59.78 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 76856 21 999 Years 2.13 $26.7305 $56.94 1/1/2016 0.00 $56.94 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 76857 0 20 Years 1.33 $28.0672 $37.33 1/1/2016 0.00 $37.33 1/1/2016
FAMILY
PLANNING
CLINIC 4 RADIOLOGY 76857 21 999 Years 1.33 $26.7305 $35.55 1/1/2016 0.00 $35.55 1/1/2016
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 76857 0 20 Years 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 53 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
FAMILY
PLANNING
CLINIC I
PROFESSIONAL
COMPONENT 76857 21 999 Years 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 76857 0 20 Years 0.64 $28.0672 $17.96 1/1/2016 0.00 $17.96 1/1/2016
FAMILY
PLANNING
CLINIC T
TECHNICAL
COMPONENT 76857 21 999 Years 0.64 $26.7305 $17.11 1/1/2016 0.00 $17.11 1/1/2016
FAMILY
PLANNING
CLINIC 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 -5.00 $5.86 9 0.22 $28.0672 $6.17 4/1/2015 -5.00 $5.86 9 4/1/2015
FAMILY
PLANNING
CLINIC 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 -5.00 $5.59 9 0.22 $26.7305 $5.88 4/1/2015 -5.00 $5.59 9 4/1/2015
FAMILY
PLANNING
CLINIC 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -5.00 $24.00 9 0.90 $28.0672 $25.26 4/1/2015 -5.00 $24.00 9 4/1/2015
FAMILY
PLANNING
CLINIC 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -5.00 $22.86 9 0.90 $26.7305 $24.06 4/1/2015 -5.00 $22.86 9 4/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 7/1/2013 0.00 $9.30 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99201 0 20 Years 0.83 $27.2760 $22.64 7/1/2009 -7.00 $21.06 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99201 21 999 Years 0.83 $27.2760 $22.64 7/1/2009 -7.00 $21.06 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99202 0 20 Years 1.31 $27.2760 $35.73 7/1/2009 -7.00 $33.23 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99202 21 999 Years 1.31 $27.2760 $35.73 7/1/2009 -7.00 $33.23 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99203 0 20 Years 1.77 $27.2760 $48.28 9/1/2002 -7.00 $44.90 1 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99203 21 999 Years 1.77 $27.2760 $48.28 9/1/2002 -7.00 $44.90 1 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99204 0 20 Years 2.59 $27.2760 $70.64 7/1/2009 -7.00 $65.70 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99204 21 999 Years 2.59 $27.2760 $70.64 7/1/2009 -7.00 $65.70 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99204 FP 0 20 Years 2.59 $27.2760 $70.64 9/1/2007 -7.00 $65.70 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99204 FP 21 999 Years 2.59 $27.2760 $70.64 9/1/2007 -7.00 $65.70 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99205 0 20 Years 3.22 $27.2760 $87.83 7/1/2009 -7.00 $81.68 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 54 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99205 21 999 Years 3.22 $27.2760 $87.83 7/1/2009 -7.00 $81.68 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99211 0 20 Years 0.43 $27.2760 $11.73 7/1/2009 -7.00 $10.91 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99211 21 999 Years 0.43 $27.2760 $11.73 7/1/2009 -7.00 $10.91 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99212 0 20 Years 0.72 $27.2760 $19.64 7/1/2009 -7.00 $18.27 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99212 21 999 Years 0.72 $27.2760 $19.64 7/1/2009 -7.00 $18.27 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $29.52 1/18/2002 -7.00 $27.45 1 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $29.52 1/18/2002 -7.00 $27.45 1 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99214 0 20 Years 1.52 $27.2760 $41.46 9/1/2002 -7.00 $38.56 1 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99214 21 999 Years 1.52 $27.2760 $41.46 7/1/2009 -7.00 $38.56 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99214 FP 0 20 Years 1.52 $27.2760 $41.46 9/1/2007 -7.00 $38.56 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99214 FP 21 999 Years 1.52 $27.2760 $41.46 9/1/2007 -7.00 $38.56 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99215 0 20 Years 2.34 $27.2760 $63.83 7/1/2009 -7.00 $59.36 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99215 21 999 Years 2.34 $27.2760 $63.83 7/1/2009 -7.00 $59.36 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -7.00 $41.73 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -7.00 $37.64 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -7.00 $65.33 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -7.00 $58.93 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -7.00 $84.42 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -7.00 $76.14 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -7.00 $118.37 1/1/2015
FAMILY
PLANNING
CLINIC 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -7.00 $106.76 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99385 18 39 Years 2.95 $27.2760 $80.46 1/1/2014 -7.00 $74.83 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 55 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99386 40 64 Years 3.45 $27.2760 $94.10 1/1/2010 -7.00 $87.51 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99395 18 39 Years 2.56 $27.2760 $69.83 1/1/2014 -7.00 $64.94 1/1/2015
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES 99396 40 64 Years 2.80 $27.2760 $76.37 1/1/2010 -7.00 $71.02 1/1/2015
FAMILY
PLANNING
CLINIC 9
OTHER MEDICAL
ITEMS OR
SERVICES A4261 0 999 Years 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 1/1/2016
FAMILY
PLANNING
CLINIC 9
OTHER MEDICAL
ITEMS OR
SERVICES A4264 21 999 Years 0.00 $0.0000 $1,560.00 9/1/2013 0.00 $1,560.00 1/1/2016
FAMILY
PLANNING
CLINIC 9
OTHER MEDICAL
ITEMS OR
SERVICES A4266 0 999 Years 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES A4267 0 999 Years 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES A4268 0 999 Years 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES A4269 10 55 Years 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES A9150 FP 0 999 Years 0.00 $0.0000 $14.00 4/1/1995 0.00 $14.00 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES H1010 0 20 Years 0.00 $0.0000 $12.91 10/1/2014 0.00 $12.91 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES H1010 21 999 Years 0.00 $0.0000 $12.30 10/1/2014 0.00 $12.30 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J1050 0 999 Years 0.00 $0.0000 $0.19 1/1/2013 0.00 $0.19 9 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J1050 U1 0 999 Years 0.00 $0.0000 $64.98 1/1/2013 0.00 $64.98 9 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7297 10 55 Years 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7297 U8 10 55 Years 0.00 $0.0000 $125.00 1/1/2016 0.00 $125.00 0.00 $0.0000 $125.00 1/1/2016 0.00 $125.00 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7298 10 55 Years 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7298 U8 10 55 Years 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7300 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7300 FP U8 0 999 Years 0.00 $0.0000 $376.89 1/1/2016 0.00 $376.89 0.00 $0.0000 $376.89 1/1/2016 0.00 $376.89 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7300 U8 0 999 Years 0.00 $0.0000 $376.89 1/1/2016 0.00 $376.89 0.00 $0.0000 $376.89 1/1/2016 0.00 $376.89 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 56 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7301 10 55 Years 0.00 $0.0000 $663.32 1/1/2016 0.00 $663.32 9 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7301 U8 10 55 Years 0.00 $0.0000 $530.66 1/1/2016 0.00 $530.66 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7303 0 999 Years 0.00 $0.0000 $113.32 1/1/2016 0.00 $113.32 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7304 0 999 Years 0.00 $0.0000 $37.48 10/1/2014 0.00 $37.48 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES J7307 0 999 Years 0.00 $0.0000 $786.95 1/1/2016 0.00 $786.95 1/1/2016
FAMILY
PLANNING
CLINIC 1
MEDICAL
SERVICES S4993 10 55 Years 0.00 $0.0000 $19.42 10/1/2014 0.00 $19.42 0.00 $0.0000 $19.42 10/1/2014 0.00 $19.42 1/1/2016
GENETICS G GENETICS 99213 0 20 Years 2.14 $28.0672 $60.06 7/1/2013 0.00 $60.06 1.46 $28.0672 $40.98 7/1/2013 0.00 $40.98 1/1/2015
GENETICS G GENETICS 99213 21 999 Years 2.14 $26.7305 $57.20 7/1/2013 0.00 $57.20 1.46 $26.7305 $39.03 7/1/2013 0.00 $39.03 1/1/2015
GENETICS G GENETICS 99214 0 20 Years 3.14 $28.0672 $88.13 7/1/2013 0.00 $88.13 2.25 $28.0672 $63.15 7/1/2013 0.00 $63.15 1/1/2015
GENETICS G GENETICS 99214 21 999 Years 3.14 $26.7305 $83.93 7/1/2013 0.00 $83.93 2.25 $26.7305 $60.14 7/1/2013 0.00 $60.14 1/1/2015
GENETICS G GENETICS 99215 0 20 Years 4.20 $28.0672 $117.88 7/1/2013 0.00 $117.88 3.17 $28.0672 $88.97 7/1/2013 0.00 $88.97 1/1/2015
GENETICS G GENETICS 99215 21 999 Years 4.20 $26.7305 $112.27 7/1/2013 0.00 $112.27 3.17 $26.7305 $84.74 7/1/2013 0.00 $84.74 1/1/2015
GENETICS G GENETICS 99244 0 20 Years 5.20 $28.0672 $145.95 7/1/2013 0.00 $145.95 4.38 $28.0672 $122.93 7/1/2013 0.00 $122.93 1/1/2015
GENETICS G GENETICS 99244 21 999 Years 5.20 $26.7305 $139.00 7/1/2013 0.00 $139.00 4.38 $26.7305 $117.08 7/1/2013 0.00 $117.08 1/1/2015
HOME
HEALTH DME 1
MEDICAL
SERVICES A9150 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2016INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 57 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateINDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA I
PROFESSIONAL
COMPONENT 88160 0 20 Years 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA I
PROFESSIONAL
COMPONENT 88160 21 999 Years 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88160 0 20 Years 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88160 21 999 Years 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA I
PROFESSIONAL
COMPONENT 88161 0 20 Years 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA I
PROFESSIONAL
COMPONENT 88161 21 999 Years 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88161 0 20 Years 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88161 21 999 Years 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 58 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateINDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88172 0 20 Years 0.55 $28.0672 $15.44 4/1/2015 0.00 $15.44 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88172 21 999 Years 0.55 $26.7305 $14.70 4/1/2015 0.00 $14.70 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88173 0 20 Years 2.22 $28.0672 $62.31 4/1/2015 0.00 $62.31 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88173 21 999 Years 2.22 $26.7305 $59.34 4/1/2015 0.00 $59.34 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88305 0 20 Years 0.95 $28.0672 $26.66 4/1/2015 0.00 $26.66 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 59 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateINDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88305 21 999 Years 0.95 $26.7305 $25.39 4/1/2015 0.00 $25.39 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $240.82 4/1/2015 0.00 $240.82 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $229.35 4/1/2015 0.00 $229.35 9 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88307 0 20 Years 6.17 $28.0672 $173.17 4/1/2015 0.00 $173.17 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA T
TECHNICAL
COMPONENT 88307 21 999 Years 6.17 $26.7305 $164.93 4/1/2015 0.00 $164.93 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB (NO
PHYSICIA 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 60 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I I
PROFESSIONAL
COMPONENT 88160 0 20 Years 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I I
PROFESSIONAL
COMPONENT 88160 21 999 Years 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88160 0 20 Years 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88160 21 999 Years 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 61 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I I
PROFESSIONAL
COMPONENT 88161 0 20 Years 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I I
PROFESSIONAL
COMPONENT 88161 21 999 Years 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88161 0 20 Years 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88161 21 999 Years 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88172 0 20 Years 0.55 $28.0672 $15.44 4/1/2015 0.00 $15.44 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88172 21 999 Years 0.55 $26.7305 $14.70 4/1/2015 0.00 $14.70 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 62 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88173 0 20 Years 2.22 $28.0672 $62.31 4/1/2015 0.00 $62.31 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88173 21 999 Years 2.22 $26.7305 $59.34 4/1/2015 0.00 $59.34 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88305 0 20 Years 0.95 $28.0672 $26.66 4/1/2015 0.00 $26.66 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88305 21 999 Years 0.95 $26.7305 $25.39 4/1/2015 0.00 $25.39 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $240.82 4/1/2015 0.00 $240.82 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 63 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $229.35 4/1/2015 0.00 $229.35 9 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88307 0 20 Years 6.17 $28.0672 $173.17 4/1/2015 0.00 $173.17 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I T
TECHNICAL
COMPONENT 88307 21 999 Years 6.17 $26.7305 $164.93 4/1/2015 0.00 $164.93 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015
INDEPENDEN
T
LAB/PRIVATE
LY OWNED
LAB
(PHYSICIAN I 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
LICENSED
CLINICAL
SOCIAL
WORKER
(LCSW) 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 7/1/2013
LICENSED
CLINICAL
SOCIAL
WORKER
(LCSW) 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 7/1/2013
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 0.00 $0.0000 $28.87 1/1/2009 -2.00 $28.29 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 64 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MATERNITY
SERVICE
CLINIC 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 0.00 $0.0000 $41.09 1/1/2009 -2.00 $40.27 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 0.00 $0.0000 $61.56 1/1/2009 -2.00 $60.33 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 0.00 $0.0000 $90.07 1/1/2009 -2.00 $88.27 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 0.00 $0.0000 $101.00 1/1/2009 -2.00 $98.98 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 0.00 $0.0000 $13.49 1/1/2009 -2.00 $13.22 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 0.00 $0.0000 $25.04 1/1/2009 -2.00 $24.54 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99213 TH 10 20 Years 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 65 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99213 TH 21 55 Years 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99213 10 20 Years 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99213 21 55 Years 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 0.00 $0.0000 $37.64 1/1/2009 -2.00 $36.89 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99214 TH 10 20 Years 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99214 TH 21 55 Years 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99214 10 20 Years 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99214 21 55 Years 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 0.00 $0.0000 $52.86 1/1/2009 -2.00 $51.80 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99215 TH 10 20 Years 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 1/1/2015
MATERNITY
SERVICE
CLINIC 1
MEDICAL
SERVICES 99215 TH 21 55 Years 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99215 10 20 Years 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 1/1/2015
MATERNITY
SERVICE
CLINIC 2 SURGERY 99215 21 55 Years 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 0.00 $0.0000 $73.40 1/1/2009 -2.00 $71.93 1/1/2015
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES A9150 0 999 Years 0.00 $0.0000 $0.00 5/1/2003 $0.00 5 1/1/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 4 RADIOLOGY 71010 0 Y 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 4 RADIOLOGY 71010 21 Y 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 66 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 4 RADIOLOGY 71020 0 Y 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 4 RADIOLOGY 71020 21 Y 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 4 RADIOLOGY 76830 0 Y 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 4 RADIOLOGY 76830 21 Y 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 5 LABORATORY 80050 0 Y 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 5 LABORATORY 86580 0 Y 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 5 LABORATORY 86580 21 Y 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 5 LABORATORY 88305 0 Y 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 5 LABORATORY 88305 21 Y 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 5 LABORATORY 93000 0 Y 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 5 LABORATORY 93000 21 Y 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 67 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 99000 0 Y 0.00 $0.0000 $9.30 7/1/2013 0.00 $9.30 1/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES J0558 0 Y 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES J0561 0 Y 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES J0690 0 Y 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES J0696 0 Y 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES J2010 0 Y 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
OPTOMETRIC
GROUP 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
OPTOMETRIC
GROUP 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 68 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
OPTOMETRIC
GROUP 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
OPTOMETRIC
GROUP 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
OPTOMETRIC
GROUP 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
OPTOMETRIC
GROUP 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
OPTOMETRIC
GROUP 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
OPTOMETRIC
GROUP 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
OPTOMETRIC
GROUP 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 69 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OPTOMETRIC
GROUP 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
OPTOMETRIC
GROUP 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
OPTOMETRIC
GROUP 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
OPTOMETRIS
T 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
OPTOMETRIS
T 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
OPTOMETRIS
T 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
OPTOMETRIS
T 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
OPTOMETRIS
T 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
OPTOMETRIS
T 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
OPTOMETRIS
T 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
OPTOMETRIS
T 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
OPTOMETRIS
T 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
OPTOMETRIS
T 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
OPTOMETRIS
T 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 70 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OPTOMETRIS
T 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
OPTOMETRIS
T 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
OPTOMETRIS
T 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
OPTOMETRIS
T 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
OPTOMETRIS
T 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
PHYSICIAN
(D.O.) 7 ANESTHESIA 00400 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(D.O.) 7 ANESTHESIA 00400 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(D.O.) 7 ANESTHESIA 00851 21 999 Years 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 1/1/2016
PHYSICIAN
(D.O.) 7 ANESTHESIA 00940 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(D.O.) 7 ANESTHESIA 00940 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(D.O.) 2 SURGERY 10022 0 20 Years 3.94 $28.0672 $110.58 1/1/2015 0.00 $110.58 1.88 $28.0672 $52.77 1/1/2015 0.00 $52.77 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 10022 21 999 Years 3.94 $26.7305 $105.32 1/1/2015 0.00 $105.32 1.88 $26.7305 $50.25 1/1/2015 0.00 $50.25 1/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 10022 0 20 Years 0.00 $0.0000 $14.48 1/1/2015 0.00 $14.48 1/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 10022 21 999 Years 0.00 $0.0000 $13.78 1/1/2015 0.00 $13.78 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 11976 10 55 Years 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 11981 0 20 Years 3.98 $28.0672 $111.71 10/1/2016 0.00 $111.71 2.37 $28.0672 $66.52 10/1/2016 0.00 $66.52 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 11981 21 999 Years 3.98 $26.7305 $106.39 10/1/2016 0.00 $106.39 2.37 $26.7305 $63.35 10/1/2016 0.00 $63.35 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 71 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 2 SURGERY 11982 0 20 Years 4.52 $28.0672 $126.86 10/1/2016 0.00 $126.86 2.88 $28.0672 $80.83 10/1/2016 0.00 $80.83 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 11982 21 999 Years 4.52 $26.7305 $120.82 10/1/2016 0.00 $120.82 2.88 $26.7305 $76.98 10/1/2016 0.00 $76.98 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 11983 0 20 Years 6.31 $28.0672 $177.10 10/1/2016 0.00 $177.10 4.99 $28.0672 $140.06 10/1/2016 0.00 $140.06 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 11983 21 999 Years 6.31 $26.7305 $168.67 10/1/2016 0.00 $168.67 4.99 $26.7305 $133.39 10/1/2016 0.00 $133.39 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19000 0 20 Years 3.21 $28.0672 $90.10 10/1/2016 0.00 $90.10 1.26 $28.0672 $35.36 10/1/2014 0.00 $35.36 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19000 21 999 Years 3.21 $26.7305 $85.80 10/1/2016 0.00 $85.80 1.26 $26.7305 $33.68 10/1/2014 0.00 $33.68 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19081 0 20 Years 19.70 $28.0672 $552.92 10/1/2016 0.00 $552.92 4.90 $28.0672 $137.53 10/1/2016 0.00 $137.53 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19081 21 999 Years 19.70 $26.7305 $526.59 10/1/2016 0.00 $526.59 4.90 $26.7305 $130.98 10/1/2016 0.00 $130.98 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19082 0 20 Years 16.28 $28.0672 $456.93 10/1/2016 0.00 $456.93 2.45 $28.0672 $68.76 10/1/2016 0.00 $68.76 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19082 21 999 Years 16.28 $26.7305 $435.17 10/1/2016 0.00 $435.17 2.45 $26.7305 $65.49 10/1/2016 0.00 $65.49 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19083 0 20 Years 19.05 $28.0672 $534.68 10/1/2016 0.00 $534.68 4.59 $28.0672 $128.83 10/1/2016 0.00 $128.83 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19083 21 999 Years 19.05 $26.7305 $509.22 10/1/2016 0.00 $509.22 4.59 $26.7305 $122.69 10/1/2016 0.00 $122.69 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19084 0 20 Years 15.66 $28.0672 $439.53 10/1/2016 0.00 $439.53 2.30 $28.0672 $64.55 10/1/2016 0.00 $64.55 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19084 21 999 Years 15.66 $26.7305 $418.60 10/1/2016 0.00 $418.60 2.30 $26.7305 $61.48 10/1/2016 0.00 $61.48 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19100 0 20 Years 4.28 $28.0672 $120.13 10/1/2016 0.00 $120.13 2.02 $28.0672 $56.70 10/1/2016 0.00 $56.70 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19100 21 999 Years 4.28 $26.7305 $114.41 10/1/2016 0.00 $114.41 2.02 $26.7305 $54.00 10/1/2016 0.00 $54.00 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19101 0 20 Years 9.71 $28.0672 $272.53 10/1/2016 0.00 $272.53 6.37 $28.0672 $178.79 10/1/2016 0.00 $178.79 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19101 21 999 Years 9.71 $26.7305 $259.55 10/1/2016 0.00 $259.55 6.37 $26.7305 $170.27 10/1/2016 0.00 $170.27 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19120 0 20 Years 14.11 $28.0672 $396.03 10/1/2016 0.00 $396.03 11.89 $28.0672 $333.72 10/1/2016 0.00 $333.72 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19120 21 999 Years 14.11 $26.7305 $377.17 10/1/2016 0.00 $377.17 11.89 $26.7305 $317.83 10/1/2016 0.00 $317.83 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19125 0 20 Years 13.22 $28.0672 $371.05 10/1/2016 0.00 $371.05 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19125 21 999 Years 13.22 $26.7305 $353.38 10/1/2016 0.00 $353.38 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19126 0 20 Years 4.68 $28.0672 $131.35 10/1/2016 0.00 $131.35 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19126 21 999 Years 4.68 $26.7305 $125.10 10/1/2016 0.00 $125.10 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19281 0 20 Years 6.80 $28.0672 $190.86 10/1/2016 0.00 $190.86 2.93 $28.0672 $82.24 1/1/2014 0.00 $82.24 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19281 21 999 Years 6.80 $26.7305 $181.77 10/1/2016 0.00 $181.77 2.93 $26.7305 $78.32 1/1/2014 0.00 $78.32 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19282 0 20 Years 4.76 $28.0672 $133.60 1/1/2014 0.00 $133.60 1.47 $28.0672 $41.26 10/1/2016 0.00 $41.26 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19282 21 999 Years 4.76 $26.7305 $127.24 1/1/2014 0.00 $127.24 1.47 $26.7305 $39.29 10/1/2016 0.00 $39.29 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19283 0 20 Years 7.65 $28.0672 $214.71 10/1/2016 0.00 $214.71 2.95 $28.0672 $82.80 10/1/2016 0.00 $82.80 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19283 21 999 Years 7.65 $26.7305 $204.49 10/1/2016 0.00 $204.49 2.95 $26.7305 $78.85 10/1/2016 0.00 $78.85 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19284 0 20 Years 5.77 $28.0672 $161.95 10/1/2016 0.00 $161.95 1.49 $28.0672 $41.82 10/1/2016 0.00 $41.82 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19284 21 999 Years 5.77 $26.7305 $154.23 10/1/2016 0.00 $154.23 1.49 $26.7305 $39.83 10/1/2016 0.00 $39.83 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19285 0 20 Years 14.62 $28.0672 $410.34 10/1/2016 0.00 $410.34 2.50 $28.0672 $70.17 10/1/2016 0.00 $70.17 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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RVUs/
Base Units
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Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 2 SURGERY 19285 21 999 Years 14.62 $26.7305 $390.80 10/1/2016 0.00 $390.80 2.50 $26.7305 $66.83 10/1/2016 0.00 $66.83 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19286 0 20 Years 12.84 $28.0672 $360.38 10/1/2016 0.00 $360.38 1.26 $28.0672 $35.36 10/1/2016 0.00 $35.36 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 19286 21 999 Years 12.84 $26.7305 $343.22 10/1/2016 0.00 $343.22 1.26 $26.7305 $33.68 10/1/2016 0.00 $33.68 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56405 0 20 Years 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56405 21 999 Years 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56420 0 20 Years 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56420 21 999 Years 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56501 0 20 Years 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56501 21 999 Years 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56515 0 20 Years 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56515 21 999 Years 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56605 0 20 Years 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56605 21 999 Years 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56606 0 20 Years 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56606 21 999 Years 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56820 0 20 Years 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 56820 21 999 Years 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57023 0 20 Years 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57023 21 999 Years 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57061 0 20 Years 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57061 21 999 Years 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57100 0 20 Years 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57100 21 999 Years 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57170 10 20 Years 1.72 $28.0672 $48.28 1/1/2016 0.00 $48.28 1.38 $28.0672 $38.73 1/1/2016 0.00 $38.73 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57170 21 55 Years 1.72 $26.7305 $45.98 1/1/2016 0.00 $45.98 1.38 $26.7305 $36.89 1/1/2016 0.00 $36.89 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57421 0 20 Years 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57421 21 999 Years 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57452 0 20 Years 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57452 21 999 Years 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57454 0 20 Years 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57454 21 999 Years 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57455 0 20 Years 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57455 21 999 Years 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 73 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 2 SURGERY 57456 0 20 Years 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57456 21 999 Years 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57460 0 20 Years 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57460 21 999 Years 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57461 0 20 Years 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57461 21 999 Years 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57500 0 20 Years 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57500 21 999 Years 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57505 0 20 Years 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57505 21 999 Years 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57511 0 20 Years 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57511 21 999 Years 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57520 0 20 Years 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57520 21 999 Years 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57522 0 20 Years 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 57522 21 999 Years 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58100 0 20 Years 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58100 21 999 Years 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58110 0 20 Years 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58110 21 999 Years 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58300 0 20 Years 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58300 21 999 Years 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58301 0 20 Years 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58301 21 999 Years 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58340 0 20 Years 3.36 $28.0672 $94.31 1/1/2016 0.00 $94.31 1.66 $28.0672 $46.59 10/1/2014 0.00 $46.59 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58340 21 999 Years 3.36 $26.7305 $89.81 1/1/2016 0.00 $89.81 1.66 $26.7305 $44.37 10/1/2014 0.00 $44.37 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58562 0 20 Years 7.92 $28.6400 $226.83 4/1/2010 -2.00 $222.29 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58562 21 999 Years 7.92 $27.2760 $216.03 4/1/2010 -2.00 $211.71 10/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58565 21 999 Years 0.00 $0.0000 $1,543.15 1/1/2016 0.00 $1,543.15 0.00 $0.0000 $348.03 1/1/2016 0.00 $348.03 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58600 21 999 Years 0.00 $0.0000 $292.70 1/1/2016 0.00 $292.70 10 1/1/2016
