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9/15/2020 1 of 93TEXAS MEDICAID FEE SCHEDULE -

DENTAL

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:

Change Ind:

1 2 3 1 2 3

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0120 0 20 Years 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0140 0 20 Years 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0150 0 20 Years 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0160 1 20 Years 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0170 0 20 Years 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 10/1/2017

Indicator denoting that the Fee Schedule row has been added/updated since the last run. 'C' for change; blank for no changes.

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.

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.

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 “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.

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).

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 every two years or as necessary. This column shows the date on which the most recent review was conducted.

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

Ind

Texas Medicaid Fee Schedule Information

DENTALThis 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.

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.

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.

TOS TOS DescProc

Code

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.

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.


DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0180 13 20 Years 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0210 2 20 Years 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0220 1 20 Years 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0230 1 20 Years 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0240 0 20 Years 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0250 1 20 Years 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0270 1 20 Years 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0272 1 20 Years 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0273 1 20 Years 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0274 2 20 Years 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0277 2 20 Years 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0310 1 20 Years 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0320 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0321 1 20 Years 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0322 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0330 3 20 Years 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0340 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0350 0 20 Years 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0415 1 20 Years 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0460 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0470 1 20 Years 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0502 1 20 Years 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D0999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1110 13 20 Years 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1120 6 155 Months 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1206 6 251 Months 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1330 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1351 0 20 Years 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1352 5 20 Years 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1510 1 20 Years 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1516 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1517 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1520 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1526 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1527 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1551 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1552 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1553 1 20 Years 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 1/1/2020

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1556 1 20 Years 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 1/1/2020

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1557 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1558 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D1575 3 7 Years 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 10/1/2017

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2140 0 20 Years 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2150 0 20 Years 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2160 1 20 Years 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2161 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2330 0 20 Years 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2331 0 20 Years 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2332 1 20 Years 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2335 1 20 Years 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2390 0 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2391 0 20 Years 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2392 0 20 Years 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2393 1 20 Years 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2394 1 20 Years 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2510 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2520 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2530 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2542 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2543 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2544 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2650 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2651 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2652 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2662 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2663 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2664 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2710 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2720 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2721 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2722 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2740 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2750 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2751 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2752 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2780 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2781 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2782 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2783 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2790 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2791 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2792 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2794 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2910 13 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2915 4 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2920 1 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2930 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2931 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2932 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2933 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2934 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2940 0 20 Years 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2950 4 20 Years 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2951 4 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2952 13 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2953 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2954 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2955 4 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2957 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2960 13 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2961 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2962 13 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2971 13 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2980 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D2999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3110 1 20 Years 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3120 1 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3220 0 20 Years 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3230 1 20 Years 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3240 1 20 Years 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3310 6 20 Years 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3320 6 20 Years 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3330 6 20 Years 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3346 6 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3347 6 20 Years 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3348 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3351 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3352 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3353 6 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3410 6 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3421 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3425 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3426 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3430 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3450 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3460 16 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3470 6 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3910 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3920 6 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3950 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D3999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4210 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4211 13 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4230 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4231 13 20 Years 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4240 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4241 13 20 Years 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4245 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4249 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4260 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4261 13 20 Years 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4266 13 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4267 13 20 Years 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4270 13 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4273 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4274 13 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4275 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4276 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4283 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4285 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4320 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4321 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4341 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4342 13 20 Years 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4355 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4381 13 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4910 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4920 13 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D4999 13 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5110 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5120 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5130 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5140 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5211 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5212 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5213 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5214 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5410 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5411 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5421 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5422 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5511 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5512 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5520 3 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5611 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5612 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5630 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5640 6 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5650 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5660 6 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5670 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5671 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5710 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5711 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5720 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5721 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5730 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5731 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5740 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5741 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5750 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5751 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5760 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5761 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5810 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5811 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5820 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5821 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5850 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5851 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5862 4 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5911 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5912 1 20 Years 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5913 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5914 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5915 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5916 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5919 1 20 Years 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5922 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5923 1 20 Years 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5924 1 20 Years 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5925 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5926 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5927 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5928 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5929 1 20 Years 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5931 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5932 1 20 Years 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5933 1 20 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5934 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5935 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5936 1 20 Years 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5937 1 20 Years 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5951 0 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5952 0 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5953 13 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5954 0 20 Years 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5955 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5958 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5959 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5960 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5982 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5984 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5985 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5986 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5987 1 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5988 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5992 0 999 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5993 0 999 Years 0.00 $0.0000 $1,979.16 9/1/2018 0.00 $1,979.16 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D5999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6210 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6211 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6212 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6240 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6241 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6242 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6245 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6250 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6251 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6252 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6545 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6548 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6720 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6721 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6722 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6740 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6750 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6751 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6752 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6780 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6781 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6782 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6783 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6790 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6791 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6792 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6920 16 20 Years 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6930 16 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6940 16 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6950 16 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6980 16 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D6999 16 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7111 0 20 Years 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7140 0 20 Years 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7210 1 20 Years 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7220 1 20 Years 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7230 1 20 Years 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7240 1 20 Years 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7241 1 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7250 1 20 Years 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7260 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7261 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7270 1 20 Years 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7272 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7280 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7282 4 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7283 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7285 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7286 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7290 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7291 4 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7310 1 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7320 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7340 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7350 1 20 Years 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7410 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7411 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7413 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7414 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7440 1 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7441 1 20 Years 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7450 1 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7451 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7460 0 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7461 0 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7465 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7472 1 20 Years 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7510 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7520 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7530 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7540 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7550 1 20 Years 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7560 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7670 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7820 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7880 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7910 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7911 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7912 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7955 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7960 1 20 Years 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7970 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7971 1 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7972 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7980 1 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7997 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D7999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8050 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8060 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8080 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8210 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8220 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8660 0 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8670 0 20 Years 0.00 $0.0000 $65.07 9/1/2018 0.00 $65.07 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8680 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8690 0 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D8999 0 20 Years 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9110 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9120 13 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9210 1 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9211 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9212 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 1 20 Years 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 UZ 1 20 Years 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9230 1 20 Years 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9239 1 20 Years 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9248 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9310 1 20 Years 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9410 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9420 1 20 Years 0.00 $0.0000 $36.31 9/1/2018 0.00 $36.31 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9430 1 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9440 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9610 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9612 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9630 1 20 Years 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9910 18 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9920 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9930 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9944 16 20 Years 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 1/1/2019

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9950 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9951 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9952 13 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9970 1 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9974 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORAL

MAXILOFACIA

L SURGEON W

THSTEPS

DENTAL/ORTHOD

ONTIA D9999 1 20 Years 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0120 0 20 Years 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0140 0 20 Years 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0150 0 20 Years 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0160 1 20 Years 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0170 0 20 Years 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0180 13 20 Years 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0210 2 20 Years 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0220 1 20 Years 