PHYSICIAN
(D.O.) 8
ASSISTANT
SURGERY 58600 0 20 Years 1.75 $28.0672 $49.12 9/1/2013 0.00 $49.12 10/1/2014
PHYSICIAN
(D.O.) 2 SURGERY 58611 21 55 Years 0.00 $0.0000 $61.75 1/1/2016 0.00 $61.75 10 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58615 21 55 Years 0.00 $0.0000 $195.67 1/1/2016 0.00 $195.67 10 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 74 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
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FacilityClient Age
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 8
ASSISTANT
SURGERY 58615 0 20 Years 1.17 $28.0672 $32.84 9/1/2013 0.00 $32.84 10/1/2014
PHYSICIAN
(D.O.) 2 SURGERY 58670 21 55 Years 10.35 $26.7305 $276.66 1/1/2016 0.00 $276.66 1/1/2016
PHYSICIAN
(D.O.) 2 SURGERY 58671 21 55 Years 10.33 $26.7305 $276.13 1/1/2016 0.00 $276.13 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 71010 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 71010 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 71010 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 71010 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 71020 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 71020 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 71020 0 20 Years 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 71020 21 999 Years 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 73060 0 20 Years 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 73060 21 999 Years 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 73060 0 20 Years 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 73060 21 999 Years 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 73060 0 20 Years 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 73060 21 999 Years 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 74000 0 20 Years 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 74000 21 999 Years 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 74000 0 20 Years 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 74000 21 999 Years 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 74000 0 20 Years 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 74000 21 999 Years 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 74010 0 20 Years 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 74010 21 999 Years 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 74010 0 20 Years 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 74010 21 999 Years 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 74010 0 20 Years 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 74010 21 999 Years 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 75 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 4 RADIOLOGY 74740 0 20 Years 2.11 $28.0672 $59.22 1/1/2016 0.00 $59.22 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 74740 21 999 Years 2.11 $26.7305 $56.40 1/1/2016 0.00 $56.40 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 74740 0 20 Years 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 74740 21 999 Years 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 74740 0 20 Years 1.56 $28.0672 $43.78 1/1/2016 0.00 $43.78 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 74740 21 999 Years 1.56 $26.7305 $41.70 1/1/2016 0.00 $41.70 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76098 0 20 Years 0.56 $28.0672 $15.72 1/1/2014 0.00 $15.72 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76098 21 999 Years 0.56 $26.7305 $14.97 1/1/2014 0.00 $14.97 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76098 0 20 Years 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76098 21 999 Years 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76098 0 20 Years 0.33 $28.0672 $9.26 1/1/2014 0.00 $9.26 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76098 21 999 Years 0.33 $26.7305 $8.82 1/1/2014 0.00 $8.82 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76641 0 20 Years 3.06 $28.0672 $85.89 1/1/2015 0.00 $85.89 9 7/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 76641 21 999 Years 3.06 $26.7305 $81.80 1/1/2015 0.00 $81.80 9 7/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76641 0 20 Years 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 7/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76641 21 999 Years 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 7/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76641 0 20 Years 2.01 $28.0672 $56.42 1/1/2015 0.00 $56.42 9 7/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76641 21 999 Years 2.01 $26.7305 $53.73 1/1/2015 0.00 $53.73 9 7/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 76642 0 20 Years 2.52 $28.0672 $70.73 1/1/2015 0.00 $70.73 9 7/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 76642 21 999 Years 2.52 $26.7305 $67.36 1/1/2015 0.00 $67.36 9 7/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76642 0 20 Years 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 7/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76642 21 999 Years 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 7/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76642 0 20 Years 1.54 $28.0672 $43.22 1/1/2015 0.00 $43.22 9 7/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76642 21 999 Years 1.54 $26.7305 $41.16 1/1/2015 0.00 $41.16 9 7/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 76700 0 20 Years 4.21 $28.0672 $118.16 1/1/2014 0.00 $118.16 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76700 21 999 Years 4.21 $26.7305 $112.54 1/1/2014 0.00 $112.54 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76700 0 20 Years 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76700 21 999 Years 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76700 0 20 Years 3.06 $28.0672 $85.89 1/1/2014 0.00 $85.89 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76700 21 999 Years 3.06 $26.7305 $81.80 1/1/2014 0.00 $81.80 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76705 0 20 Years 3.24 $28.0672 $90.94 1/1/2014 0.00 $90.94 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76705 21 999 Years 3.24 $26.7305 $86.61 1/1/2014 0.00 $86.61 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76705 0 20 Years 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 76 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76705 21 999 Years 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76705 0 20 Years 2.41 $28.0672 $67.64 1/1/2014 0.00 $67.64 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76705 21 999 Years 2.41 $26.7305 $64.42 1/1/2014 0.00 $64.42 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76770 0 20 Years 3.97 $28.0672 $111.43 1/1/2014 0.00 $111.43 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76770 21 999 Years 3.97 $26.7305 $106.12 1/1/2014 0.00 $106.12 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76770 0 20 Years 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76770 21 999 Years 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76770 0 20 Years 2.92 $28.0672 $81.96 1/1/2014 0.00 $81.96 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76770 21 999 Years 2.92 $26.7305 $78.05 1/1/2014 0.00 $78.05 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76830 0 20 Years 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76830 21 999 Years 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76856 0 20 Years 3.10 $28.0672 $87.01 1/1/2016 0.00 $87.01 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76856 21 999 Years 3.10 $26.7305 $82.86 1/1/2016 0.00 $82.86 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76856 0 20 Years 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76856 21 999 Years 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76856 0 20 Years 2.13 $28.0672 $59.78 1/1/2016 0.00 $59.78 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76856 21 999 Years 2.13 $26.7305 $56.94 1/1/2016 0.00 $56.94 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76857 0 20 Years 1.33 $28.0672 $37.33 1/1/2016 0.00 $37.33 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76857 21 999 Years 1.33 $26.7305 $35.55 1/1/2016 0.00 $35.55 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76857 0 20 Years 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76857 21 999 Years 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76857 0 20 Years 0.64 $28.0672 $17.96 1/1/2016 0.00 $17.96 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76857 21 999 Years 0.64 $26.7305 $17.11 1/1/2016 0.00 $17.11 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76881 0 20 Years 3.29 $28.0672 $92.34 1/1/2016 0.00 $92.34 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76881 21 999 Years 3.29 $26.7305 $87.94 1/1/2016 0.00 $87.94 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76881 0 20 Years 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76881 21 999 Years 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76881 0 20 Years 2.39 $28.0672 $67.08 1/1/2016 0.00 $67.08 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76881 21 999 Years 2.39 $26.7305 $63.89 1/1/2016 0.00 $63.89 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 77 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 4 RADIOLOGY 76882 0 20 Years 1.02 $28.0672 $28.63 1/1/2016 0.00 $28.63 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY 76882 21 999 Years 1.02 $26.7305 $27.27 1/1/2016 0.00 $27.27 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76882 0 20 Years 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 1/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76882 21 999 Years 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 1/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76882 0 20 Years 0.32 $28.0672 $8.98 1/1/2016 0.00 $8.98 10/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76882 21 999 Years 0.32 $26.7305 $8.55 1/1/2016 0.00 $8.55 10/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76942 0 20 Years 6.13 $28.0672 $172.05 1/1/2014 0.00 $172.05 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76942 21 999 Years 6.13 $26.7305 $163.86 1/1/2014 0.00 $163.86 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76942 0 20 Years 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76942 21 999 Years 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76942 0 20 Years 5.17 $28.0672 $145.11 1/1/2014 0.00 $145.11 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76942 21 999 Years 5.17 $26.7305 $138.20 1/1/2014 0.00 $138.20 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76998 0 20 Years 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 76998 21 999 Years 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76998 0 20 Years 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 76998 21 999 Years 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76998 0 20 Years 0.00 $0.0000 $91.76 1/1/2014 0.00 $91.76 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 76998 21 999 Years 0.00 $0.0000 $87.40 1/1/2014 0.00 $87.40 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 77051 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77051 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77051 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77051 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77051 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77051 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77052 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77052 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77052 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77052 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77052 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77052 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77053 0 20 Years 1.76 $28.0672 $49.40 1/1/2014 0.00 $49.40 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 77053 21 999 Years 1.76 $26.7305 $47.05 1/1/2014 0.00 $47.05 9 1/1/2014
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77053 0 20 Years 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 78 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77053 21 999 Years 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77053 0 20 Years 1.26 $28.0672 $35.36 1/1/2014 0.00 $35.36 9 1/1/2014
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77053 21 999 Years 1.26 $26.7305 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014
PHYSICIAN
(D.O.) 4 RADIOLOGY 77055 0 20 Years 2.52 $28.0672 $70.73 11/1/2015 0.00 $70.73 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77055 21 999 Years 2.52 $26.7305 $67.36 11/1/2015 0.00 $67.36 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77055 0 20 Years 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77055 21 999 Years 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77055 0 20 Years 1.52 $28.0672 $42.66 11/1/2015 0.00 $42.66 9 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77055 21 999 Years 1.52 $26.7305 $40.63 11/1/2015 0.00 $40.63 9 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77056 0 20 Years 3.24 $28.0672 $90.94 11/1/2015 0.00 $90.94 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77056 21 999 Years 3.24 $26.7305 $86.61 11/1/2015 0.00 $86.61 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77056 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77056 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77056 0 20 Years 2.00 $28.0672 $56.13 11/1/2015 0.00 $56.13 9 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77056 21 999 Years 2.00 $26.7305 $53.46 11/1/2015 0.00 $53.46 9 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77057 0 20 Years 2.31 $28.0672 $64.84 11/1/2015 0.00 $64.84 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77057 21 999 Years 2.31 $26.7305 $61.75 11/1/2015 0.00 $61.75 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77057 0 20 Years 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77057 21 999 Years 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77057 0 20 Years 1.31 $28.0672 $36.77 11/1/2015 0.00 $36.77 9 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77057 21 999 Years 1.31 $26.7305 $35.02 11/1/2015 0.00 $35.02 9 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77058 0 20 Years 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77058 21 999 Years 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77058 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77058 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77058 0 20 Years 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77058 21 999 Years 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77059 0 20 Years 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 11/1/2015
PHYSICIAN
(D.O.) 4 RADIOLOGY 77059 21 999 Years 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77059 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 77059 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77059 0 20 Years 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 11/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 77059 21 999 Years 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 79 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88160 0 20 Years 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88160 21 999 Years 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 4/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 88160 0 20 Years 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 4/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 88160 21 999 Years 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88161 0 20 Years 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88161 21 999 Years 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 4/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 88161 0 20 Years 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 4/1/2015
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT 88161 21 999 Years 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88172 0 20 Years 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88172 21 999 Years 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88173 0 20 Years 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88173 21 999 Years 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88305 0 20 Years 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88305 21 999 Years 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $240.82 4/1/2015 0.00 $240.82 9 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $229.35 4/1/2015 0.00 $229.35 9 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88307 0 20 Years 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 4/1/2015
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT 88307 21 999 Years 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 80 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90471 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90472 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90632 21 999 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90636 21 999 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90649 21 26 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90650 19 26 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90651 19 999 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90654 19 999 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90656 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90656 U1 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90670 19 999 Years 0.00 $0.0000 $170.58 10/1/2016 0.00 $170.58 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90707 21 999 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90714 21 999 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90715 21 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 81 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90732 21 999 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90736 60 999 Years 0.00 $0.0000 $221.88 10/1/2016 0.00 $221.88 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90746 21 999 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 7/1/2013
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 7/1/2013
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90792 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 7/1/2013
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90792 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 7/1/2013
PHYSICIAN
(D.O.) 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 94760 0 20 Years 0.09 $28.0672 $2.53 4/1/2015 0.00 $2.53 4/1/2015
PHYSICIAN
(D.O.) 5 LABORATORY 94760 21 999 Years 0.09 $26.7305 $2.41 4/1/2015 0.00 $2.41 4/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99078 0 999 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99078 TH 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99078 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99204 FP 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99204 FP 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 83 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99213 TH 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99213 TH 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99213 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99213 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99214 FP 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99214 FP 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99214 TH 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99214 TH 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99214 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99214 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99215 TH 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99215 TH 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99215 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
PHYSICIAN
(D.O.) 2 SURGERY 99215 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
PHYSICIAN
(D.O.) 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99385 18 39 Years 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99386 40 64 Years 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99395 18 39 Years 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99396 40 64 Years 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99406 10 20 Years 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 84 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99406 21 55 Years 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99407 10 20 Years 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 1/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 99407 21 55 Years 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 1/1/2015
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4261 0 999 Years 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 1/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4264 21 999 Years 0.00 $0.0000 $1,560.00 9/1/2013 0.00 $1,560.00 1/1/2016
PHYSICIAN
(D.O.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4266 0 999 Years 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES A4267 0 999 Years 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES A4268 0 999 Years 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES A4269 10 55 Years 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES A9150 FP 0 999 Years 0.00 $0.0000 $14.00 4/1/1995 0.00 $14.00 1/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY G0202 0 20 Years 3.77 $28.0672 $105.81 4/1/2014 0.00 $105.81 4/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY G0202 21 999 Years 3.77 $26.7305 $100.77 4/1/2014 0.00 $100.77 4/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT G0202 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT G0202 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT G0202 0 20 Years 2.78 $28.0672 $78.03 4/1/2014 0.00 $78.03 4/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT G0202 21 999 Years 2.78 $26.7305 $74.31 4/1/2014 0.00 $74.31 4/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY G0204 0 20 Years 4.60 $28.0672 $129.11 4/1/2014 0.00 $129.11 4/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY G0204 21 999 Years 4.60 $26.7305 $122.96 4/1/2014 0.00 $122.96 4/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT G0204 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 4/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT G0204 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 4/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT G0204 0 20 Years 3.36 $28.0672 $94.31 4/1/2014 0.00 $94.31 4/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT G0204 21 999 Years 3.36 $26.7305 $89.81 4/1/2014 0.00 $89.81 4/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY G0206 0 20 Years 3.62 $28.0672 $101.60 4/1/2014 0.00 $101.60 4/1/2016
PHYSICIAN
(D.O.) 4 RADIOLOGY G0206 21 999 Years 3.62 $26.7305 $96.76 4/1/2014 0.00 $96.76 4/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT G0206 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
(D.O.) I
PROFESSIONAL
COMPONENT G0206 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT G0206 0 20 Years 2.63 $28.0672 $73.82 4/1/2014 0.00 $73.82 4/1/2016
PHYSICIAN
(D.O.) T
TECHNICAL
COMPONENT G0206 21 999 Years 2.63 $26.7305 $70.30 4/1/2014 0.00 $70.30 4/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES H1010 0 20 Years 0.00 $0.0000 $12.91 10/1/2014 0.00 $12.91 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES H1010 21 999 Years 0.00 $0.0000 $12.30 10/1/2014 0.00 $12.30 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J1050 0 999 Years 0.00 $0.0000 $0.19 1/1/2013 0.00 $0.19 9 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J1050 U1 0 999 Years 0.00 $0.0000 $64.98 1/1/2013 0.00 $64.98 9 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7297 10 55 Years 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7297 U8 10 55 Years 0.00 $0.0000 $335.63 1/1/2016 0.00 $335.63 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7298 10 55 Years 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7298 U8 10 55 Years 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7300 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7300 FP 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7301 10 55 Years 0.00 $0.0000 $663.32 1/1/2016 0.00 $663.32 9 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7301 U8 10 55 Years 0.00 $0.0000 $530.66 1/1/2016 0.00 $530.66 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7307 0 999 Years 0.00 $0.0000 $786.95 1/1/2016 0.00 $786.95 1/1/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES J7307 U8 0 999 Years 0.00 $0.0000 $629.56 1/1/2016 0.00 $629.56 1/1/2016
PHYSICIAN
(M.D.) 7 ANESTHESIA 00400 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(M.D.) 7 ANESTHESIA 00400 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(M.D.) 7 ANESTHESIA 00851 21 999 Years 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 1/1/2016
PHYSICIAN
(M.D.) 7 ANESTHESIA 00940 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(M.D.) 7 ANESTHESIA 00940 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
(M.D.) 2 SURGERY 10022 0 20 Years 3.94 $28.0672 $110.58 1/1/2015 0.00 $110.58 1.88 $28.0672 $52.77 1/1/2015 0.00 $52.77 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 10022 21 999 Years 3.94 $26.7305 $105.32 1/1/2015 0.00 $105.32 1.88 $26.7305 $50.25 1/1/2015 0.00 $50.25 1/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 10022 0 20 Years 0.00 $0.0000 $14.48 1/1/2015 0.00 $14.48 1/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 10022 21 999 Years 0.00 $0.0000 $13.78 1/1/2015 0.00 $13.78 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 11976 10 55 Years 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 11981 0 20 Years 3.98 $28.0672 $111.71 10/1/2016 0.00 $111.71 2.37 $28.0672 $66.52 10/1/2016 0.00 $66.52 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 11981 21 999 Years 3.98 $26.7305 $106.39 10/1/2016 0.00 $106.39 2.37 $26.7305 $63.35 10/1/2016 0.00 $63.35 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 11982 0 20 Years 4.52 $28.0672 $126.86 10/1/2016 0.00 $126.86 2.88 $28.0672 $80.83 10/1/2016 0.00 $80.83 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 11982 21 999 Years 4.52 $26.7305 $120.82 10/1/2016 0.00 $120.82 2.88 $26.7305 $76.98 10/1/2016 0.00 $76.98 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 11983 0 20 Years 6.31 $28.0672 $177.10 10/1/2016 0.00 $177.10 4.99 $28.0672 $140.06 10/1/2016 0.00 $140.06 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 86 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 2 SURGERY 11983 21 999 Years 6.31 $26.7305 $168.67 10/1/2016 0.00 $168.67 4.99 $26.7305 $133.39 10/1/2016 0.00 $133.39 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19000 0 20 Years 3.21 $28.0672 $90.10 10/1/2016 0.00 $90.10 1.26 $28.0672 $35.36 10/1/2014 0.00 $35.36 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19000 21 999 Years 3.21 $26.7305 $85.80 10/1/2016 0.00 $85.80 1.26 $26.7305 $33.68 10/1/2014 0.00 $33.68 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19081 0 20 Years 19.70 $28.0672 $552.92 10/1/2016 0.00 $552.92 4.90 $28.0672 $137.53 10/1/2016 0.00 $137.53 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19081 21 999 Years 19.70 $26.7305 $526.59 10/1/2016 0.00 $526.59 4.90 $26.7305 $130.98 10/1/2016 0.00 $130.98 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19082 0 20 Years 16.28 $28.0672 $456.93 10/1/2016 0.00 $456.93 2.45 $28.0672 $68.76 10/1/2016 0.00 $68.76 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19082 21 999 Years 16.28 $26.7305 $435.17 10/1/2016 0.00 $435.17 2.45 $26.7305 $65.49 10/1/2016 0.00 $65.49 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19083 0 20 Years 19.05 $28.0672 $534.68 10/1/2016 0.00 $534.68 4.59 $28.0672 $128.83 10/1/2016 0.00 $128.83 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19083 21 999 Years 19.05 $26.7305 $509.22 10/1/2016 0.00 $509.22 4.59 $26.7305 $122.69 10/1/2016 0.00 $122.69 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19084 0 20 Years 15.66 $28.0672 $439.53 10/1/2016 0.00 $439.53 2.30 $28.0672 $64.55 10/1/2016 0.00 $64.55 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19084 21 999 Years 15.66 $26.7305 $418.60 10/1/2016 0.00 $418.60 2.30 $26.7305 $61.48 10/1/2016 0.00 $61.48 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19100 0 20 Years 4.28 $28.0672 $120.13 10/1/2016 0.00 $120.13 2.02 $28.0672 $56.70 10/1/2016 0.00 $56.70 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19100 21 999 Years 4.28 $26.7305 $114.41 10/1/2016 0.00 $114.41 2.02 $26.7305 $54.00 10/1/2016 0.00 $54.00 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19101 0 20 Years 9.71 $28.0672 $272.53 10/1/2016 0.00 $272.53 6.37 $28.0672 $178.79 10/1/2016 0.00 $178.79 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19101 21 999 Years 9.71 $26.7305 $259.55 10/1/2016 0.00 $259.55 6.37 $26.7305 $170.27 10/1/2016 0.00 $170.27 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19120 0 20 Years 14.11 $28.0672 $396.03 10/1/2016 0.00 $396.03 11.89 $28.0672 $333.72 10/1/2016 0.00 $333.72 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19120 21 999 Years 14.11 $26.7305 $377.17 10/1/2016 0.00 $377.17 11.89 $26.7305 $317.83 10/1/2016 0.00 $317.83 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19125 0 20 Years 13.22 $28.0672 $371.05 10/1/2016 0.00 $371.05 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19125 21 999 Years 13.22 $26.7305 $353.38 10/1/2016 0.00 $353.38 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19126 0 20 Years 4.68 $28.0672 $131.35 10/1/2016 0.00 $131.35 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19126 21 999 Years 4.68 $26.7305 $125.10 10/1/2016 0.00 $125.10 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19281 0 20 Years 6.80 $28.0672 $190.86 10/1/2016 0.00 $190.86 2.93 $28.0672 $82.24 1/1/2014 0.00 $82.24 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19281 21 999 Years 6.80 $26.7305 $181.77 10/1/2016 0.00 $181.77 2.93 $26.7305 $78.32 1/1/2014 0.00 $78.32 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19282 0 20 Years 4.76 $28.0672 $133.60 1/1/2014 0.00 $133.60 1.47 $28.0672 $41.26 10/1/2016 0.00 $41.26 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19282 21 999 Years 4.76 $26.7305 $127.24 1/1/2014 0.00 $127.24 1.47 $26.7305 $39.29 10/1/2016 0.00 $39.29 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19283 0 20 Years 7.65 $28.0672 $214.71 10/1/2016 0.00 $214.71 2.95 $28.0672 $82.80 10/1/2016 0.00 $82.80 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19283 21 999 Years 7.65 $26.7305 $204.49 10/1/2016 0.00 $204.49 2.95 $26.7305 $78.85 10/1/2016 0.00 $78.85 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19284 0 20 Years 5.77 $28.0672 $161.95 10/1/2016 0.00 $161.95 1.49 $28.0672 $41.82 10/1/2016 0.00 $41.82 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19284 21 999 Years 5.77 $26.7305 $154.23 10/1/2016 0.00 $154.23 1.49 $26.7305 $39.83 10/1/2016 0.00 $39.83 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19285 0 20 Years 14.62 $28.0672 $410.34 10/1/2016 0.00 $410.34 2.50 $28.0672 $70.17 10/1/2016 0.00 $70.17 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19285 21 999 Years 14.62 $26.7305 $390.80 10/1/2016 0.00 $390.80 2.50 $26.7305 $66.83 10/1/2016 0.00 $66.83 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19286 0 20 Years 12.84 $28.0672 $360.38 10/1/2016 0.00 $360.38 1.26 $28.0672 $35.36 10/1/2016 0.00 $35.36 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 19286 21 999 Years 12.84 $26.7305 $343.22 10/1/2016 0.00 $343.22 1.26 $26.7305 $33.68 10/1/2016 0.00 $33.68 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 87 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 2 SURGERY 56405 0 20 Years 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56405 21 999 Years 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56420 0 20 Years 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56420 21 999 Years 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56501 0 20 Years 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56501 21 999 Years 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56515 0 20 Years 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56515 21 999 Years 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56605 0 20 Years 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56605 21 999 Years 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56606 0 20 Years 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56606 21 999 Years 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56820 0 20 Years 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 56820 21 999 Years 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57023 0 20 Years 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57023 21 999 Years 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57061 0 20 Years 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57061 21 999 Years 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57100 0 20 Years 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57100 21 999 Years 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57170 10 20 Years 1.72 $28.0672 $48.28 1/1/2016 0.00 $48.28 1.38 $28.0672 $38.73 1/1/2016 0.00 $38.73 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57170 21 55 Years 1.72 $26.7305 $45.98 1/1/2016 0.00 $45.98 1.38 $26.7305 $36.89 1/1/2016 0.00 $36.89 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57421 0 20 Years 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57421 21 999 Years 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57452 0 20 Years 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57452 21 999 Years 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57454 0 20 Years 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57454 21 999 Years 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57455 0 20 Years 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57455 21 999 Years 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57456 0 20 Years 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57456 21 999 Years 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57460 0 20 Years 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 88 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 2 SURGERY 57460 21 999 Years 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57461 0 20 Years 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57461 21 999 Years 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57500 0 20 Years 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57500 21 999 Years 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57505 0 20 Years 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57505 21 999 Years 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57511 0 20 Years 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57511 21 999 Years 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57520 0 20 Years 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57520 21 999 Years 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57522 0 20 Years 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 57522 21 999 Years 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58100 0 20 Years 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58100 21 999 Years 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58110 0 20 Years 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58110 21 999 Years 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58300 0 20 Years 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58300 21 999 Years 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58301 0 20 Years 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58301 21 999 Years 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58340 0 20 Years 3.36 $28.0672 $94.31 1/1/2016 0.00 $94.31 1.66 $28.0672 $46.59 10/1/2014 0.00 $46.59 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58340 21 999 Years 3.36 $26.7305 $89.81 1/1/2016 0.00 $89.81 1.66 $26.7305 $44.37 10/1/2014 0.00 $44.37 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58562 0 20 Years 7.92 $28.6400 $226.83 4/1/2010 -2.00 $222.29 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58562 21 999 Years 7.92 $27.2760 $216.03 4/1/2010 -2.00 $211.71 10/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58565 21 999 Years 0.00 $0.0000 $1,543.15 1/1/2016 0.00 $1,543.15 0.00 $0.0000 $348.03 1/1/2016 0.00 $348.03 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58600 21 999 Years 0.00 $0.0000 $292.70 1/1/2016 0.00 $292.70 10 1/1/2016
PHYSICIAN
(M.D.) 8
ASSISTANT
SURGERY 58600 0 20 Years 1.75 $28.0672 $49.12 9/1/2013 0.00 $49.12 10/1/2014
PHYSICIAN
(M.D.) 2 SURGERY 58611 21 55 Years 0.00 $0.0000 $61.75 1/1/2016 0.00 $61.75 10 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58615 21 55 Years 0.00 $0.0000 $195.67 1/1/2016 0.00 $195.67 10 1/1/2016
PHYSICIAN
(M.D.) 8
ASSISTANT
SURGERY 58615 0 20 Years 1.17 $28.0672 $32.84 9/1/2013 0.00 $32.84 10/1/2014
PHYSICIAN
(M.D.) 2 SURGERY 58670 21 55 Years 10.35 $26.7305 $276.66 1/1/2016 0.00 $276.66 1/1/2016
PHYSICIAN
(M.D.) 2 SURGERY 58671 21 55 Years 10.33 $26.7305 $276.13 1/1/2016 0.00 $276.13 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 89 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 71010 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 71010 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 71010 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 71010 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 71020 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 71020 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 71020 0 20 Years 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 71020 21 999 Years 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 73060 0 20 Years 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 73060 21 999 Years 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 73060 0 20 Years 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 73060 21 999 Years 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 73060 0 20 Years 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 73060 21 999 Years 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 74000 0 20 Years 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 74000 21 999 Years 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 74000 0 20 Years 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 74000 21 999 Years 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 74000 0 20 Years 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 74000 21 999 Years 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 74010 0 20 Years 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 74010 21 999 Years 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 74010 0 20 Years 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 74010 21 999 Years 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 74010 0 20 Years 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 74010 21 999 Years 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 74740 0 20 Years 2.11 $28.0672 $59.22 1/1/2016 0.00 $59.22 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 74740 21 999 Years 2.11 $26.7305 $56.40 1/1/2016 0.00 $56.40 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 74740 0 20 Years 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 90 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 74740 21 999 Years 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 74740 0 20 Years 1.56 $28.0672 $43.78 1/1/2016 0.00 $43.78 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 74740 21 999 Years 1.56 $26.7305 $41.70 1/1/2016 0.00 $41.70 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76098 0 20 Years 0.56 $28.0672 $15.72 1/1/2014 0.00 $15.72 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76098 21 999 Years 0.56 $26.7305 $14.97 1/1/2014 0.00 $14.97 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76098 0 20 Years 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76098 21 999 Years 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76098 0 20 Years 0.33 $28.0672 $9.26 1/1/2014 0.00 $9.26 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76098 21 999 Years 0.33 $26.7305 $8.82 1/1/2014 0.00 $8.82 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76641 0 20 Years 3.06 $28.0672 $85.89 1/1/2015 0.00 $85.89 9 7/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 76641 21 999 Years 3.06 $26.7305 $81.80 1/1/2015 0.00 $81.80 9 7/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76641 0 20 Years 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 7/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76641 21 999 Years 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 7/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76641 0 20 Years 2.01 $28.0672 $56.42 1/1/2015 0.00 $56.42 9 7/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76641 21 999 Years 2.01 $26.7305 $53.73 1/1/2015 0.00 $53.73 9 7/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 76642 0 20 Years 2.52 $28.0672 $70.73 1/1/2015 0.00 $70.73 9 7/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 76642 21 999 Years 2.52 $26.7305 $67.36 1/1/2015 0.00 $67.36 9 7/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76642 0 20 Years 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 7/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76642 21 999 Years 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 7/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76642 0 20 Years 1.54 $28.0672 $43.22 1/1/2015 0.00 $43.22 9 7/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76642 21 999 Years 1.54 $26.7305 $41.16 1/1/2015 0.00 $41.16 9 7/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 76700 0 20 Years 4.21 $28.0672 $118.16 1/1/2014 0.00 $118.16 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76700 21 999 Years 4.21 $26.7305 $112.54 1/1/2014 0.00 $112.54 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76700 0 20 Years 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76700 21 999 Years 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76700 0 20 Years 3.06 $28.0672 $85.89 1/1/2014 0.00 $85.89 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76700 21 999 Years 3.06 $26.7305 $81.80 1/1/2014 0.00 $81.80 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76705 0 20 Years 3.24 $28.0672 $90.94 1/1/2014 0.00 $90.94 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76705 21 999 Years 3.24 $26.7305 $86.61 1/1/2014 0.00 $86.61 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76705 0 20 Years 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76705 21 999 Years 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76705 0 20 Years 2.41 $28.0672 $67.64 1/1/2014 0.00 $67.64 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76705 21 999 Years 2.41 $26.7305 $64.42 1/1/2014 0.00 $64.42 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 91 of 197TEXAS MEDICAID FEE SCHEDULE -
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 4 RADIOLOGY 76770 0 20 Years 3.97 $28.0672 $111.43 1/1/2014 0.00 $111.43 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76770 21 999 Years 3.97 $26.7305 $106.12 1/1/2014 0.00 $106.12 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76770 0 20 Years 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76770 21 999 Years 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76770 0 20 Years 2.92 $28.0672 $81.96 1/1/2014 0.00 $81.96 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76770 21 999 Years 2.92 $26.7305 $78.05 1/1/2014 0.00 $78.05 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76830 0 20 Years 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76830 21 999 Years 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76856 0 20 Years 3.10 $28.0672 $87.01 1/1/2016 0.00 $87.01 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76856 21 999 Years 3.10 $26.7305 $82.86 1/1/2016 0.00 $82.86 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76856 0 20 Years 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76856 21 999 Years 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76856 0 20 Years 2.13 $28.0672 $59.78 1/1/2016 0.00 $59.78 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76856 21 999 Years 2.13 $26.7305 $56.94 1/1/2016 0.00 $56.94 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76857 0 20 Years 1.33 $28.0672 $37.33 1/1/2016 0.00 $37.33 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76857 21 999 Years 1.33 $26.7305 $35.55 1/1/2016 0.00 $35.55 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76857 0 20 Years 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76857 21 999 Years 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76857 0 20 Years 0.64 $28.0672 $17.96 1/1/2016 0.00 $17.96 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76857 21 999 Years 0.64 $26.7305 $17.11 1/1/2016 0.00 $17.11 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76881 0 20 Years 3.29 $28.0672 $92.34 1/1/2016 0.00 $92.34 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76881 21 999 Years 3.29 $26.7305 $87.94 1/1/2016 0.00 $87.94 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76881 0 20 Years 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76881 21 999 Years 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76881 0 20 Years 2.39 $28.0672 $67.08 1/1/2016 0.00 $67.08 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76881 21 999 Years 2.39 $26.7305 $63.89 1/1/2016 0.00 $63.89 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76882 0 20 Years 1.02 $28.0672 $28.63 1/1/2016 0.00 $28.63 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY 76882 21 999 Years 1.02 $26.7305 $27.27 1/1/2016 0.00 $27.27 1/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76882 0 20 Years 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 92 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76882 21 999 Years 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 1/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76882 0 20 Years 0.32 $28.0672 $8.98 1/1/2016 0.00 $8.98 10/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76882 21 999 Years 0.32 $26.7305 $8.55 1/1/2016 0.00 $8.55 10/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76942 0 20 Years 6.13 $28.0672 $172.05 1/1/2014 0.00 $172.05 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76942 21 999 Years 6.13 $26.7305 $163.86 1/1/2014 0.00 $163.86 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76942 0 20 Years 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76942 21 999 Years 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76942 0 20 Years 5.17 $28.0672 $145.11 1/1/2014 0.00 $145.11 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76942 21 999 Years 5.17 $26.7305 $138.20 1/1/2014 0.00 $138.20 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76998 0 20 Years 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 76998 21 999 Years 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76998 0 20 Years 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 76998 21 999 Years 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76998 0 20 Years 0.00 $0.0000 $91.76 1/1/2014 0.00 $91.76 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 76998 21 999 Years 0.00 $0.0000 $87.40 1/1/2014 0.00 $87.40 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 77051 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77051 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77051 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77051 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77051 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77051 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77052 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77052 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77052 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77052 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77052 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77052 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77053 0 20 Years 1.76 $28.0672 $49.40 1/1/2014 0.00 $49.40 9 1/1/2014
PHYSICIAN
(M.D.) 4 RADIOLOGY 77053 21 999 Years 1.76 $26.7305 $47.05 1/1/2014 0.00 $47.05 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77053 0 20 Years 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 1/1/2014
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77053 21 999 Years 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77053 0 20 Years 1.26 $28.0672 $35.36 1/1/2014 0.00 $35.36 9 1/1/2014
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77053 21 999 Years 1.26 $26.7305 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 93 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 4 RADIOLOGY 77055 0 20 Years 2.52 $28.0672 $70.73 11/1/2015 0.00 $70.73 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77055 21 999 Years 2.52 $26.7305 $67.36 11/1/2015 0.00 $67.36 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77055 0 20 Years 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77055 21 999 Years 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77055 0 20 Years 1.52 $28.0672 $42.66 11/1/2015 0.00 $42.66 9 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77055 21 999 Years 1.52 $26.7305 $40.63 11/1/2015 0.00 $40.63 9 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77056 0 20 Years 3.24 $28.0672 $90.94 11/1/2015 0.00 $90.94 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77056 21 999 Years 3.24 $26.7305 $86.61 11/1/2015 0.00 $86.61 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77056 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77056 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77056 0 20 Years 2.00 $28.0672 $56.13 11/1/2015 0.00 $56.13 9 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77056 21 999 Years 2.00 $26.7305 $53.46 11/1/2015 0.00 $53.46 9 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77057 0 20 Years 2.31 $28.0672 $64.84 11/1/2015 0.00 $64.84 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77057 21 999 Years 2.31 $26.7305 $61.75 11/1/2015 0.00 $61.75 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77057 0 20 Years 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77057 21 999 Years 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77057 0 20 Years 1.31 $28.0672 $36.77 11/1/2015 0.00 $36.77 9 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77057 21 999 Years 1.31 $26.7305 $35.02 11/1/2015 0.00 $35.02 9 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77058 0 20 Years 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77058 21 999 Years 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77058 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77058 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77058 0 20 Years 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77058 21 999 Years 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77059 0 20 Years 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 11/1/2015
PHYSICIAN
(M.D.) 4 RADIOLOGY 77059 21 999 Years 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77059 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 77059 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77059 0 20 Years 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 11/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 77059 21 999 Years 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 11/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 94 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88160 0 20 Years 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88160 21 999 Years 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 4/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 88160 0 20 Years 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 4/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 88160 21 999 Years 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88161 0 20 Years 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88161 21 999 Years 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 4/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 88161 0 20 Years 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 4/1/2015
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT 88161 21 999 Years 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88172 0 20 Years 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88172 21 999 Years 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88173 0 20 Years 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88173 21 999 Years 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88305 0 20 Years 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88305 21 999 Years 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $240.82 4/1/2015 0.00 $240.82 9 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $229.35 4/1/2015 0.00 $229.35 9 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88307 0 20 Years 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 4/1/2015
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT 88307 21 999 Years 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 4/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90471 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90472 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90632 21 999 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90636 21 999 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90649 21 26 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90650 19 26 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90651 19 999 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90654 19 999 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90656 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90656 U1 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90670 19 999 Years 0.00 $0.0000 $170.58 10/1/2016 0.00 $170.58 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90707 21 999 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90714 21 999 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90715 21 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90732 21 999 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 96 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90736 60 999 Years 0.00 $0.0000 $221.88 10/1/2016 0.00 $221.88 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90746 21 999 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 7/1/2013
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 7/1/2013
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90792 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 7/1/2013
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90792 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 7/1/2013
PHYSICIAN
(M.D.) 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 94760 0 20 Years 0.09 $28.0672 $2.53 4/1/2015 0.00 $2.53 4/1/2015
PHYSICIAN
(M.D.) 5 LABORATORY 94760 21 999 Years 0.09 $26.7305 $2.41 4/1/2015 0.00 $2.41 4/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99078 0 999 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99078 TH 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99078 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 97 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99204 FP 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99204 FP 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99213 TH 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 98 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
2
FacilityClient Age
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99213 TH 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99213 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99213 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99214 FP 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99214 FP 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99214 TH 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99214 TH 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99214 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99214 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99215 TH 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99215 TH 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99215 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
PHYSICIAN
(M.D.) 2 SURGERY 99215 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
PHYSICIAN
(M.D.) 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99385 18 39 Years 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99386 40 64 Years 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99395 18 39 Years 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99396 40 64 Years 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99406 10 20 Years 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99406 21 55 Years 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99407 10 20 Years 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 1/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 99407 21 55 Years 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 99 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4261 0 999 Years 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 1/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4264 21 999 Years 0.00 $0.0000 $1,560.00 9/1/2013 0.00 $1,560.00 1/1/2016
PHYSICIAN
(M.D.) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4266 0 999 Years 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES A4267 0 999 Years 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES A4268 0 999 Years 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES A4269 10 55 Years 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES A9150 FP 0 999 Years 0.00 $0.0000 $14.00 4/1/1995 0.00 $14.00 1/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY G0202 0 20 Years 3.77 $28.0672 $105.81 4/1/2014 0.00 $105.81 4/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY G0202 21 999 Years 3.77 $26.7305 $100.77 4/1/2014 0.00 $100.77 4/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT G0202 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT G0202 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT G0202 0 20 Years 2.78 $28.0672 $78.03 4/1/2014 0.00 $78.03 4/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT G0202 21 999 Years 2.78 $26.7305 $74.31 4/1/2014 0.00 $74.31 4/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY G0204 0 20 Years 4.60 $28.0672 $129.11 4/1/2014 0.00 $129.11 4/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY G0204 21 999 Years 4.60 $26.7305 $122.96 4/1/2014 0.00 $122.96 4/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT G0204 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 4/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT G0204 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 4/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT G0204 0 20 Years 3.36 $28.0672 $94.31 4/1/2014 0.00 $94.31 4/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT G0204 21 999 Years 3.36 $26.7305 $89.81 4/1/2014 0.00 $89.81 4/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY G0206 0 20 Years 3.62 $28.0672 $101.60 4/1/2014 0.00 $101.60 4/1/2016
PHYSICIAN
(M.D.) 4 RADIOLOGY G0206 21 999 Years 3.62 $26.7305 $96.76 4/1/2014 0.00 $96.76 4/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT G0206 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
(M.D.) I
PROFESSIONAL
COMPONENT G0206 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT G0206 0 20 Years 2.63 $28.0672 $73.82 4/1/2014 0.00 $73.82 4/1/2016
PHYSICIAN
(M.D.) T
TECHNICAL
COMPONENT G0206 21 999 Years 2.63 $26.7305 $70.30 4/1/2014 0.00 $70.30 4/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES H1010 0 20 Years 0.00 $0.0000 $12.91 10/1/2014 0.00 $12.91 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES H1010 21 999 Years 0.00 $0.0000 $12.30 10/1/2014 0.00 $12.30 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 100 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J1050 0 999 Years 0.00 $0.0000 $0.19 1/1/2013 0.00 $0.19 9 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J1050 U1 0 999 Years 0.00 $0.0000 $64.98 1/1/2013 0.00 $64.98 9 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7297 10 55 Years 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7297 U8 10 55 Years 0.00 $0.0000 $335.63 1/1/2016 0.00 $335.63 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7298 10 55 Years 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7298 U8 10 55 Years 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7300 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7300 FP 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7301 10 55 Years 0.00 $0.0000 $663.32 1/1/2016 0.00 $663.32 9 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7301 U8 10 55 Years 0.00 $0.0000 $530.66 1/1/2016 0.00 $530.66 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7307 0 999 Years 0.00 $0.0000 $786.95 1/1/2016 0.00 $786.95 1/1/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES J7307 U8 0 999 Years 0.00 $0.0000 $629.56 1/1/2016 0.00 $629.56 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 10022 0 20 Years 3.94 $28.0672 $101.73 1/1/2015 0.00 $101.73 1.88 $28.0672 $48.55 1/1/2015 0.00 $48.55 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 10022 21 999 Years 3.94 $26.7305 $96.89 1/1/2015 0.00 $96.89 1.88 $26.7305 $46.23 1/1/2015 0.00 $46.23 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 10022 0 20 Years 0.00 $0.0000 $13.32 1/1/2015 0.00 $13.32 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 10022 21 999 Years 0.00 $0.0000 $12.68 1/1/2015 0.00 $12.68 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 11976 10 55 Years 0.00 $0.0000 $95.36 1/1/2016 0.00 $95.36 0.00 $0.0000 $95.36 1/1/2016 0.00 $95.36 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 11981 0 20 Years 3.98 $28.0672 $102.77 10/1/2016 0.00 $102.77 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 11981 21 999 Years 3.98 $26.7305 $97.88 10/1/2016 0.00 $97.88 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 11982 0 20 Years 4.52 $28.0672 $116.71 10/1/2016 0.00 $116.71 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 11982 21 999 Years 4.52 $26.7305 $111.15 10/1/2016 0.00 $111.15 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 11983 0 20 Years 6.31 $28.0672 $162.93 10/1/2016 0.00 $162.93 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 11983 21 999 Years 6.31 $26.7305 $155.18 10/1/2016 0.00 $155.18 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 19000 0 20 Years 3.21 $28.0672 $82.89 10/1/2016 0.00 $82.89 1.26 $28.0672 $32.53 10/1/2014 0.00 $32.53 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 19000 21 999 Years 3.21 $26.7305 $78.94 10/1/2016 0.00 $78.94 1.26 $26.7305 $30.99 10/1/2014 0.00 $30.99 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 19100 0 20 Years 4.28 $28.0672 $110.52 10/1/2016 0.00 $110.52 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 19100 21 999 Years 4.28 $26.7305 $105.26 10/1/2016 0.00 $105.26 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 19101 0 20 Years 9.71 $28.0672 $250.73 10/1/2016 0.00 $250.73 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 19101 21 999 Years 9.71 $26.7305 $238.79 10/1/2016 0.00 $238.79 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56405 0 20 Years 2.87 $28.6400 $75.62 4/1/2010 -2.00 $74.11 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56405 21 999 Years 2.87 $27.2760 $72.02 4/1/2010 -2.00 $70.58 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56420 0 20 Years 2.49 $28.6400 $65.61 4/1/2010 -2.00 $64.30 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56420 21 999 Years 2.49 $27.2760 $62.49 4/1/2010 -2.00 $61.24 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56501 0 20 Years 3.05 $28.6400 $80.36 4/1/2010 -2.00 $78.75 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56501 21 999 Years 3.05 $27.2760 $76.53 4/1/2010 -2.00 $75.00 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56515 0 20 Years 5.32 $28.6400 $140.17 4/1/2010 -2.00 $137.37 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56515 21 999 Years 5.32 $27.2760 $133.50 4/1/2010 -2.00 $130.83 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56605 0 20 Years 1.64 $28.6400 $43.21 4/1/2010 -2.00 $42.35 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56605 21 999 Years 1.64 $27.2760 $41.15 4/1/2010 -2.00 $40.33 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56606 0 20 Years 0.81 $28.6400 $21.34 4/1/2010 -2.00 $20.91 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56606 21 999 Years 0.81 $27.2760 $20.32 4/1/2010 -2.00 $19.91 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56820 0 20 Years 2.30 $28.6400 $60.60 4/1/2010 -2.00 $59.39 2.30 $28.6400 $60.60 4/1/2010 -2.00 $59.39 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 56820 21 999 Years 2.30 $27.2760 $57.71 4/1/2010 -2.00 $56.56 2.30 $27.2760 $57.71 4/1/2010 -2.00 $56.56 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57023 0 20 Years 8.42 $28.6400 $221.86 4/1/2010 -2.00 $217.42 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57023 21 999 Years 8.42 $27.2760 $211.29 4/1/2010 -2.00 $207.06 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57061 0 20 Years 2.60 $28.6400 $68.50 4/1/2010 -2.00 $67.13 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57061 21 999 Years 2.60 $27.2760 $65.25 4/1/2010 -2.00 $63.95 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57100 0 20 Years 1.78 $28.6400 $46.90 4/1/2010 -2.00 $45.96 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57100 21 999 Years 1.78 $27.2760 $44.67 4/1/2010 -2.00 $43.78 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57170 10 20 Years 1.72 $28.0672 $44.42 1/1/2016 0.00 $44.42 1.38 $28.0672 $35.63 1/1/2016 0.00 $35.63 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57170 21 55 Years 1.72 $26.7305 $42.30 1/1/2016 0.00 $42.30 1.38 $26.7305 $33.94 1/1/2016 0.00 $33.94 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57421 0 20 Years 3.33 $28.6400 $87.74 4/1/2010 -2.00 $85.99 3.33 $28.6400 $87.74 4/1/2010 -2.00 $85.99 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57421 21 999 Years 3.33 $27.2760 $83.56 4/1/2010 -2.00 $81.89 3.33 $27.2760 $83.56 4/1/2010 -2.00 $81.89 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57452 0 20 Years 2.47 $28.6400 $65.08 4/1/2010 -2.00 $63.78 2.47 $28.6400 $65.08 4/1/2010 -2.00 $63.78 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57452 21 999 Years 2.47 $27.2760 $61.98 4/1/2010 -2.00 $60.74 2.47 $27.2760 $61.98 4/1/2010 -2.00 $60.74 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57454 0 20 Years 3.69 $28.6400 $97.23 4/1/2010 -2.00 $95.29 3.69 $28.6400 $97.23 4/1/2010 -2.00 $95.29 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57454 21 999 Years 3.69 $27.2760 $92.60 4/1/2010 -2.00 $90.75 3.69 $27.2760 $92.60 4/1/2010 -2.00 $90.75 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57455 0 20 Years 3.01 $28.6400 $79.31 4/1/2010 -2.00 $77.72 3.01 $28.6400 $79.31 4/1/2010 -2.00 $77.72 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57455 21 999 Years 3.01 $27.2760 $75.53 4/1/2010 -2.00 $74.02 3.01 $27.2760 $75.53 4/1/2010 -2.00 $74.02 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57456 0 20 Years 2.81 $28.6400 $74.04 4/1/2010 -2.00 $72.56 2.81 $28.6400 $74.04 4/1/2010 -2.00 $72.56 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57456 21 999 Years 2.81 $27.2760 $70.52 4/1/2010 -2.00 $69.11 2.81 $27.2760 $70.52 4/1/2010 -2.00 $69.11 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57460 0 20 Years 4.43 $28.6400 $116.73 4/1/2010 -2.00 $114.40 4.43 $28.6400 $116.73 4/1/2010 -2.00 $114.40 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57460 21 999 Years 4.43 $27.2760 $111.16 4/1/2010 -2.00 $108.94 4.43 $27.2760 $111.16 4/1/2010 -2.00 $108.94 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57461 0 20 Years 5.13 $28.6400 $135.17 4/1/2010 -2.00 $132.47 5.13 $28.6400 $135.17 4/1/2010 -2.00 $132.47 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57461 21 999 Years 5.13 $27.2760 $128.74 4/1/2010 -2.00 $126.17 5.13 $27.2760 $128.74 4/1/2010 -2.00 $126.17 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57500 0 20 Years 2.02 $28.6400 $53.22 4/1/2010 -2.00 $52.16 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57500 21 999 Years 2.02 $27.2760 $50.69 4/1/2010 -2.00 $49.68 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57505 0 20 Years 2.44 $28.6400 $64.29 4/1/2010 -2.00 $63.00 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57505 21 999 Years 2.44 $27.2760 $61.23 4/1/2010 -2.00 $60.01 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57511 0 20 Years 3.54 $28.6400 $93.28 4/1/2010 -2.00 $91.41 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 57511 21 999 Years 3.54 $27.2760 $88.84 4/1/2010 -2.00 $87.06 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58100 0 20 Years 2.37 $28.6400 $62.45 4/1/2010 -2.00 $61.20 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58100 21 999 Years 2.37 $27.2760 $59.47 4/1/2010 -2.00 $58.28 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58110 0 20 Years 1.13 $28.6400 $29.77 4/1/2010 -2.00 $29.17 1.13 $28.6400 $29.77 4/1/2010 -2.00 $29.17 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58110 21 999 Years 1.13 $27.2760 $28.35 4/1/2010 -2.00 $27.78 1.13 $27.2760 $28.35 4/1/2010 -2.00 $27.78 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58300 0 20 Years 0.00 $0.0000 $53.19 1/1/2016 0.00 $53.19 0.00 $0.0000 $53.19 1/1/2016 0.00 $53.19 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58300 21 999 Years 0.00 $0.0000 $50.66 1/1/2016 0.00 $50.66 0.00 $0.0000 $50.66 1/1/2016 0.00 $50.66 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58301 0 20 Years 0.00 $0.0000 $74.11 1/1/2016 0.00 $74.11 0.00 $0.0000 $74.11 1/1/2016 0.00 $74.11 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58301 21 999 Years 0.00 $0.0000 $70.58 1/1/2016 0.00 $70.58 0.00 $0.0000 $70.58 1/1/2016 0.00 $70.58 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 58565 21 999 Years 0.00 $0.0000 $1,419.70 1/1/2016 0.00 $1,419.70 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 8
ASSISTANT
SURGERY 58600 21 999 Years 1.75 $26.7305 $43.04 9/1/2013 0.00 $43.04 10/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 8
ASSISTANT
SURGERY 58611 21 55 Years 0.00 $0.0000 $9.09 1/1/2016 0.00 $9.09 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 8
ASSISTANT
SURGERY 58615 21 55 Years 1.17 $26.7305 $28.77 9/1/2013 0.00 $28.77 10/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 71010 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 71010 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 71010 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 71010 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 71020 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 71020 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 71020 0 20 Years 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 71020 21 999 Years 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 73060 0 20 Years 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 73060 21 999 Years 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 73060 0 20 Years 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 110 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 73060 21 999 Years 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 73060 0 20 Years 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 73060 21 999 Years 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 74000 0 20 Years 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 74000 21 999 Years 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 74000 0 20 Years 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 74000 21 999 Years 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 74000 0 20 Years 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 74000 21 999 Years 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 111 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 74010 0 20 Years 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 74010 21 999 Years 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 74010 0 20 Years 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 74010 21 999 Years 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 74010 0 20 Years 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 74010 21 999 Years 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76098 0 20 Years 0.56 $28.0672 $15.72 1/1/2014 0.00 $15.72 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76098 21 999 Years 0.56 $26.7305 $14.97 1/1/2014 0.00 $14.97 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76098 0 20 Years 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 112 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76098 21 999 Years 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76098 0 20 Years 0.33 $28.0672 $9.26 1/1/2014 0.00 $9.26 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76098 21 999 Years 0.33 $26.7305 $8.82 1/1/2014 0.00 $8.82 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76641 0 20 Years 3.06 $28.0672 $85.89 1/1/2015 0.00 $85.89 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76641 21 999 Years 3.06 $26.7305 $81.80 1/1/2015 0.00 $81.80 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76641 0 20 Years 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76641 21 999 Years 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76641 0 20 Years 2.01 $28.0672 $56.42 1/1/2015 0.00 $56.42 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76641 21 999 Years 2.01 $26.7305 $53.73 1/1/2015 0.00 $53.73 9 7/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76642 0 20 Years 2.52 $28.0672 $70.73 1/1/2015 0.00 $70.73 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76642 21 999 Years 2.52 $26.7305 $67.36 1/1/2015 0.00 $67.36 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76642 0 20 Years 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76642 21 999 Years 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76642 0 20 Years 1.54 $28.0672 $43.22 1/1/2015 0.00 $43.22 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76642 21 999 Years 1.54 $26.7305 $41.16 1/1/2015 0.00 $41.16 9 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76830 0 20 Years 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 114 of 197TEXAS MEDICAID FEE SCHEDULE -
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76830 21 999 Years 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76942 0 20 Years 6.13 $28.0672 $172.05 1/1/2014 0.00 $172.05 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76942 21 999 Years 6.13 $26.7305 $163.86 1/1/2014 0.00 $163.86 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76998 0 20 Years 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 76998 21 999 Years 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76998 0 20 Years 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 76998 21 999 Years 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76998 0 20 Years 0.00 $0.0000 $91.76 1/1/2014 0.00 $91.76 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 76998 21 999 Years 0.00 $0.0000 $87.40 1/1/2014 0.00 $87.40 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77053 0 20 Years 1.76 $28.0672 $49.40 1/1/2014 0.00 $49.40 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77053 21 999 Years 1.76 $26.7305 $47.05 1/1/2014 0.00 $47.05 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77053 0 20 Years 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77053 21 999 Years 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77053 0 20 Years 1.26 $28.0672 $35.36 1/1/2014 0.00 $35.36 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77053 21 999 Years 1.26 $26.7305 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77055 0 20 Years 2.52 $28.0672 $70.73 11/1/2015 0.00 $70.73 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 116 of 197TEXAS MEDICAID FEE SCHEDULE -
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77055 21 999 Years 2.52 $26.7305 $67.36 11/1/2015 0.00 $67.36 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77055 0 20 Years 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77055 21 999 Years 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77055 0 20 Years 1.52 $28.0672 $42.66 11/1/2015 0.00 $42.66 9 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77055 21 999 Years 1.52 $26.7305 $40.63 11/1/2015 0.00 $40.63 9 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77056 0 20 Years 3.24 $28.0672 $90.94 11/1/2015 0.00 $90.94 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77056 21 999 Years 3.24 $26.7305 $86.61 11/1/2015 0.00 $86.61 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77056 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77056 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 117 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77056 0 20 Years 2.00 $28.0672 $56.13 11/1/2015 0.00 $56.13 9 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77056 21 999 Years 2.00 $26.7305 $53.46 11/1/2015 0.00 $53.46 9 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77057 0 20 Years 2.31 $28.0672 $64.84 11/1/2015 0.00 $64.84 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY 77057 21 999 Years 2.31 $26.7305 $61.75 11/1/2015 0.00 $61.75 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77057 0 20 Years 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 77057 21 999 Years 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77057 0 20 Years 1.31 $28.0672 $36.77 11/1/2015 0.00 $36.77 9 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT 77057 21 999 Years 1.31 $26.7305 $35.02 11/1/2015 0.00 $35.02 9 11/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $38.72 4/1/2015 0.00 $38.72 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 118 of 197TEXAS MEDICAID FEE SCHEDULE -
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 119 of 197TEXAS MEDICAID FEE SCHEDULE -
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88172 0 20 Years 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88172 21 999 Years 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88173 0 20 Years 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88173 21 999 Years 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88305 0 20 Years 1.09 $28.0672 $28.14 4/1/2015 0.00 $28.14 1.09 $28.0672 $28.14 4/1/2015 0.00 $28.14 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88305 21 999 Years 1.09 $26.7305 $26.81 4/1/2015 0.00 $26.81 1.09 $26.7305 $26.81 4/1/2015 0.00 $26.81 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $221.55 4/1/2015 0.00 $221.55 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $211.00 4/1/2015 0.00 $211.00 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88307 0 20 Years 2.41 $28.0672 $62.23 4/1/2013 0.00 $62.23 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT 88307 21 999 Years 2.41 $26.7305 $59.27 4/1/2013 0.00 $59.27 9 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90471 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90472 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90632 21 999 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90636 21 999 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90649 21 26 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90650 19 26 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90651 19 999 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90654 19 999 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90656 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90656 U1 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90670 19 999 Years 0.00 $0.0000 $170.58 10/1/2016 0.00 $170.58 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 123 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90707 21 999 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90714 21 999 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90715 21 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90732 21 999 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90736 60 999 Years 0.00 $0.0000 $221.88 10/1/2016 0.00 $221.88 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90746 21 999 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 125 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $110.23 1/1/2013 0.00 $110.23 E1 0.00 $0.0000 $110.23 1/1/2013 0.00 $110.23 E1 7/1/2013
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $104.80 1/1/2013 0.00 $104.80 E1 0.00 $0.0000 $104.80 1/1/2013 0.00 $104.80 E1 7/1/2013
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90792 0 20 Years 0.00 $0.0000 $110.23 1/1/2013 0.00 $110.23 0.00 $0.0000 $110.23 1/1/2013 0.00 $110.23 7/1/2013
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90792 21 999 Years 0.00 $0.0000 $104.80 1/1/2013 0.00 $104.80 0.00 $0.0000 $104.80 1/1/2013 0.00 $104.80 7/1/2013
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $12.39 4/1/2015 0.00 $12.39 0.48 $28.0672 $12.39 4/1/2015 0.00 $12.39 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $11.80 4/1/2015 0.00 $11.80 0.48 $26.7305 $11.80 4/1/2015 0.00 $11.80 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 94760 0 20 Years 0.09 $28.0672 $2.33 4/1/2015 0.00 $2.33 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 5 LABORATORY 94760 21 999 Years 0.09 $26.7305 $2.22 4/1/2015 0.00 $2.22 4/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 126 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $8.56 10/1/2014 0.00 $8.56 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99078 0 999 Years 0.00 $0.0000 $27.05 7/1/2013 0.00 $27.05 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 0.00 $0.0000 $26.56 9/1/2007 -2.00 $26.03 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 0.00 $0.0000 $23.96 9/1/2007 -2.00 $23.48 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 0.00 $0.0000 $41.92 9/1/2007 -2.00 $41.08 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 0.00 $0.0000 $37.80 9/1/2007 -2.00 $37.04 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 0.00 $0.0000 $56.64 9/1/2007 -2.00 $55.51 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 0.00 $0.0000 $51.08 9/1/2007 -2.00 $50.06 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99204 FP 0 20 Years 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99204 FP 21 999 Years 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 129 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 0.00 $0.0000 $82.86 9/1/2007 -2.00 $81.20 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 0.00 $0.0000 $74.74 9/1/2007 -2.00 $73.25 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 0.00 $0.0000 $103.02 9/1/2007 -2.00 $100.96 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 0.00 $0.0000 $92.92 9/1/2007 -2.00 $91.06 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 0.00 $0.0000 $13.76 9/1/2007 -2.00 $13.48 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 0.00 $0.0000 $12.41 9/1/2007 -2.00 $12.16 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 131 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 0.00 $0.0000 $23.04 9/1/2007 -2.00 $22.58 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 0.00 $0.0000 $20.78 9/1/2007 -2.00 $20.36 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99213 TH 10 20 Years 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99213 TH 21 55 Years 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99213 10 20 Years 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 0.00 $0.0000 $34.63 9/1/2007 -2.00 $33.94 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99213 21 55 Years 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 0.00 $0.0000 $31.23 9/1/2007 -2.00 $30.61 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 132 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99214 FP 0 20 Years 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99214 FP 21 999 Years 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99214 TH 10 20 Years 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99214 TH 21 55 Years 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99214 10 20 Years 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 0.00 $0.0000 $48.63 9/1/2007 -2.00 $47.66 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99214 21 55 Years 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 0.00 $0.0000 $43.87 9/1/2007 -2.00 $42.99 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 133 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99215 TH 10 20 Years 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99215 TH 21 55 Years 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99215 10 20 Years 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 0.00 $0.0000 $74.87 9/1/2007 -2.00 $73.37 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 2 SURGERY 99215 21 55 Years 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 0.00 $0.0000 $67.53 9/1/2007 -2.00 $66.18 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $41.28 9/1/2007 -2.00 $40.45 0.00 $0.0000 $41.28 9/1/2007 -2.00 $40.45 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $37.23 9/1/2007 -2.00 $36.49 0.00 $0.0000 $37.23 9/1/2007 -2.00 $36.49 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $64.63 9/1/2007 -2.00 $63.34 0.00 $0.0000 $64.63 9/1/2007 -2.00 $63.34 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $58.30 9/1/2007 -2.00 $57.13 0.00 $0.0000 $58.30 9/1/2007 -2.00 $57.13 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $83.51 9/1/2007 -2.00 $81.84 0.00 $0.0000 $83.51 9/1/2007 -2.00 $81.84 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $75.32 9/1/2007 -2.00 $73.81 0.00 $0.0000 $75.32 9/1/2007 -2.00 $73.81 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $117.10 9/1/2007 -2.00 $114.76 0.00 $0.0000 $117.10 9/1/2007 -2.00 $114.76 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $105.62 9/1/2007 -2.00 $103.51 0.00 $0.0000 $105.62 9/1/2007 -2.00 $103.51 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99385 18 39 Years 2.95 $27.2760 $74.02 1/1/2014 -2.00 $72.54 2.95 $27.2760 $74.02 1/1/2014 -2.00 $72.54 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99386 40 64 Years 3.45 $27.2760 $86.57 1/1/2010 -2.00 $84.84 3.45 $27.2760 $86.57 1/1/2010 -2.00 $84.84 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99395 18 39 Years 2.56 $27.2760 $64.24 1/1/2014 -2.00 $62.96 2.56 $27.2760 $64.24 1/1/2014 -2.00 $62.96 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99396 40 64 Years 2.80 $27.2760 $70.26 1/1/2010 -2.00 $68.85 2.80 $27.2760 $70.26 1/1/2010 -2.00 $68.85 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99406 10 20 Years 0.41 $28.6400 $10.80 1/1/2012 -2.00 $10.58 0.41 $28.6400 $10.80 1/1/2012 -2.00 $10.58 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99406 21 55 Years 0.41 $27.2760 $10.29 1/1/2012 -2.00 $10.08 0.41 $27.2760 $10.29 1/1/2012 -2.00 $10.08 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 135 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99407 10 20 Years 0.80 $28.6400 $21.08 1/1/2012 -2.00 $20.66 0.80 $28.6400 $21.08 1/1/2012 -2.00 $20.66 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 99407 21 55 Years 0.80 $27.2760 $20.07 1/1/2012 -2.00 $19.67 0.80 $27.2760 $20.07 1/1/2012 -2.00 $19.67 1/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 9
OTHER MEDICAL
ITEMS OR
SERVICES A4261 0 999 Years 0.00 $0.0000 $46.77 10/1/2010 0.00 $46.77 0.00 $0.0000 $46.77 10/1/2010 0.00 $46.77 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 9
OTHER MEDICAL
ITEMS OR
SERVICES A4264 21 999 Years 0.00 $0.0000 $1,435.20 9/1/2013 0.00 $1,435.20 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 9
OTHER MEDICAL
ITEMS OR
SERVICES A4266 0 999 Years 0.00 $0.0000 $31.38 10/1/2010 0.00 $31.38 0.00 $0.0000 $31.38 10/1/2010 0.00 $31.38 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES A4267 0 999 Years 0.00 $0.0000 $0.50 10/1/2010 0.00 $0.50 0.00 $0.0000 $0.50 10/1/2010 0.00 $0.50 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES A4268 0 999 Years 0.00 $0.0000 $2.60 10/1/2010 0.00 $2.60 0.00 $0.0000 $2.60 10/1/2010 0.00 $2.60 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES A4269 10 55 Years 0.00 $0.0000 $11.28 10/1/2010 0.00 $11.28 0.00 $0.0000 $11.28 10/1/2010 0.00 $11.28 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES A9150 FP 0 999 Years 0.00 $0.0000 $12.88 10/1/2010 0.00 $12.88 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY G0202 0 20 Years 3.77 $28.0672 $105.81 4/1/2014 0.00 $105.81 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY G0202 21 999 Years 3.77 $26.7305 $100.77 4/1/2014 0.00 $100.77 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT G0202 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT G0202 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT G0202 0 20 Years 2.78 $28.0672 $78.03 4/1/2014 0.00 $78.03 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT G0202 21 999 Years 2.78 $26.7305 $74.31 4/1/2014 0.00 $74.31 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY G0204 0 20 Years 4.60 $28.0672 $129.11 4/1/2014 0.00 $129.11 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY G0204 21 999 Years 4.60 $26.7305 $122.96 4/1/2014 0.00 $122.96 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT G0204 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 137 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT G0204 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT G0204 0 20 Years 3.36 $28.0672 $94.31 4/1/2014 0.00 $94.31 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT G0204 21 999 Years 3.36 $26.7305 $89.81 4/1/2014 0.00 $89.81 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY G0206 0 20 Years 3.62 $28.0672 $101.60 4/1/2014 0.00 $101.60 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 4 RADIOLOGY G0206 21 999 Years 3.62 $26.7305 $96.76 4/1/2014 0.00 $96.76 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT G0206 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC I
PROFESSIONAL
COMPONENT G0206 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT G0206 0 20 Years 2.63 $28.0672 $73.82 4/1/2014 0.00 $73.82 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC T
TECHNICAL
COMPONENT G0206 21 999 Years 2.63 $26.7305 $70.30 4/1/2014 0.00 $70.30 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 138 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES H1010 0 20 Years 0.00 $0.0000 $11.88 10/1/2014 0.00 $11.88 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES H1010 21 999 Years 0.00 $0.0000 $11.32 10/1/2014 0.00 $11.32 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J1050 0 999 Years 0.00 $0.0000 $0.19 1/1/2013 0.00 $0.19 9 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J1050 U1 0 999 Years 0.00 $0.0000 $64.98 1/1/2013 0.00 $64.98 9 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 139 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7297 10 55 Years 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7297 U8 10 55 Years 0.00 $0.0000 $335.63 1/1/2016 0.00 $335.63 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7298 10 55 Years 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7298 U8 10 55 Years 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7300 0 999 Years 0.00 $0.0000 $693.48 1/1/2016 0.00 $693.48 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7300 FP 0 999 Years 0.00 $0.0000 $693.48 1/1/2016 0.00 $693.48 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7301 10 55 Years 0.00 $0.0000 $663.32 1/1/2016 0.00 $663.32 9 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7301 U8 10 55 Years 0.00 $0.0000 $530.66 1/1/2016 0.00 $530.66 1/1/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7307 0 999 Years 0.00 $0.0000 $723.99 1/1/2016 0.00 $723.99 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 140 of 197TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES J7307 U8 0 999 Years 0.00 $0.0000 $579.20 1/1/2016 0.00 $579.20 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 7 ANESTHESIA 00400 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 7 ANESTHESIA 00400 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 7 ANESTHESIA 00851 21 999 Years 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 6.00 $19.5800 $0.00 1/1/2010 -2.00 $0.00 12 3 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 7 ANESTHESIA 00940 0 20 Years 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 3.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 7 ANESTHESIA 00940 21 999 Years 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 3.00 $18.4200 $0.00 1/1/2010 -2.00 $0.00 12 3 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 10022 0 20 Years 3.94 $28.0672 $110.58 1/1/2015 0.00 $110.58 1.88 $28.0672 $52.77 1/1/2015 0.00 $52.77 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 10022 21 999 Years 3.94 $26.7305 $105.32 1/1/2015 0.00 $105.32 1.88 $26.7305 $50.25 1/1/2015 0.00 $50.25 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 10022 0 20 Years 0.00 $0.0000 $14.48 1/1/2015 0.00 $14.48 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 10022 21 999 Years 0.00 $0.0000 $13.78 1/1/2015 0.00 $13.78 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 11976 10 55 Years 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 0.00 $0.0000 $103.65 1/1/2016 0.00 $103.65 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 11981 0 20 Years 3.98 $28.0672 $111.71 10/1/2016 0.00 $111.71 2.37 $28.0672 $66.52 10/1/2016 0.00 $66.52 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 11981 21 999 Years 3.98 $26.7305 $106.39 10/1/2016 0.00 $106.39 2.37 $26.7305 $63.35 10/1/2016 0.00 $63.35 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 11982 0 20 Years 4.52 $28.0672 $126.86 10/1/2016 0.00 $126.86 2.88 $28.0672 $80.83 10/1/2016 0.00 $80.83 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 11982 21 999 Years 4.52 $26.7305 $120.82 10/1/2016 0.00 $120.82 2.88 $26.7305 $76.98 10/1/2016 0.00 $76.98 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 11983 0 20 Years 6.31 $28.0672 $177.10 10/1/2016 0.00 $177.10 4.99 $28.0672 $140.06 10/1/2016 0.00 $140.06 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 141 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 11983 21 999 Years 6.31 $26.7305 $168.67 10/1/2016 0.00 $168.67 4.99 $26.7305 $133.39 10/1/2016 0.00 $133.39 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19000 0 20 Years 3.21 $28.0672 $90.10 10/1/2016 0.00 $90.10 1.26 $28.0672 $35.36 10/1/2014 0.00 $35.36 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19000 21 999 Years 3.21 $26.7305 $85.80 10/1/2016 0.00 $85.80 1.26 $26.7305 $33.68 10/1/2014 0.00 $33.68 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19081 0 20 Years 19.70 $28.0672 $552.92 10/1/2016 0.00 $552.92 4.90 $28.0672 $137.53 10/1/2016 0.00 $137.53 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19081 21 999 Years 19.70 $26.7305 $526.59 10/1/2016 0.00 $526.59 4.90 $26.7305 $130.98 10/1/2016 0.00 $130.98 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19082 0 20 Years 16.28 $28.0672 $456.93 10/1/2016 0.00 $456.93 2.45 $28.0672 $68.76 10/1/2016 0.00 $68.76 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19082 21 999 Years 16.28 $26.7305 $435.17 10/1/2016 0.00 $435.17 2.45 $26.7305 $65.49 10/1/2016 0.00 $65.49 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19083 0 20 Years 19.05 $28.0672 $534.68 10/1/2016 0.00 $534.68 4.59 $28.0672 $128.83 10/1/2016 0.00 $128.83 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19083 21 999 Years 19.05 $26.7305 $509.22 10/1/2016 0.00 $509.22 4.59 $26.7305 $122.69 10/1/2016 0.00 $122.69 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19084 0 20 Years 15.66 $28.0672 $439.53 10/1/2016 0.00 $439.53 2.30 $28.0672 $64.55 10/1/2016 0.00 $64.55 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19084 21 999 Years 15.66 $26.7305 $418.60 10/1/2016 0.00 $418.60 2.30 $26.7305 $61.48 10/1/2016 0.00 $61.48 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19100 0 20 Years 4.28 $28.0672 $120.13 10/1/2016 0.00 $120.13 2.02 $28.0672 $56.70 10/1/2016 0.00 $56.70 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19100 21 999 Years 4.28 $26.7305 $114.41 10/1/2016 0.00 $114.41 2.02 $26.7305 $54.00 10/1/2016 0.00 $54.00 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19101 0 20 Years 9.71 $28.0672 $272.53 10/1/2016 0.00 $272.53 6.37 $28.0672 $178.79 10/1/2016 0.00 $178.79 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19101 21 999 Years 9.71 $26.7305 $259.55 10/1/2016 0.00 $259.55 6.37 $26.7305 $170.27 10/1/2016 0.00 $170.27 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19120 0 20 Years 14.11 $28.0672 $396.03 10/1/2016 0.00 $396.03 11.89 $28.0672 $333.72 10/1/2016 0.00 $333.72 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19120 21 999 Years 14.11 $26.7305 $377.17 10/1/2016 0.00 $377.17 11.89 $26.7305 $317.83 10/1/2016 0.00 $317.83 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 142 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19125 0 20 Years 13.22 $28.0672 $371.05 10/1/2016 0.00 $371.05 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19125 21 999 Years 13.22 $26.7305 $353.38 10/1/2016 0.00 $353.38 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19126 0 20 Years 4.68 $28.0672 $131.35 10/1/2016 0.00 $131.35 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19126 21 999 Years 4.68 $26.7305 $125.10 10/1/2016 0.00 $125.10 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19281 0 20 Years 6.80 $28.0672 $190.86 10/1/2016 0.00 $190.86 2.93 $28.0672 $82.24 1/1/2014 0.00 $82.24 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19281 21 999 Years 6.80 $26.7305 $181.77 10/1/2016 0.00 $181.77 2.93 $26.7305 $78.32 1/1/2014 0.00 $78.32 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19282 0 20 Years 4.76 $28.0672 $133.60 1/1/2014 0.00 $133.60 1.47 $28.0672 $41.26 10/1/2016 0.00 $41.26 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19282 21 999 Years 4.76 $26.7305 $127.24 1/1/2014 0.00 $127.24 1.47 $26.7305 $39.29 10/1/2016 0.00 $39.29 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19283 0 20 Years 7.65 $28.0672 $214.71 10/1/2016 0.00 $214.71 2.95 $28.0672 $82.80 10/1/2016 0.00 $82.80 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19283 21 999 Years 7.65 $26.7305 $204.49 10/1/2016 0.00 $204.49 2.95 $26.7305 $78.85 10/1/2016 0.00 $78.85 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19284 0 20 Years 5.77 $28.0672 $161.95 10/1/2016 0.00 $161.95 1.49 $28.0672 $41.82 10/1/2016 0.00 $41.82 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19284 21 999 Years 5.77 $26.7305 $154.23 10/1/2016 0.00 $154.23 1.49 $26.7305 $39.83 10/1/2016 0.00 $39.83 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19285 0 20 Years 14.62 $28.0672 $410.34 10/1/2016 0.00 $410.34 2.50 $28.0672 $70.17 10/1/2016 0.00 $70.17 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19285 21 999 Years 14.62 $26.7305 $390.80 10/1/2016 0.00 $390.80 2.50 $26.7305 $66.83 10/1/2016 0.00 $66.83 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19286 0 20 Years 12.84 $28.0672 $360.38 10/1/2016 0.00 $360.38 1.26 $28.0672 $35.36 10/1/2016 0.00 $35.36 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 19286 21 999 Years 12.84 $26.7305 $343.22 10/1/2016 0.00 $343.22 1.26 $26.7305 $33.68 10/1/2016 0.00 $33.68 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56405 0 20 Years 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 2.87 $28.6400 $82.20 4/1/2010 -2.00 $80.56 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 143 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56405 21 999 Years 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 2.87 $27.2760 $78.28 4/1/2010 -2.00 $76.71 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56420 0 20 Years 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 2.49 $28.6400 $71.31 4/1/2010 -2.00 $69.88 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56420 21 999 Years 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 2.49 $27.2760 $67.92 4/1/2010 -2.00 $66.56 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56501 0 20 Years 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 3.05 $28.6400 $87.35 4/1/2010 -2.00 $85.60 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56501 21 999 Years 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 3.05 $27.2760 $83.19 4/1/2010 -2.00 $81.53 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56515 0 20 Years 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 5.32 $28.6400 $152.36 4/1/2010 -2.00 $149.31 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56515 21 999 Years 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 5.32 $27.2760 $145.11 4/1/2010 -2.00 $142.21 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56605 0 20 Years 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 1.64 $28.6400 $46.97 4/1/2010 -2.00 $46.03 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56605 21 999 Years 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 1.64 $27.2760 $44.73 4/1/2010 -2.00 $43.84 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56606 0 20 Years 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 0.81 $28.6400 $23.20 4/1/2010 -2.00 $22.74 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56606 21 999 Years 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 0.81 $27.2760 $22.09 4/1/2010 -2.00 $21.65 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56820 0 20 Years 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 2.30 $28.6400 $65.87 4/1/2010 -2.00 $64.55 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 56820 21 999 Years 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 2.30 $27.2760 $62.73 4/1/2010 -2.00 $61.48 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57023 0 20 Years 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 8.42 $28.6400 $241.15 4/1/2010 -2.00 $236.33 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57023 21 999 Years 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 8.42 $27.2760 $229.66 4/1/2010 -2.00 $225.07 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57061 0 20 Years 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 2.60 $28.6400 $74.46 4/1/2010 -2.00 $72.97 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57061 21 999 Years 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 2.60 $27.2760 $70.92 4/1/2010 -2.00 $69.50 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 144 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57100 0 20 Years 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 1.78 $28.6400 $50.98 4/1/2010 -2.00 $49.96 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57100 21 999 Years 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 1.78 $27.2760 $48.55 4/1/2010 -2.00 $47.58 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57170 10 20 Years 1.72 $28.0672 $48.28 1/1/2016 0.00 $48.28 1.38 $28.0672 $38.73 1/1/2016 0.00 $38.73 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57170 21 55 Years 1.72 $26.7305 $45.98 1/1/2016 0.00 $45.98 1.38 $26.7305 $36.89 1/1/2016 0.00 $36.89 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57421 0 20 Years 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 3.33 $28.6400 $95.37 4/1/2010 -2.00 $93.46 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57421 21 999 Years 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 3.33 $27.2760 $90.83 4/1/2010 -2.00 $89.01 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57452 0 20 Years 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 2.47 $28.6400 $70.74 4/1/2010 -2.00 $69.33 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57452 21 999 Years 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 2.47 $27.2760 $67.37 4/1/2010 -2.00 $66.02 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57454 0 20 Years 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 3.69 $28.6400 $105.68 4/1/2010 -2.00 $103.57 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57454 21 999 Years 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 3.69 $27.2760 $100.65 4/1/2010 -2.00 $98.64 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57455 0 20 Years 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 3.01 $28.6400 $86.21 4/1/2010 -2.00 $84.49 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57455 21 999 Years 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 3.01 $27.2760 $82.10 4/1/2010 -2.00 $80.46 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57456 0 20 Years 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 2.81 $28.6400 $80.48 4/1/2010 -2.00 $78.87 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57456 21 999 Years 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 2.81 $27.2760 $76.65 4/1/2010 -2.00 $75.12 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57460 0 20 Years 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 4.43 $28.6400 $126.88 4/1/2010 -2.00 $124.34 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57460 21 999 Years 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 4.43 $27.2760 $120.83 4/1/2010 -2.00 $118.41 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57461 0 20 Years 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 5.13 $28.6400 $146.92 4/1/2010 -2.00 $143.98 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 145 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57461 21 999 Years 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 5.13 $27.2760 $139.93 4/1/2010 -2.00 $137.13 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57500 0 20 Years 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 2.02 $28.6400 $57.85 4/1/2010 -2.00 $56.69 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57500 21 999 Years 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 2.02 $27.2760 $55.10 4/1/2010 -2.00 $54.00 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57505 0 20 Years 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 2.44 $28.6400 $69.88 4/1/2010 -2.00 $68.48 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57505 21 999 Years 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 2.44 $27.2760 $66.55 4/1/2010 -2.00 $65.22 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57511 0 20 Years 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 3.54 $28.6400 $101.39 4/1/2010 -2.00 $99.36 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57511 21 999 Years 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 3.54 $27.2760 $96.56 4/1/2010 -2.00 $94.63 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57520 0 20 Years 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 7.32 $28.6400 $209.64 4/1/2010 -2.00 $205.45 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57520 21 999 Years 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 7.32 $27.2760 $199.66 4/1/2010 -2.00 $195.67 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57522 0 20 Years 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 6.53 $28.6400 $187.02 4/1/2010 -2.00 $183.28 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 57522 21 999 Years 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 6.53 $27.2760 $178.11 4/1/2010 -2.00 $174.55 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58100 0 20 Years 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 2.37 $28.6400 $67.88 4/1/2010 -2.00 $66.52 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58100 21 999 Years 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 2.37 $27.2760 $64.64 4/1/2010 -2.00 $63.35 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58110 0 20 Years 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 1.13 $28.6400 $32.36 4/1/2010 -2.00 $31.71 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58110 21 999 Years 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 1.13 $27.2760 $30.82 4/1/2010 -2.00 $30.20 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58300 0 20 Years 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 0.00 $0.0000 $57.82 1/1/2016 0.00 $57.82 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58300 21 999 Years 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 0.00 $0.0000 $55.06 1/1/2016 0.00 $55.06 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 146 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58301 0 20 Years 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 0.00 $0.0000 $80.55 1/1/2016 0.00 $80.55 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58301 21 999 Years 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 0.00 $0.0000 $76.72 1/1/2016 0.00 $76.72 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58340 0 20 Years 3.36 $28.0672 $94.31 1/1/2016 0.00 $94.31 1.66 $28.0672 $46.59 10/1/2014 0.00 $46.59 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58340 21 999 Years 3.36 $26.7305 $89.81 1/1/2016 0.00 $89.81 1.66 $26.7305 $44.37 10/1/2014 0.00 $44.37 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58562 0 20 Years 7.92 $28.6400 $226.83 4/1/2010 -2.00 $222.29 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58562 21 999 Years 7.92 $27.2760 $216.03 4/1/2010 -2.00 $211.71 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58565 21 999 Years 0.00 $0.0000 $1,543.15 1/1/2016 0.00 $1,543.15 0.00 $0.0000 $348.03 1/1/2016 0.00 $348.03 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58600 21 999 Years 0.00 $0.0000 $292.70 1/1/2016 0.00 $292.70 10 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 8
ASSISTANT
SURGERY 58600 0 20 Years 1.75 $28.0672 $49.12 9/1/2013 0.00 $49.12 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58611 21 55 Years 0.00 $0.0000 $61.75 1/1/2016 0.00 $61.75 10 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58615 21 55 Years 0.00 $0.0000 $195.67 1/1/2016 0.00 $195.67 10 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 8
ASSISTANT
SURGERY 58615 0 20 Years 1.17 $28.0672 $32.84 9/1/2013 0.00 $32.84 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58670 21 55 Years 10.35 $26.7305 $276.66 1/1/2016 0.00 $276.66 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 58671 21 55 Years 10.33 $26.7305 $276.13 1/1/2016 0.00 $276.13 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 71010 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 147 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 71010 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 71010 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 71010 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 71020 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 71020 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 71020 0 20 Years 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 71020 21 999 Years 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 73060 0 20 Years 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 73060 21 999 Years 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 73060 0 20 Years 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 73060 21 999 Years 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 73060 0 20 Years 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 73060 21 999 Years 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 74000 0 20 Years 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 74000 21 999 Years 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 148 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 74000 0 20 Years 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 0.26 $28.0672 $7.30 10/1/2014 0.00 $7.30 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 74000 21 999 Years 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 0.26 $26.7305 $6.95 10/1/2014 0.00 $6.95 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 74000 0 20 Years 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 74000 21 999 Years 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 74010 0 20 Years 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 74010 21 999 Years 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 74010 0 20 Years 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 0.33 $28.0672 $9.26 10/1/2014 0.00 $9.26 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 74010 21 999 Years 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 0.33 $26.7305 $8.82 10/1/2014 0.00 $8.82 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 74010 0 20 Years 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 74010 21 999 Years 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 74740 0 20 Years 2.11 $28.0672 $59.22 1/1/2016 0.00 $59.22 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 74740 21 999 Years 2.11 $26.7305 $56.40 1/1/2016 0.00 $56.40 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 74740 0 20 Years 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 0.55 $28.0672 $15.44 1/1/2016 0.00 $15.44 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 74740 21 999 Years 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 0.55 $26.7305 $14.70 1/1/2016 0.00 $14.70 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 74740 0 20 Years 1.56 $28.0672 $43.78 1/1/2016 0.00 $43.78 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 74740 21 999 Years 1.56 $26.7305 $41.70 1/1/2016 0.00 $41.70 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76098 0 20 Years 0.56 $28.0672 $15.72 1/1/2014 0.00 $15.72 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 149 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76098 21 999 Years 0.56 $26.7305 $14.97 1/1/2014 0.00 $14.97 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76098 0 20 Years 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76098 21 999 Years 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76098 0 20 Years 0.33 $28.0672 $9.26 1/1/2014 0.00 $9.26 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76098 21 999 Years 0.33 $26.7305 $8.82 1/1/2014 0.00 $8.82 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76641 0 20 Years 3.06 $28.0672 $85.89 1/1/2015 0.00 $85.89 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76641 21 999 Years 3.06 $26.7305 $81.80 1/1/2015 0.00 $81.80 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76641 0 20 Years 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 1.05 $28.0672 $29.47 1/1/2015 0.00 $29.47 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76641 21 999 Years 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 1.05 $26.7305 $28.07 1/1/2015 0.00 $28.07 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76641 0 20 Years 2.01 $28.0672 $56.42 1/1/2015 0.00 $56.42 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76641 21 999 Years 2.01 $26.7305 $53.73 1/1/2015 0.00 $53.73 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76642 0 20 Years 2.52 $28.0672 $70.73 1/1/2015 0.00 $70.73 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76642 21 999 Years 2.52 $26.7305 $67.36 1/1/2015 0.00 $67.36 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76642 0 20 Years 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 0.98 $28.0672 $27.51 1/1/2015 0.00 $27.51 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76642 21 999 Years 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 0.98 $26.7305 $26.20 1/1/2015 0.00 $26.20 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76642 0 20 Years 1.54 $28.0672 $43.22 1/1/2015 0.00 $43.22 9 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76642 21 999 Years 1.54 $26.7305 $41.16 1/1/2015 0.00 $41.16 9 7/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 150 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76700 0 20 Years 4.21 $28.0672 $118.16 1/1/2014 0.00 $118.16 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76700 21 999 Years 4.21 $26.7305 $112.54 1/1/2014 0.00 $112.54 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76700 0 20 Years 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1.15 $28.0672 $32.28 1/1/2014 0.00 $32.28 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76700 21 999 Years 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1.15 $26.7305 $30.74 1/1/2014 0.00 $30.74 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76700 0 20 Years 3.06 $28.0672 $85.89 1/1/2014 0.00 $85.89 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76700 21 999 Years 3.06 $26.7305 $81.80 1/1/2014 0.00 $81.80 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76705 0 20 Years 3.24 $28.0672 $90.94 1/1/2014 0.00 $90.94 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76705 21 999 Years 3.24 $26.7305 $86.61 1/1/2014 0.00 $86.61 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76705 0 20 Years 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76705 21 999 Years 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76705 0 20 Years 2.41 $28.0672 $67.64 1/1/2014 0.00 $67.64 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76705 21 999 Years 2.41 $26.7305 $64.42 1/1/2014 0.00 $64.42 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76770 0 20 Years 3.97 $28.0672 $111.43 1/1/2014 0.00 $111.43 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76770 21 999 Years 3.97 $26.7305 $106.12 1/1/2014 0.00 $106.12 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76770 0 20 Years 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76770 21 999 Years 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76770 0 20 Years 2.92 $28.0672 $81.96 1/1/2014 0.00 $81.96 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 151 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76770 21 999 Years 2.92 $26.7305 $78.05 1/1/2014 0.00 $78.05 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76830 0 20 Years 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76830 21 999 Years 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76856 0 20 Years 3.10 $28.0672 $87.01 1/1/2016 0.00 $87.01 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76856 21 999 Years 3.10 $26.7305 $82.86 1/1/2016 0.00 $82.86 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76856 0 20 Years 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 0.97 $28.0672 $27.23 10/1/2014 0.00 $27.23 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76856 21 999 Years 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 0.97 $26.7305 $25.93 10/1/2014 0.00 $25.93 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76856 0 20 Years 2.13 $28.0672 $59.78 1/1/2016 0.00 $59.78 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76856 21 999 Years 2.13 $26.7305 $56.94 1/1/2016 0.00 $56.94 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76857 0 20 Years 1.33 $28.0672 $37.33 1/1/2016 0.00 $37.33 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76857 21 999 Years 1.33 $26.7305 $35.55 1/1/2016 0.00 $35.55 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76857 0 20 Years 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 0.69 $28.0672 $19.37 1/1/2016 0.00 $19.37 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76857 21 999 Years 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 0.69 $26.7305 $18.44 1/1/2016 0.00 $18.44 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 152 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76857 0 20 Years 0.64 $28.0672 $17.96 1/1/2016 0.00 $17.96 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76857 21 999 Years 0.64 $26.7305 $17.11 1/1/2016 0.00 $17.11 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76881 0 20 Years 3.29 $28.0672 $92.34 1/1/2016 0.00 $92.34 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76881 21 999 Years 3.29 $26.7305 $87.94 1/1/2016 0.00 $87.94 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76881 0 20 Years 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76881 21 999 Years 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76881 0 20 Years 2.39 $28.0672 $67.08 1/1/2016 0.00 $67.08 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76881 21 999 Years 2.39 $26.7305 $63.89 1/1/2016 0.00 $63.89 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76882 0 20 Years 1.02 $28.0672 $28.63 1/1/2016 0.00 $28.63 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76882 21 999 Years 1.02 $26.7305 $27.27 1/1/2016 0.00 $27.27 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76882 0 20 Years 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76882 21 999 Years 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76882 0 20 Years 0.32 $28.0672 $8.98 1/1/2016 0.00 $8.98 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76882 21 999 Years 0.32 $26.7305 $8.55 1/1/2016 0.00 $8.55 10/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76942 0 20 Years 6.13 $28.0672 $172.05 1/1/2014 0.00 $172.05 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76942 21 999 Years 6.13 $26.7305 $163.86 1/1/2014 0.00 $163.86 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76942 0 20 Years 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 0.96 $28.0672 $26.94 1/1/2014 0.00 $26.94 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 153 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76942 21 999 Years 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 0.96 $26.7305 $25.66 1/1/2014 0.00 $25.66 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76942 0 20 Years 5.17 $28.0672 $145.11 1/1/2014 0.00 $145.11 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76942 21 999 Years 5.17 $26.7305 $138.20 1/1/2014 0.00 $138.20 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76998 0 20 Years 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 0.00 $0.0000 $144.53 1/1/2014 0.00 $144.53 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 76998 21 999 Years 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 0.00 $0.0000 $137.65 1/1/2014 0.00 $137.65 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76998 0 20 Years 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1.88 $28.0672 $52.77 1/1/2014 0.00 $52.77 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 76998 21 999 Years 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1.88 $26.7305 $50.25 1/1/2014 0.00 $50.25 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76998 0 20 Years 0.00 $0.0000 $91.76 1/1/2014 0.00 $91.76 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 76998 21 999 Years 0.00 $0.0000 $87.40 1/1/2014 0.00 $87.40 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77051 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77051 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77051 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77051 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77051 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77051 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77052 0 20 Years 0.25 $28.0672 $7.02 11/1/2015 0.00 $7.02 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77052 21 999 Years 0.25 $26.7305 $6.68 11/1/2015 0.00 $6.68 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 154 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77052 0 20 Years 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 0.09 $28.0672 $2.53 4/1/2014 0.00 $2.53 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77052 21 999 Years 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 0.09 $26.7305 $2.41 4/1/2014 0.00 $2.41 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77052 0 20 Years 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77052 21 999 Years 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77053 0 20 Years 1.76 $28.0672 $49.40 1/1/2014 0.00 $49.40 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77053 21 999 Years 1.76 $26.7305 $47.05 1/1/2014 0.00 $47.05 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77053 0 20 Years 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 0.50 $28.0672 $14.03 1/1/2014 0.00 $14.03 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77053 21 999 Years 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 0.50 $26.7305 $13.37 1/1/2014 0.00 $13.37 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77053 0 20 Years 1.26 $28.0672 $35.36 1/1/2014 0.00 $35.36 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77053 21 999 Years 1.26 $26.7305 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77055 0 20 Years 2.52 $28.0672 $70.73 11/1/2015 0.00 $70.73 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77055 21 999 Years 2.52 $26.7305 $67.36 11/1/2015 0.00 $67.36 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77055 0 20 Years 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 1.00 $28.0672 $28.07 11/1/2015 0.00 $28.07 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77055 21 999 Years 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 1.00 $26.7305 $26.73 11/1/2015 0.00 $26.73 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77055 0 20 Years 1.52 $28.0672 $42.66 11/1/2015 0.00 $42.66 9 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77055 21 999 Years 1.52 $26.7305 $40.63 11/1/2015 0.00 $40.63 9 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77056 0 20 Years 3.24 $28.0672 $90.94 11/1/2015 0.00 $90.94 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 155 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77056 21 999 Years 3.24 $26.7305 $86.61 11/1/2015 0.00 $86.61 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77056 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77056 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77056 0 20 Years 2.00 $28.0672 $56.13 11/1/2015 0.00 $56.13 9 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77056 21 999 Years 2.00 $26.7305 $53.46 11/1/2015 0.00 $53.46 9 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77057 0 20 Years 2.31 $28.0672 $64.84 11/1/2015 0.00 $64.84 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77057 21 999 Years 2.31 $26.7305 $61.75 11/1/2015 0.00 $61.75 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77057 0 20 Years 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 1.00 $28.0672 $28.07 4/1/2014 0.00 $28.07 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77057 21 999 Years 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 1.00 $26.7305 $26.73 4/1/2014 0.00 $26.73 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77057 0 20 Years 1.31 $28.0672 $36.77 11/1/2015 0.00 $36.77 9 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77057 21 999 Years 1.31 $26.7305 $35.02 11/1/2015 0.00 $35.02 9 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77058 0 20 Years 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77058 21 999 Years 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77058 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77058 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77058 0 20 Years 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77058 21 999 Years 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 156 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77059 0 20 Years 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY 77059 21 999 Years 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77059 0 20 Years 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 77059 21 999 Years 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77059 0 20 Years 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 77059 21 999 Years 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 11/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88141 0 20 Years 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 0.90 $28.0672 $25.26 4/1/2015 -2.00 $24.75 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88141 21 999 Years 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 0.90 $26.7305 $24.06 4/1/2015 -2.00 $23.58 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88160 0 20 Years 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 1.88 $28.0672 $52.77 4/1/2015 0.00 $52.77 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88160 21 999 Years 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 1.88 $26.7305 $50.25 4/1/2015 0.00 $50.25 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88160 0 20 Years 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 0.75 $28.0672 $21.05 4/1/2015 0.00 $21.05 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88160 21 999 Years 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 0.75 $26.7305 $20.05 4/1/2015 0.00 $20.05 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 88160 0 20 Years 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 1.13 $28.0672 $31.72 4/1/2015 0.00 $31.72 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 88160 21 999 Years 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 1.13 $26.7305 $30.21 4/1/2015 0.00 $30.21 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 157 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88161 0 20 Years 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 1.70 $28.0672 $47.71 4/1/2015 0.00 $47.71 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88161 21 999 Years 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 1.70 $26.7305 $45.44 4/1/2015 0.00 $45.44 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88161 0 20 Years 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 0.72 $28.0672 $20.21 4/1/2013 0.00 $20.21 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88161 21 999 Years 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 0.72 $26.7305 $19.25 4/1/2013 0.00 $19.25 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 88161 0 20 Years 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 0.98 $28.0672 $27.51 4/1/2015 0.00 $27.51 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT 88161 21 999 Years 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 0.98 $26.7305 $26.20 4/1/2015 0.00 $26.20 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88172 0 20 Years 1.59 $28.0672 $44.63 4/1/2015 0.00 $44.63 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88172 21 999 Years 1.59 $26.7305 $42.50 4/1/2015 0.00 $42.50 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88172 0 20 Years 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 1.04 $28.0672 $29.19 4/1/2013 0.00 $29.19 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88172 21 999 Years 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 1.04 $26.7305 $27.80 4/1/2013 0.00 $27.80 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88173 0 20 Years 4.24 $28.0672 $119.00 4/1/2015 0.00 $119.00 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88173 21 999 Years 4.24 $26.7305 $113.34 4/1/2015 0.00 $113.34 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88173 0 20 Years 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 2.02 $28.0672 $56.70 4/1/2015 0.00 $56.70 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88173 21 999 Years 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 2.02 $26.7305 $54.00 4/1/2015 0.00 $54.00 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88305 0 20 Years 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 158 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88305 21 999 Years 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88307 0 20 Years 8.58 $28.0672 $240.82 4/1/2015 0.00 $240.82 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 88307 21 999 Years 8.58 $26.7305 $229.35 4/1/2015 0.00 $229.35 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88307 0 20 Years 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 2.41 $28.0672 $67.64 4/1/2013 0.00 $67.64 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT 88307 21 999 Years 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 2.41 $26.7305 $64.42 4/1/2013 0.00 $64.42 9 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90471 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90472 21 999 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90632 21 999 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90636 21 999 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90649 21 26 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 159 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90650 19 26 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90651 19 999 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90654 19 999 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90656 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90656 U1 3 999 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90670 19 999 Years 0.00 $0.0000 $170.58 10/1/2016 0.00 $170.58 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90707 21 999 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90714 21 999 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 160 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90715 21 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90732 21 999 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90736 60 999 Years 0.00 $0.0000 $221.88 10/1/2016 0.00 $221.88 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90746 21 999 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 7/1/2013
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 7/1/2013
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90792 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 7/1/2013
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90792 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 7/1/2013
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 161 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 94760 0 20 Years 0.09 $28.0672 $2.53 4/1/2015 0.00 $2.53 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 5 LABORATORY 94760 21 999 Years 0.09 $26.7305 $2.41 4/1/2015 0.00 $2.41 4/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99078 0 999 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99078 TH 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99078 10 55 Years 0.00 $0.0000 $29.40 7/1/2013 0.00 $29.40 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 162 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99204 FP 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99204 FP 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 163 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99211 TH 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99211 TH 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99211 10 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99211 21 55 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99212 TH 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99212 TH 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 164 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99212 10 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99212 21 55 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99213 TH 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99213 TH 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99213 10 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99213 21 55 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99214 FP 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99214 FP 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99214 TH 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99214 TH 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99214 10 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99214 21 55 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 165 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99215 TH 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99215 TH 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99215 10 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 2 SURGERY 99215 21 55 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99385 18 39 Years 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 2.95 $27.2760 $80.46 1/1/2014 -2.00 $78.85 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99386 40 64 Years 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 3.45 $27.2760 $94.10 1/1/2010 -2.00 $92.22 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99395 18 39 Years 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 2.56 $27.2760 $69.83 1/1/2014 -2.00 $68.43 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99396 40 64 Years 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 2.80 $27.2760 $76.37 1/1/2010 -2.00 $74.84 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 166 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99406 10 20 Years 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 0.41 $28.6400 $11.74 1/1/2012 -2.00 $11.51 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99406 21 55 Years 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 0.41 $27.2760 $11.18 1/1/2012 -2.00 $10.96 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99407 10 20 Years 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 0.80 $28.6400 $22.91 1/1/2012 -2.00 $22.45 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 99407 21 55 Years 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 0.80 $27.2760 $21.82 1/1/2012 -2.00 $21.38 1/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4261 0 999 Years 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 0.00 $0.0000 $50.84 10/1/2010 0.00 $50.84 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4264 21 999 Years 0.00 $0.0000 $1,560.00 9/1/2013 0.00 $1,560.00 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 9
OTHER MEDICAL
ITEMS OR
SERVICES A4266 0 999 Years 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 0.00 $0.0000 $34.11 10/1/2010 0.00 $34.11 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES A4267 0 999 Years 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 0.00 $0.0000 $0.54 10/1/2010 0.00 $0.54 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES A4268 0 999 Years 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 0.00 $0.0000 $2.83 10/1/2010 0.00 $2.83 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES A4269 10 55 Years 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 0.00 $0.0000 $12.26 10/1/2010 0.00 $12.26 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES A9150 FP 0 999 Years 0.00 $0.0000 $14.00 4/1/1995 0.00 $14.00 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY G0202 0 20 Years 3.77 $28.0672 $105.81 4/1/2014 0.00 $105.81 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY G0202 21 999 Years 3.77 $26.7305 $100.77 4/1/2014 0.00 $100.77 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT G0202 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT G0202 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT G0202 0 20 Years 2.78 $28.0672 $78.03 4/1/2014 0.00 $78.03 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT G0202 21 999 Years 2.78 $26.7305 $74.31 4/1/2014 0.00 $74.31 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 167 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY G0204 0 20 Years 4.60 $28.0672 $129.11 4/1/2014 0.00 $129.11 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY G0204 21 999 Years 4.60 $26.7305 $122.96 4/1/2014 0.00 $122.96 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT G0204 0 20 Years 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 1.24 $28.0672 $34.80 4/1/2014 0.00 $34.80 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT G0204 21 999 Years 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 1.24 $26.7305 $33.15 4/1/2014 0.00 $33.15 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT G0204 0 20 Years 3.36 $28.0672 $94.31 4/1/2014 0.00 $94.31 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT G0204 21 999 Years 3.36 $26.7305 $89.81 4/1/2014 0.00 $89.81 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY G0206 0 20 Years 3.62 $28.0672 $101.60 4/1/2014 0.00 $101.60 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 4 RADIOLOGY G0206 21 999 Years 3.62 $26.7305 $96.76 4/1/2014 0.00 $96.76 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT G0206 0 20 Years 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 0.99 $28.0672 $27.79 4/1/2014 0.00 $27.79 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) I
PROFESSIONAL
COMPONENT G0206 21 999 Years 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 0.99 $26.7305 $26.46 4/1/2014 0.00 $26.46 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT G0206 0 20 Years 2.63 $28.0672 $73.82 4/1/2014 0.00 $73.82 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) T
TECHNICAL
COMPONENT G0206 21 999 Years 2.63 $26.7305 $70.30 4/1/2014 0.00 $70.30 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES H1010 0 20 Years 0.00 $0.0000 $12.91 10/1/2014 0.00 $12.91 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES H1010 21 999 Years 0.00 $0.0000 $12.30 10/1/2014 0.00 $12.30 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 168 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J1050 0 999 Years 0.00 $0.0000 $0.19 1/1/2013 0.00 $0.19 9 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J1050 U1 0 999 Years 0.00 $0.0000 $64.98 1/1/2013 0.00 $64.98 9 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7297 10 55 Years 0.00 $0.0000 $671.25 1/1/2016 0.00 $671.25 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7297 U8 10 55 Years 0.00 $0.0000 $335.63 1/1/2016 0.00 $335.63 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7298 10 55 Years 0.00 $0.0000 $826.72 1/1/2016 0.00 $826.72 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7298 U8 10 55 Years 0.00 $0.0000 $413.36 1/1/2016 0.00 $413.36 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7300 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7300 FP 0 999 Years 0.00 $0.0000 $753.78 1/1/2016 0.00 $753.78 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7301 10 55 Years 0.00 $0.0000 $663.32 1/1/2016 0.00 $663.32 9 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7301 U8 10 55 Years 0.00 $0.0000 $530.66 1/1/2016 0.00 $530.66 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7307 0 999 Years 0.00 $0.0000 $786.95 1/1/2016 0.00 $786.95 1/1/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES J7307 U8 0 999 Years 0.00 $0.0000 $629.56 1/1/2016 0.00 $629.56 1/1/2016
PODIATRIST 4 RADIOLOGY 76881 0 20 Years 3.29 $28.0672 $92.34 1/1/2016 0.00 $92.34 1/1/2016
PODIATRIST 4 RADIOLOGY 76881 21 999 Years 3.29 $26.7305 $87.94 1/1/2016 0.00 $87.94 1/1/2016
PODIATRIST I
PROFESSIONAL
COMPONENT 76881 0 20 Years 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 1/1/2016
PODIATRIST I
PROFESSIONAL
COMPONENT 76881 21 999 Years 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 169 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST T
TECHNICAL
COMPONENT 76881 0 20 Years 2.39 $28.0672 $67.08 1/1/2016 0.00 $67.08 1/1/2016
PODIATRIST T
TECHNICAL
COMPONENT 76881 21 999 Years 2.39 $26.7305 $63.89 1/1/2016 0.00 $63.89 1/1/2016
PODIATRIST 4 RADIOLOGY 76882 0 20 Years 1.02 $28.0672 $28.63 1/1/2016 0.00 $28.63 1/1/2016
PODIATRIST 4 RADIOLOGY 76882 21 999 Years 1.02 $26.7305 $27.27 1/1/2016 0.00 $27.27 1/1/2016
PODIATRIST I
PROFESSIONAL
COMPONENT 76882 0 20 Years 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 1/1/2016
PODIATRIST I
PROFESSIONAL
COMPONENT 76882 21 999 Years 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 1/1/2016
PODIATRIST T
TECHNICAL
COMPONENT 76882 0 20 Years 0.32 $28.0672 $8.98 1/1/2016 0.00 $8.98 10/1/2014
PODIATRIST T
TECHNICAL
COMPONENT 76882 21 999 Years 0.32 $26.7305 $8.55 1/1/2016 0.00 $8.55 10/1/2014
PODIATRIST 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
PODIATRIST 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
PODIATRIST 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
PODIATRIST 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
PODIATRIST 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
PODIATRIST 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
PODIATRIST 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
PODIATRIST 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PODIATRIST 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PODIATRIST 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PODIATRIST 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PODIATRIST 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PODIATRIST 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PODIATRIST 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 170 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PODIATRIST 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PODIATRIST 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PODIATRIST 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PODIATRIST 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
PODIATRIST 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
PODIATRIST 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
PODIATRIST 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
PODIATRIST 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
PODIATRIST 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
PODIATRIST 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
PODIATRIST 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
PODIATRIST 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
PODIATRIST 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
PODIATRIST 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
PODIATRIST 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 171 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
PODIATRIST 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
PODIATRIST 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016
PODIATRY
GROUP 4 RADIOLOGY 76881 0 20 Years 3.29 $28.0672 $92.34 1/1/2016 0.00 $92.34 1/1/2016
PODIATRY
GROUP 4 RADIOLOGY 76881 21 999 Years 3.29 $26.7305 $87.94 1/1/2016 0.00 $87.94 1/1/2016
PODIATRY
GROUP I
PROFESSIONAL
COMPONENT 76881 0 20 Years 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 0.90 $28.0672 $25.26 10/1/2014 0.00 $25.26 1/1/2016
PODIATRY
GROUP I
PROFESSIONAL
COMPONENT 76881 21 999 Years 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 0.90 $26.7305 $24.06 10/1/2014 0.00 $24.06 1/1/2016
PODIATRY
GROUP T
TECHNICAL
COMPONENT 76881 0 20 Years 2.39 $28.0672 $67.08 1/1/2016 0.00 $67.08 1/1/2016
PODIATRY
GROUP T
TECHNICAL
COMPONENT 76881 21 999 Years 2.39 $26.7305 $63.89 1/1/2016 0.00 $63.89 1/1/2016
PODIATRY
GROUP 4 RADIOLOGY 76882 0 20 Years 1.02 $28.0672 $28.63 1/1/2016 0.00 $28.63 1/1/2016
PODIATRY
GROUP 4 RADIOLOGY 76882 21 999 Years 1.02 $26.7305 $27.27 1/1/2016 0.00 $27.27 1/1/2016
PODIATRY
GROUP I
PROFESSIONAL
COMPONENT 76882 0 20 Years 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 0.70 $28.0672 $19.65 10/1/2014 0.00 $19.65 1/1/2016
PODIATRY
GROUP I
PROFESSIONAL
COMPONENT 76882 21 999 Years 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 0.70 $26.7305 $18.71 10/1/2014 0.00 $18.71 1/1/2016
PODIATRY
GROUP T
TECHNICAL
COMPONENT 76882 0 20 Years 0.32 $28.0672 $8.98 1/1/2016 0.00 $8.98 10/1/2014
PODIATRY
GROUP T
TECHNICAL
COMPONENT 76882 21 999 Years 0.32 $26.7305 $8.55 1/1/2016 0.00 $8.55 10/1/2014
PODIATRY
GROUP 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
PODIATRY
GROUP 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
PODIATRY
GROUP 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
PODIATRY
GROUP 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99201 TH 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PODIATRY
GROUP 2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015
PODIATRY
GROUP 2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99202 TH 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99202 TH 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PODIATRY
GROUP 2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 172 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRY
GROUP 2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99203 TH 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99203 TH 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PODIATRY
GROUP 2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015
PODIATRY
GROUP 2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99204 TH 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99204 TH 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PODIATRY
GROUP 2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015
PODIATRY
GROUP 2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99205 TH 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99205 TH 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PODIATRY
GROUP 2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015
PODIATRY
GROUP 2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015
PODIATRY
GROUP 3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015
PODIATRY
GROUP 3 CONSULTATION 99241 21 999 Years 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 0.00 $0.0000 $40.47 9/1/2007 -2.00 $39.66 1/1/2015
PODIATRY
GROUP 3 CONSULTATION 99242 0 999 Years 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 0.00 $0.0000 $70.25 9/1/2007 -2.00 $68.85 1/1/2015
PODIATRY
GROUP 3 CONSULTATION 99242 21 999 Years 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 0.00 $0.0000 $63.37 9/1/2007 -2.00 $62.10 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 173 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRY
GROUP 3 CONSULTATION 99243 0 999 Years 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 0.00 $0.0000 $90.77 9/1/2007 -2.00 $88.95 1/1/2015
PODIATRY
GROUP 3 CONSULTATION 99243 21 999 Years 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 0.00 $0.0000 $81.87 9/1/2007 -2.00 $80.23 1/1/2015
PODIATRY
GROUP 3 CONSULTATION 99244 0 999 Years 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 0.00 $0.0000 $127.28 9/1/2007 -2.00 $124.73 1/1/2015
PODIATRY
GROUP 3 CONSULTATION 99244 21 999 Years 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 0.00 $0.0000 $114.80 9/1/2007 -2.00 $112.50 1/1/2015
PODIATRY
GROUP 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 10022 20 Y 0.00 $0.0000 $14.48 1/1/2015 0.00 $14.48 1/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 10022 999 Y 0.00 $0.0000 $13.78 1/1/2015 0.00 $13.78 1/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 10022 20 Y 0.00 $0.0000 $80.25 1/1/2015 0.00 $80.25 1/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 10022 999 Y 0.00 $0.0000 $76.43 1/1/2015 0.00 $76.43 1/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 71010 20 Y 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 71010 999 Y 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 71010 20 Y 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 71010 999 Y 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 174 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 71010 20 Y 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 71010 999 Y 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 71020 20 Y 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 71020 999 Y 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 71020 20 Y 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 71020 999 Y 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 71020 20 Y 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 71020 999 Y 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 73060 20 Y 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 73060 999 Y 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 73060 20 Y 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 175 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 73060 999 Y 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 74000 20 Y 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 74000 999 Y 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 74000 20 Y 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 74000 999 Y 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 74010 20 Y 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 74010 999 Y 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 74010 20 Y 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 74010 999 Y 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 74740 20 Y 2.11 $28.0672 $59.22 1/1/2016 0.00 $59.22 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 74740 999 Y 2.11 $26.7305 $56.40 1/1/2016 0.00 $56.40 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 176 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 74740 20 Y 1.56 $28.0672 $43.78 1/1/2016 0.00 $43.78 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 74740 999 Y 1.56 $26.7305 $41.70 1/1/2016 0.00 $41.70 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76098 20 Y 0.33 $28.0672 $9.26 1/1/2014 0.00 $9.26 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76098 999 Y 0.33 $26.7305 $8.82 1/1/2014 0.00 $8.82 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76641 20 Y 2.01 $28.0672 $56.42 1/1/2015 0.00 $56.42 9 7/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76641 999 Y 2.01 $26.7305 $53.73 1/1/2015 0.00 $53.73 9 7/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76642 20 Y 1.54 $28.0672 $43.22 1/1/2015 0.00 $43.22 9 7/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76642 999 Y 1.54 $26.7305 $41.16 1/1/2015 0.00 $41.16 9 7/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76700 20 Y 4.21 $28.0672 $118.16 1/1/2014 0.00 $118.16 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76700 999 Y 4.21 $26.7305 $112.54 1/1/2014 0.00 $112.54 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76700 20 Y 3.06 $28.0672 $85.89 1/1/2014 0.00 $85.89 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 177 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76700 999 Y 3.06 $26.7305 $81.80 1/1/2014 0.00 $81.80 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76705 20 Y 3.24 $28.0672 $90.94 1/1/2014 0.00 $90.94 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76705 999 Y 3.24 $26.7305 $86.61 1/1/2014 0.00 $86.61 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76705 20 Y 2.41 $28.0672 $67.64 1/1/2014 0.00 $67.64 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76705 999 Y 2.41 $26.7305 $64.42 1/1/2014 0.00 $64.42 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76770 20 Y 3.97 $28.0672 $111.43 1/1/2014 0.00 $111.43 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76770 999 Y 3.97 $26.7305 $106.12 1/1/2014 0.00 $106.12 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76770 20 Y 2.92 $28.0672 $81.96 1/1/2014 0.00 $81.96 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76770 999 Y 2.92 $26.7305 $78.05 1/1/2014 0.00 $78.05 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76830 20 Y 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76830 999 Y 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 178 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 76830 20 Y 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1.00 $28.0672 $28.07 1/1/2016 0.00 $28.07 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 76830 999 Y 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1.00 $26.7305 $26.73 1/1/2016 0.00 $26.73 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76830 20 Y 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76830 999 Y 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76856 20 Y 3.10 $28.0672 $87.01 1/1/2016 0.00 $87.01 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76856 999 Y 3.10 $26.7305 $82.86 1/1/2016 0.00 $82.86 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76856 20 Y 2.13 $28.0672 $59.78 1/1/2016 0.00 $59.78 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76856 999 Y 2.13 $26.7305 $56.94 1/1/2016 0.00 $56.94 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76857 20 Y 1.33 $28.0672 $37.33 1/1/2016 0.00 $37.33 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76857 999 Y 1.33 $26.7305 $35.55 1/1/2016 0.00 $35.55 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76857 20 Y 0.64 $28.0672 $17.96 1/1/2016 0.00 $17.96 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 179 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76857 999 Y 0.64 $26.7305 $17.11 1/1/2016 0.00 $17.11 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76881 20 Y 3.29 $28.0672 $92.34 1/1/2016 0.00 $92.34 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76881 999 Y 3.29 $26.7305 $87.94 1/1/2016 0.00 $87.94 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76881 20 Y 2.39 $28.0672 $67.08 1/1/2016 0.00 $67.08 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76881 999 Y 2.39 $26.7305 $63.89 1/1/2016 0.00 $63.89 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76882 20 Y 1.02 $28.0672 $28.63 1/1/2016 0.00 $28.63 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76882 999 Y 1.02 $26.7305 $27.27 1/1/2016 0.00 $27.27 1/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76882 20 Y 0.32 $28.0672 $8.98 1/1/2016 0.00 $8.98 10/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76882 999 Y 0.32 $26.7305 $8.55 1/1/2016 0.00 $8.55 10/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76942 20 Y 6.13 $28.0672 $172.05 1/1/2014 0.00 $172.05 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 76942 999 Y 6.13 $26.7305 $163.86 1/1/2014 0.00 $163.86 9 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 180 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76942 20 Y 5.17 $28.0672 $145.11 1/1/2014 0.00 $145.11 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76942 999 Y 5.17 $26.7305 $138.20 1/1/2014 0.00 $138.20 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76998 20 Y 0.00 $0.0000 $91.76 1/1/2014 0.00 $91.76 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 76998 999 Y 0.00 $0.0000 $87.40 1/1/2014 0.00 $87.40 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77051 20 Y 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77051 999 Y 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77052 20 Y 0.16 $28.0672 $4.49 11/1/2015 0.00 $4.49 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77052 999 Y 0.16 $26.7305 $4.28 11/1/2015 0.00 $4.28 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77053 20 Y 1.26 $28.0672 $35.36 1/1/2014 0.00 $35.36 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77053 999 Y 1.26 $26.7305 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77055 20 Y 1.52 $28.0672 $42.66 11/1/2015 0.00 $42.66 9 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 181 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77055 999 Y 1.52 $26.7305 $40.63 11/1/2015 0.00 $40.63 9 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77056 20 Y 2.00 $28.0672 $56.13 11/1/2015 0.00 $56.13 9 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77056 999 Y 2.00 $26.7305 $53.46 11/1/2015 0.00 $53.46 9 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77057 20 Y 1.31 $28.0672 $36.77 11/1/2015 0.00 $36.77 9 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77057 999 Y 1.31 $26.7305 $35.02 11/1/2015 0.00 $35.02 9 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 77058 20 Y 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 77058 999 Y 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 77058 20 Y 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 77058 999 Y 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77058 20 Y 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77058 999 Y 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 182 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 77059 20 Y 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY 77059 999 Y 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 77059 20 Y 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 2.33 $28.0672 $65.40 11/1/2015 0.00 $65.40 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 77059 999 Y 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 2.33 $26.7305 $62.28 11/1/2015 0.00 $62.28 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77059 20 Y 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 77059 999 Y 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 11/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88172 20 Y 0.55 $28.0672 $15.44 4/1/2015 0.00 $15.44 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88172 999 Y 0.55 $26.7305 $14.70 4/1/2015 0.00 $14.70 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88173 20 Y 2.22 $28.0672 $62.31 4/1/2015 0.00 $62.31 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88173 999 Y 2.22 $26.7305 $59.34 4/1/2015 0.00 $59.34 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 5 LABORATORY 88305 20 Y 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 183 of 197TEXAS MEDICAID FEE SCHEDULE -
HEALTHY TEXAS WOMEN
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 5 LABORATORY 88305 999 Y 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 88305 20 Y 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 1.09 $28.0672 $30.59 4/1/2015 0.00 $30.59 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI I
PROFESSIONAL
COMPONENT 88305 999 Y 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 1.09 $26.7305 $29.14 4/1/2015 0.00 $29.14 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88305 20 Y 0.95 $28.0672 $26.66 4/1/2015 0.00 $26.66 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88305 999 Y 0.95 $26.7305 $25.39 4/1/2015 0.00 $25.39 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88307 20 Y 6.17 $28.0672 $173.17 4/1/2015 0.00 $173.17 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT 88307 999 Y 6.17 $26.7305 $164.93 4/1/2015 0.00 $164.93 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 5 LABORATORY 93000 20 Y 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 5 LABORATORY 93000 999 Y 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 5 LABORATORY 94760 20 Y 0.09 $28.0672 $2.53 4/1/2015 0.00 $2.53 4/1/2015PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 5 LABORATORY 94760 999 Y 0.09 $26.7305 $2.41 4/1/2015 0.00 $2.41 4/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 184 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY G0202 20 Y 3.77 $28.0672 $105.81 4/1/2014 0.00 $105.81 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY G0202 999 Y 3.77 $26.7305 $100.77 4/1/2014 0.00 $100.77 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT G0202 20 Y 2.78 $28.0672 $78.03 4/1/2014 0.00 $78.03 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT G0202 999 Y 2.78 $26.7305 $74.31 4/1/2014 0.00 $74.31 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY G0204 20 Y 4.60 $28.0672 $129.11 4/1/2014 0.00 $129.11 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY G0204 999 Y 4.60 $26.7305 $122.96 4/1/2014 0.00 $122.96 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT G0204 20 Y 3.36 $28.0672 $94.31 4/1/2014 0.00 $94.31 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT G0204 999 Y 3.36 $26.7305 $89.81 4/1/2014 0.00 $89.81 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY G0206 20 Y 3.62 $28.0672 $101.60 4/1/2014 0.00 $101.60 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI 4 RADIOLOGY G0206 999 Y 3.62 $26.7305 $96.76 4/1/2014 0.00 $96.76 4/1/2016PORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT G0206 20 Y 2.63 $28.0672 $73.82 4/1/2014 0.00 $73.82 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 185 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DatePORTABLE X-
RAY
SUPPLIER,
RADIOLOGIC
AL LAB,
PHYSI T
TECHNICAL
COMPONENT G0206 999 Y 2.63 $26.7305 $70.30 4/1/2014 0.00 $70.30 4/1/2016
PSYCHOLOGI
ST 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 7/1/2013
PSYCHOLOGI
ST 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 7/1/2013
PSYCHOLOGY
GROUP 1
MEDICAL
SERVICES 90791 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 E1 7/1/2013
PSYCHOLOGY
GROUP 1
MEDICAL
SERVICES 90791 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 E1 7/1/2013
PSYCHOLOGY
GROUP 1
MEDICAL
SERVICES 90792 0 20 Years 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 0.00 $0.0000 $119.82 1/1/2013 0.00 $119.82 7/1/2013
PSYCHOLOGY
GROUP 1
MEDICAL
SERVICES 90792 21 999 Years 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 0.00 $0.0000 $113.91 1/1/2013 0.00 $113.91 7/1/2013
RADIATION
THERAPY
CENTER 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 71010 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 71010 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 71020 0 20 Years 0.60 $28.0672 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 71020 21 999 Years 0.60 $26.7305 $16.04 1/1/2014 0.00 $16.04 9 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 73060 0 20 Years 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 0.88 $28.0672 $24.70 1/1/2014 0.00 $24.70 9 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 73060 21 999 Years 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 0.88 $26.7305 $23.52 1/1/2014 0.00 $23.52 9 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 73060 0 20 Years 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 73060 21 999 Years 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 74000 0 20 Years 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 0.66 $28.0672 $18.52 1/1/2016 0.00 $18.52 1/1/2016
RADIATION
THERAPY
CENTER 4 RADIOLOGY 74000 21 999 Years 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 0.66 $26.7305 $17.64 1/1/2016 0.00 $17.64 1/1/2016
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 74000 0 20 Years 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 0.40 $28.0672 $11.23 1/1/2016 0.00 $11.23 1/1/2016
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 74000 21 999 Years 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 0.40 $26.7305 $10.69 1/1/2016 0.00 $10.69 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 186 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
RADIATION
THERAPY
CENTER 4 RADIOLOGY 74010 0 20 Years 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 0.98 $28.0672 $27.51 1/1/2016 0.00 $27.51 1/1/2016
RADIATION
THERAPY
CENTER 4 RADIOLOGY 74010 21 999 Years 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 0.98 $26.7305 $26.20 1/1/2016 0.00 $26.20 1/1/2016
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 74010 0 20 Years 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 0.65 $28.0672 $18.24 1/1/2016 0.00 $18.24 1/1/2016
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 74010 21 999 Years 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 0.65 $26.7305 $17.37 1/1/2016 0.00 $17.37 1/1/2016
RADIATION
THERAPY
CENTER 4 RADIOLOGY 76700 0 20 Years 4.21 $28.0672 $118.16 1/1/2014 0.00 $118.16 4.21 $28.0672 $118.16 1/1/2014 0.00 $118.16 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 76700 21 999 Years 4.21 $26.7305 $112.54 1/1/2014 0.00 $112.54 4.21 $26.7305 $112.54 1/1/2014 0.00 $112.54 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 76700 0 20 Years 3.06 $28.0672 $85.89 1/1/2014 0.00 $85.89 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 76700 21 999 Years 3.06 $26.7305 $81.80 1/1/2014 0.00 $81.80 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 76705 0 20 Years 3.24 $28.0672 $90.94 1/1/2014 0.00 $90.94 3.24 $28.0672 $90.94 1/1/2014 0.00 $90.94 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 76705 21 999 Years 3.24 $26.7305 $86.61 1/1/2014 0.00 $86.61 3.24 $26.7305 $86.61 1/1/2014 0.00 $86.61 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 76705 0 20 Years 2.41 $28.0672 $67.64 1/1/2014 0.00 $67.64 1/1/2014
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 76705 21 999 Years 2.41 $26.7305 $64.42 1/1/2014 0.00 $64.42 1/1/2014
RADIATION
THERAPY
CENTER 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
RADIATION
THERAPY
CENTER 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 76830 0 20 Years 2.46 $28.0672 $69.05 1/1/2016 0.00 $69.05 1/1/2016
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 76830 21 999 Years 2.46 $26.7305 $65.76 1/1/2016 0.00 $65.76 1/1/2016
RADIATION
THERAPY
CENTER 4 RADIOLOGY 77058 0 20 Years 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 15.18 $28.0672 $426.06 11/1/2015 0.00 $426.06 11/1/2015
RADIATION
THERAPY
CENTER 4 RADIOLOGY 77058 21 999 Years 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 15.18 $26.7305 $405.77 11/1/2015 0.00 $405.77 11/1/2015
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 77058 0 20 Years 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 12.85 $28.0672 $360.66 11/1/2015 0.00 $360.66 11/1/2015
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 77058 21 999 Years 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 12.85 $26.7305 $343.49 11/1/2015 0.00 $343.49 11/1/2015
RADIATION
THERAPY
CENTER 4 RADIOLOGY 77059 0 20 Years 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 15.02 $28.0672 $421.57 11/1/2015 0.00 $421.57 11/1/2015
RADIATION
THERAPY
CENTER 4 RADIOLOGY 77059 21 999 Years 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 15.02 $26.7305 $401.49 11/1/2015 0.00 $401.49 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 187 of 197TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 77059 0 20 Years 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 12.69 $28.0672 $356.17 11/1/2015 0.00 $356.17 11/1/2015
RADIATION
THERAPY
CENTER T
TECHNICAL
COMPONENT 77059 21 999 Years 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 12.69 $26.7305 $339.21 11/1/2015 0.00 $339.21 11/1/2015
RADIATION
THERAPY
CENTER 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
RADIATION
THERAPY
CENTER 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
RADIATION
THERAPY
CENTER 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
RADIATION
THERAPY
CENTER 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
RADIATION
THERAPY
CENTER 1
MEDICAL
SERVICES 99000 0 999 Years 0.00 $0.0000 $9.30 10/1/2014 0.00 $9.30 1/1/2016
RENAL
DIALYSIS
FACILITY 4 RADIOLOGY 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014
RENAL
DIALYSIS
FACILITY 4 RADIOLOGY 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014
RENAL
DIALYSIS
FACILITY 4 RADIOLOGY 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014
RENAL
DIALYSIS
FACILITY 4 RADIOLOGY 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014
RENAL
DIALYSIS
FACILITY 4 RADIOLOGY 76830 0 20 Years 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 3.46 $28.0672 $97.11 1/1/2016 0.00 $97.11 9 1/1/2016
RENAL
DIALYSIS
FACILITY 4 RADIOLOGY 76830 21 999 Years 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 3.46 $26.7305 $92.49 1/1/2016 0.00 $92.49 9 1/1/2016
RENAL
DIALYSIS
FACILITY 5 LABORATORY 80050 0 999 Years 0.00 $0.0000 $42.09 4/1/2015 0.00 $42.09 4/1/2015
RENAL
DIALYSIS
FACILITY 5 LABORATORY 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 0.22 $28.0672 $6.17 4/1/2015 0.00 $6.17 9 4/1/2015
RENAL
DIALYSIS
FACILITY 5 LABORATORY 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
RENAL
DIALYSIS
FACILITY 5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015
RENAL
DIALYSIS
FACILITY 5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015
RENAL
DIALYSIS
FACILITY 5 LABORATORY 93000 0 20 Years 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 0.48 $28.0672 $13.47 4/1/2015 0.00 $13.47 4/1/2015
RENAL
DIALYSIS
FACILITY 5 LABORATORY 93000 21 999 Years 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 0.48 $26.7305 $12.83 4/1/2015 0.00 $12.83 4/1/2015
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
12/19/2016 188 of 197TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016
TB CLINIC -
GROUP D TB CLINIC 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 1/1/2014
TB CLINIC -
GROUP D TB CLINIC 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 1/1/2014
TB CLINIC -
GROUP D TB CLINIC 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 1/1/2014
TB CLINIC -
GROUP D TB CLINIC 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 1/1/2014
TB CLINIC -
GROUP D TB CLINIC 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 -5.00 $5.86 4/1/2015
TB CLINIC -
GROUP D TB CLINIC 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 -5.00 $5.59 4/1/2015
TB CLINIC -
GROUP D TB CLINIC 99000 0 999 Years 0.00 $0.0000 $9.30 7/1/2015 -5.00 $8.84 7/1/2015
TB CLINIC -
GROUP D TB CLINIC 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2009 -7.00 $26.85 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2009 -7.00 $24.22 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2009 -7.00 $42.37 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2009 -7.00 $38.21 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2009 -7.00 $57.25 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2009 -7.00 $51.63 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2009 -7.00 $104.14 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2009 -7.00 $93.93 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2009 -7.00 $13.91 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2009 -7.00 $12.55 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2009 -7.00 $23.29 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2009 -7.00 $21.01 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2009 -7.00 $35.01 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2009 -7.00 $31.57 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2009 -7.00 $49.16 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2009 -7.00 $44.34 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2009 -7.00 $75.68 1/1/2015
TB CLINIC -
GROUP D TB CLINIC 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2009 -7.00 $68.26 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 71010 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 1/1/2014
TB CLINIC -
INDIVIDUAL D TB CLINIC 71010 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
TB CLINIC -
INDIVIDUAL D TB CLINIC 71020 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 1/1/2014
TB CLINIC -
INDIVIDUAL D TB CLINIC 71020 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 1/1/2014
TB CLINIC -
INDIVIDUAL D TB CLINIC 86580 0 20 Years 0.22 $28.0672 $6.17 4/1/2015 -5.00 $5.86 4/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 86580 21 999 Years 0.22 $26.7305 $5.88 4/1/2015 -5.00 $5.59 4/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99000 0 999 Years 0.00 $0.0000 $9.30 7/1/2015 -5.00 $8.84 7/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2009 -7.00 $26.85 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2009 -7.00 $24.22 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2009 -7.00 $42.37 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2009 -7.00 $38.21 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2009 -7.00 $57.25 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2009 -7.00 $51.63 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2009 -7.00 $104.14 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2009 -7.00 $93.93 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2009 -7.00 $13.91 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2009 -7.00 $12.55 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2009 -7.00 $23.29 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2009 -7.00 $21.01 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2009 -7.00 $35.01 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2009 -7.00 $31.57 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2009 -7.00 $49.16 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2009 -7.00 $44.34 1/1/2015
TB CLINIC -
INDIVIDUAL D TB CLINIC 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2009 -7.00 $75.68 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
TB CLINIC -
INDIVIDUAL D TB CLINIC 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2009 -7.00 $68.26 1/1/2015
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 86580 0 20 Years 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 0.22 $26.7305 $5.88 4/1/2015 0.00 $5.88 9 4/1/2015
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90460 0 18 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90471 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90472 0 20 Years 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 0.00 $0.0000 $7.84 4/1/2012 0.00 $7.84 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90632 19 20 Years 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 0.00 $0.0000 $45.50 10/1/2016 0.00 $45.50 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90633 19 20 Years 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 0.00 $0.0000 $32.24 10/1/2016 0.00 $32.24 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90636 19 20 Years 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 0.00 $0.0000 $102.01 10/1/2016 0.00 $102.01 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90649 19 20 Years 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 0.00 $0.0000 $172.24 10/1/2016 0.00 $172.24 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90650 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90650 19 20 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90650 U1 9 18 Years 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 0.00 $0.0000 $142.27 10/1/2016 0.00 $142.27 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90651 19 20 Years 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 0.00 $0.0000 $190.72 10/1/2016 0.00 $190.72 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90654 19 20 Years 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 0.00 $0.0000 $17.82 10/1/2014 0.00 $17.82 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90656 19 20 Years 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 0.00 $0.0000 $13.08 4/1/2016 0.00 $13.08 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90660 19 20 Years 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 0.00 $0.0000 $22.10 4/1/2015 0.00 $22.10 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90673 19 999 Years 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 0.00 $0.0000 $35.04 4/1/2015 0.00 $35.04 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateTEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90707 19 20 Years 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 0.00 $0.0000 $67.04 10/1/2016 0.00 $67.04 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90710 19 20 Years 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 0.00 $0.0000 $192.84 4/1/2016 0.00 $192.84 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90714 19 20 Years 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 0.00 $0.0000 $20.76 10/1/2016 0.00 $20.76 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90715 19 20 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90716 19 20 Years 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 0.00 $0.0000 $121.17 10/1/2016 0.00 $121.17 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90723 19 20 Years 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 0.00 $0.0000 $77.44 10/1/2016 0.00 $77.44 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90732 19 20 Years 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 0.00 $0.0000 $84.74 10/1/2016 0.00 $84.74 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90733 19 20 Years 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 0.00 $0.0000 $132.15 4/1/2015 0.00 $132.15 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90734 19 20 Years 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 0.00 $0.0000 $121.15 4/1/2014 0.00 $121.15 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90743 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90744 19 20 Years 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 0.00 $0.0000 $23.92 10/1/2016 0.00 $23.92 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 90746 19 20 Years 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 0.00 $0.0000 $57.92 10/1/2016 0.00 $57.92 9 10/1/2016
TEXAS
HEALTH
STEPS -
MEDICAL 1
MEDICAL
SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
TEXAS
HEALTH
STEPS -
MEDICAL 1
MEDICAL
SERVICES 99211 21 999 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1/1/2015
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 99384 12 17 Years 0.00 $0.0000 $100.43 9/1/2007 -2.00 $98.42 0.00 $0.0000 $100.43 9/1/2007 -2.00 $98.42 1/1/2015
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 99385 18 20 Years 0.00 $0.0000 $100.43 9/1/2007 -2.00 $98.42 0.00 $0.0000 $100.43 9/1/2007 -2.00 $98.42 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateTEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 99394 12 17 Years 0.00 $0.0000 $92.40 9/1/2007 -2.00 $90.55 0.00 $0.0000 $92.40 9/1/2007 -2.00 $90.55 1/1/2015
TEXAS
HEALTH
STEPS -
MEDICAL S
THSTEPS
MEDICAL 99395 18 20 Years 0.00 $0.0000 $92.40 9/1/2007 -2.00 $90.55 0.00 $0.0000 $92.40 9/1/2007 -2.00 $90.55 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Proc Code:
Mod 1:
Mod 2:
Client Age
Frm:
Thru:
Client Age
Units:
Clinical Lab
Fee:
Adjusted Fee
for Report
Date:Sole
Community
Hospital Fee:
Adjusted Fee
for Report
Date:
Clin. Lab &
SCH
Fee Effect
Date:
DSHS Lab
Fee:
Adjusted Fee
for Report
Date:Fee Effect
Date:
Automated
Test Panel:
Note Codes:
Last Pricing
Review Date:
Frm Thru Units FeeAdjusted Fee for
Report DateFee
Adjusted Fee for
Report Date
Fee Effect
DateFee
Adjusted Fee
for Report
Date
Fee Effect
Date1 2 3
80048 0 999 Years $11.52 $9.68 $11.90 $10.00 7/1/2016 $11.52 $11.52 7/1/2016 Y 2 7/1/2016
80051 0 999 Years $9.55 $8.02 $9.87 $8.29 7/1/2015 $9.55 $9.55 7/1/2015 Y 2 7/1/2016
80053 0 999 Years $14.39 $12.09 $14.87 $12.49 7/1/2016 $14.39 $14.39 7/1/2016 Y 2 7/1/2016
80061 0 999 Years $18.24 $15.32 $18.85 $15.83 7/1/2016 $18.24 $18.24 7/1/2016 Y 2 7/1/2016
80069 0 999 Years $11.83 $9.94 $12.22 $10.26 7/1/2016 $11.83 $11.83 7/1/2016 Y 2 7/1/2016
Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation.
Medicaid rates are reviewed annually. This column shows the date on which the most recent review was conducted.
Proc CodeMod
1
Mod
2
Client Age Clinical LabSole Community Hospital
(SCH)
Clin. Lab &
SCH
Automated
Test Panel
Last Pricing
Review Date
Note CodesDSHS Lab
A “Y” in this column indicates that the procedure code is part of an automated test panel. Refer to the Clinical Laboratory, Automated Test Panel—Insert static fee schedule for panel pricing.
The rate for services that are rendered in a Medicare-designated sole community hospital.
A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty.
Additional information about rate changes is available on the TMHP website at www.tmhp.com.
The effective date for the Clinical Lab and Sole Community Hospital fee.
The rate for services that are performed by a Department of State Health Services (DSHS)-designated laboratory.
The rate for diagnostic tests that are performed in a clinical laboratory.
A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty.
Additional information about rate changes is available on the TMHP website at www.tmhp.com.
A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty.
Additional information about rate changes is available on the TMHP website at www.tmhp.com.
The effective date for the DSHS Lab fee.
2nd Modifier, if required for pricing determination.
The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the
first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures
Manual (TMPPM) for the exact age limitations.
The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first
row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations.
Medicaid rates are based on the client’s age in days, months or years.
This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to
the current year’s Texas Medicaid Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.
Texas Medicaid Fee Schedule Information
HEALTHY TEXAS WOMEN
The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System.
1st Modifier, if required for pricing determination.
Field Descriptions
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Frm Thru Units FeeAdjusted Fee for
Report DateFee
Adjusted Fee for
Report Date
Fee Effect
DateFee
Adjusted Fee
for Report
Date
Fee Effect
Date1 2 3
Proc CodeMod
1
Mod
2
Client Age Clinical LabSole Community Hospital
(SCH)
Clin. Lab &
SCH
Automated
Test Panel
Last Pricing
Review Date
Note CodesDSHS Lab
80074 0 999 Years $64.89 $54.51 $67.05 $56.32 7/1/2016 $64.89 $64.89 7/1/2016 Y 9 2 7/1/2016
80076 0 999 Years $11.13 $9.35 $11.50 $9.66 7/1/2016 $11.13 $11.13 7/1/2016 Y 9 2 7/1/2016
80300 0 999 Years $11.36 $9.54 $11.74 $9.86 7/1/2016 $11.36 $11.36 4/1/2012 2 7/1/2016
80301 0 999 Years $15.15 $12.73 $15.66 $13.15 7/1/2016 $15.15 $15.15 4/1/2012 2 7/1/2016
81000 0 999 Years $4.32 $3.63 $4.46 $3.75 7/1/2016 $4.32 $4.32 4/1/2012 9 2 7/1/2016
81001 0 999 Years $4.32 $3.63 $4.46 $3.75 7/1/2016 $4.32 $4.32 4/1/2012 9 2 7/1/2016
81002 0 999 Years $3.48 $2.92 $3.60 $3.02 7/1/2015 $3.48 $3.48 4/1/2012 9 2 7/1/2016
81003 0 999 Years $3.06 $2.57 $3.16 $2.65 7/1/2015 $3.06 $3.06 4/1/2012 9 2 7/1/2016
81005 0 999 Years $2.95 $2.48 $3.05 $2.56 7/1/2015 $2.95 $2.95 4/1/2012 9 2 7/1/2016
81015 0 999 Years $4.15 $3.49 $4.29 $3.60 7/1/2016 $4.15 $4.15 4/1/2012 9 2 7/1/2016
81025 10 55 Years $8.61 $7.23 $8.90 $7.48 7/1/2015 $8.61 $8.61 4/1/2012 9 2 7/1/2016
81025 0 999 Years $8.61 $7.23 $8.90 $7.48 7/1/2015 $8.61 $8.61 4/1/2012 2 7/1/2016
82270 0 999 Years $4.43 $3.72 $4.58 $3.85 7/1/2015 $4.43 $4.43 4/1/2012 9 2 7/1/2016
82465 0 999 Years $5.92 $4.97 $6.12 $5.14 7/1/2015 $5.92 $5.92 7/1/2015 Y 9 2 7/1/2016
82947 0 999 Years $5.35 $4.49 $5.53 $4.65 7/1/2016 $5.35 $5.35 7/1/2016 Y 9 2 7/1/2016
82948 0 999 Years $4.32 $3.63 $4.46 $3.75 7/1/2016 $4.32 $4.32 4/1/2012 9 2 7/1/2016
82950 0 999 Years $6.47 $5.43 $6.69 $5.62 7/1/2016 $6.47 $6.47 4/1/2012 9 2 7/1/2016
82951 0 999 Years $17.53 $14.73 $18.11 $15.21 7/1/2016 $17.53 $17.53 4/1/2012 9 2 7/1/2016
83020 0 999 Years $17.53 $14.73 $18.11 $15.21 7/1/2016 $17.53 $17.53 4/1/2012 9 2 7/1/2016
83021 0 999 Years $24.60 $20.66 $25.42 $21.35 7/1/2016 $24.60 $24.60 4/1/2012 9 2 7/1/2016
83036 0 999 Years $13.22 $11.10 $13.66 $11.47 7/1/2016 $13.22 $13.22 4/1/2012 9 2 7/1/2016
84443 0 999 Years $22.89 $19.23 $23.65 $19.87 7/1/2016 $22.89 $22.89 4/1/2012 9 2 7/1/2016
84450 0 999 Years $7.05 $5.92 $7.29 $6.12 7/1/2016 $7.05 $7.05 7/1/2016 Y 9 2 7/1/2016
84460 0 999 Years $7.22 $6.06 $7.46 $6.27 7/1/2016 $7.22 $7.22 7/1/2016 Y 9 2 7/1/2016
84478 0 999 Years $7.83 $6.58 $8.09 $6.80 7/1/2016 $7.83 $7.83 7/1/2016 Y 9 2 7/1/2016
84479 0 999 Years $8.81 $7.40 $9.10 $7.64 7/1/2015 $8.81 $8.81 4/1/2012 9 2 7/1/2016
84702 0 999 Years $11.90 $10.00 $12.30 $10.33 7/1/2016 $11.90 $11.90 4/1/2012 9 2 7/1/2016
84703 0 999 Years $10.24 $8.60 $10.58 $8.89 7/1/2016 $10.24 $10.24 4/1/2012 9 2 7/1/2016
85007 0 999 Years $4.68 $3.93 $4.84 $4.07 7/1/2015 $4.68 $4.68 4/1/2012 9 2 7/1/2016
85013 0 999 Years $3.23 $2.71 $3.34 $2.81 7/1/2015 $3.23 $3.23 4/1/2012 9 2 7/1/2016
85014 0 999 Years $3.23 $2.71 $3.34 $2.81 7/1/2015 $3.23 $3.23 4/1/2012 9 2 7/1/2016
85018 0 999 Years $3.23 $2.71 $3.34 $2.81 7/1/2015 $3.23 $3.23 4/1/2012 9 2 7/1/2016
85025 0 999 Years $10.59 $8.90 $10.94 $9.19 7/1/2016 $10.59 $10.59 4/1/2012 9 2 7/1/2016
85027 0 999 Years $8.81 $7.40 $9.10 $7.64 7/1/2015 $8.81 $8.81 4/1/2012 9 2 7/1/2016
85610 0 999 Years $5.36 $4.50 $5.54 $4.65 7/1/2016 $5.36 $5.36 4/1/2012 9 2 7/1/2016
85660 0 999 Years $7.51 $6.31 $7.76 $6.52 7/1/2016 $7.51 $7.51 4/1/2012 9 2 7/1/2016
85730 0 999 Years $8.18 $6.87 $8.45 $7.10 7/1/2016 $8.18 $8.18 4/1/2012 9 2 7/1/2016
86318 0 999 Years $17.63 $14.81 $18.22 $15.30 7/1/2016 $17.63 $17.63 4/1/2012 9 2 7/1/2016
86592 0 999 Years $5.82 $4.89 $6.01 $5.05 7/1/2016 $5.82 $5.82 4/1/2012 9 2 7/1/2016
86631 0 999 Years $11.14 $9.36 $11.51 $9.67 7/1/2016 $11.14 $11.14 4/1/2012 9 2 7/1/2016
86677 0 999 Years $11.14 $9.36 $11.51 $9.67 7/1/2016 $11.14 $11.14 4/1/2012 9 2 7/1/2016
86689 0 999 Years $26.37 $22.15 $27.25 $22.89 7/1/2016 $26.37 $26.37 4/1/2012 9 2 7/1/2016
86695 0 999 Years $17.97 $15.09 $18.57 $15.60 7/1/2016 $17.97 $17.97 4/1/2012 9 2 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Frm Thru Units FeeAdjusted Fee for
Report DateFee
Adjusted Fee for
Report Date
Fee Effect
DateFee
Adjusted Fee
for Report
Date
Fee Effect
Date1 2 3
Proc CodeMod
1
Mod
2
Client Age Clinical LabSole Community Hospital
(SCH)
Clin. Lab &
SCH
Automated
Test Panel
Last Pricing
Review Date
Note CodesDSHS Lab
86696 0 999 Years $26.37 $22.15 $27.25 $22.89 7/1/2016 $26.37 $26.37 4/1/2012 9 2 7/1/2016
86701 0 999 Years $12.11 $10.17 $12.51 $10.51 7/1/2016 $12.11 $12.11 4/1/2012 9 2 7/1/2016
86701 0 999 Years $12.11 $10.17 $12.51 $10.51 7/1/2016 $12.11 $12.11 4/1/2012 2 7/1/2016
86702 0 999 Years $14.38 $12.08 $14.86 $12.48 7/1/2016 $14.38 $14.38 4/1/2012 9 2 7/1/2016
86703 0 999 Years $18.67 $15.68 $19.29 $16.20 7/1/2016 $18.67 $18.67 4/1/2012 9 2 7/1/2016
86703 0 999 Years $18.67 $15.68 $19.29 $16.20 7/1/2016 $18.67 $18.67 4/1/2012 2 7/1/2016
86704 0 999 Years $16.41 $13.78 $16.96 $14.25 7/1/2016 $16.41 $16.41 4/1/2012 9 2 7/1/2016
86706 0 999 Years $14.63 $12.29 $15.12 $12.70 7/1/2016 $14.63 $14.63 4/1/2012 9 2 7/1/2016
86762 0 999 Years $19.61 $16.47 $20.26 $17.02 7/1/2016 $19.61 $19.61 4/1/2012 9 2 7/1/2016
86780 0 999 Years $11.91 $10.00 $12.31 $10.34 7/1/2016 $11.91 $11.91 4/1/2012 9 2 7/1/2016
86803 0 999 Years $19.44 $16.33 $20.09 $16.88 7/1/2016 $19.44 $19.44 7/1/2016 Y 9 2 7/1/2016
86885 0 999 Years $7.80 $6.55 $8.06 $6.77 7/1/2016 $7.80 $7.80 4/1/2012 9 2 7/1/2016
86900 0 999 Years $4.07 $3.42 $4.21 $3.54 7/1/2016 $4.07 $4.07 4/1/2012 9 2 7/1/2016
86901 0 999 Years $4.07 $3.42 $4.21 $3.54 7/1/2016 $4.07 $4.07 4/1/2012 9 2 7/1/2016
87070 0 999 Years $11.74 $9.86 $12.13 $10.19 7/1/2016 $11.74 $11.74 4/1/2012 9 2 7/1/2016
87086 0 999 Years $11.00 $9.24 $11.37 $9.55 7/1/2016 $11.00 $11.00 4/1/2012 9 2 7/1/2016
87088 0 999 Years $11.03 $9.27 $11.40 $9.58 7/1/2016 $11.03 $11.03 4/1/2012 9 2 7/1/2016
87102 0 999 Years $11.45 $9.62 $11.83 $9.94 7/1/2016 $11.45 $11.45 4/1/2012 9 2 7/1/2016
87110 0 999 Years $26.69 $22.42 $27.58 $23.17 7/1/2016 $26.69 $26.69 4/1/2012 9 2 7/1/2016
87205 0 999 Years $5.82 $4.89 $6.01 $5.05 7/1/2016 $5.82 $5.82 4/1/2012 9 2 7/1/2016
87210 0 999 Years $5.82 $4.89 $6.01 $5.05 7/1/2016 $5.82 $5.82 4/1/2012 9 2 7/1/2016
87220 0 999 Years $5.82 $4.89 $6.01 $5.05 7/1/2016 $5.82 $5.82 4/1/2012 9 2 7/1/2016
87252 0 999 Years $35.51 $29.83 $36.69 $30.82 7/1/2016 $35.51 $35.51 4/1/2012 9 2 7/1/2016
87270 0 999 Years $16.33 $13.72 $16.87 $14.17 7/1/2016 $16.33 $16.33 4/1/2012 9 2 7/1/2016
87340 0 999 Years $14.07 $11.82 $14.54 $12.21 7/1/2016 $14.07 $14.07 7/1/2016 Y 9 2 7/1/2016
87389 0 999 Years $32.80 $27.55 $33.89 $28.47 7/1/2016 $32.80 $32.80 4/1/2012 9 2 7/1/2016
87480 0 999 Years $27.32 $22.95 $28.23 $23.71 7/1/2016 $27.32 $27.32 4/1/2012 9 2 7/1/2016
87490 0 999 Years $27.32 $22.95 $28.23 $23.71 7/1/2016 $27.32 $27.32 4/1/2012 9 2 7/1/2016
87491 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 9 2 7/1/2016
87510 0 999 Years $27.32 $22.95 $28.23 $23.71 7/1/2016 $27.32 $27.32 4/1/2012 9 2 7/1/2016
87512 0 999 Years $38.65 $32.47 $39.94 $33.55 7/1/2016 $38.65 $38.65 4/1/2012 9 2 7/1/2016
87529 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 9 2 7/1/2016
87530 0 999 Years $38.65 $32.47 $39.94 $33.55 7/1/2016 $38.65 $38.65 4/1/2012 9 2 7/1/2016
87535 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 9 2 7/1/2016
87590 0 999 Years $27.32 $22.95 $28.23 $23.71 7/1/2016 $27.32 $27.32 4/1/2012 9 2 7/1/2016
87591 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 9 2 7/1/2016
87624 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 7/1/2016
87624 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 2 7/1/2016
87625 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 7/1/2016
87625 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 2 7/1/2016
87660 0 999 Years $27.32 $22.95 $28.23 $23.71 7/1/2016 $27.32 $27.32 4/1/2012 9 2 7/1/2016
87661 0 999 Years $47.80 $40.15 $49.39 $41.49 7/1/2016 $47.80 $47.80 4/1/2012 9 2 7/1/2016
87797 0 999 Years $27.32 $22.95 $28.23 $23.71 7/1/2016 $27.32 $27.32 4/1/2012 9 2 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Frm Thru Units FeeAdjusted Fee for
Report DateFee
Adjusted Fee for
Report Date
Fee Effect
DateFee
Adjusted Fee
for Report
Date
Fee Effect
Date1 2 3
Proc CodeMod
1
Mod
2
Client Age Clinical LabSole Community Hospital
(SCH)
Clin. Lab &
SCH
Automated
Test Panel
Last Pricing
Review Date
Note CodesDSHS Lab
87800 0 999 Years $54.64 $45.90 $56.46 $47.43 7/1/2016 $54.64 $54.64 4/1/2012 9 2 7/1/2016
87801 0 999 Years $95.62 $80.32 $98.81 $83.00 7/1/2016 $95.62 $95.62 4/1/2012 9 2 7/1/2016
87810 0 999 Years $16.33 $13.72 $16.87 $14.17 7/1/2016 $16.33 $16.33 4/1/2012 9 2 7/1/2016
87850 0 999 Years $16.33 $13.72 $16.87 $14.17 7/1/2016 $16.33 $16.33 4/1/2012 9 2 7/1/2016
88142 0 999 Years $27.60 $23.18 $28.52 $23.96 7/1/2016 $27.60 $27.60 4/1/2012 9 2 7/1/2016
88143 0 999 Years $27.60 $23.18 $28.52 $23.96 7/1/2016 $27.60 $27.60 4/1/2012 9 2 7/1/2016
88150 0 999 Years $14.39 $12.09 $14.87 $12.49 7/1/2016 $14.39 $14.39 4/1/2012 9 2 7/1/2016
88155 0 999 Years $8.16 $6.85 $8.43 $7.08 7/1/2016 $8.16 $8.16 4/1/2012 9 2 7/1/2016
88164 0 999 Years $14.39 $12.09 $14.87 $12.49 7/1/2016 $14.39 $14.39 4/1/2012 9 2 7/1/2016
88165 0 999 Years $14.39 $12.09 $14.87 $12.49 7/1/2016 $14.39 $14.39 4/1/2012 9 2 7/1/2016
88167 0 999 Years $14.39 $12.09 $14.87 $12.49 7/1/2016 $14.39 $14.39 4/1/2012 9 2 7/1/2016
88174 0 999 Years $29.11 $24.45 $30.08 $25.27 7/1/2016 $29.11 $29.11 4/1/2012 9 2 7/1/2016
88175 0 999 Years $36.09 $30.32 $37.29 $31.32 7/1/2016 $36.09 $36.09 4/1/2012 9 2 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note Code(s): 1 - In an outpatient setting, this procedure is subject to a 60% payable if diagnosis is non-emergency.
10 - Assistant surgery is payable at a percentage of surgery.
12 - CRNA/AA providers are reimbursed at 92 percent of the fee applicable to a physician for the same service.
2 - Clinical Lab Fee Schedule procedure.
3 - The calculated payable amount for anesthesia could be reduced or increased based on the modifier used.
5 - This procedure is manually reviewed to determine pricing.
5A - Procedure suspends for manual pricing if billed amount is greater than the max fee.
9 - The NP/CNS/PA/CNM Provider Fee Schedule reflects 100 percent of the fee applicable to a physician.
E1 - The Texas Medicaid rate for LPA, PLP, LCSW, LMFT, and LPC is 70% of the rate paid to a psychiatrist and psychologist.
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.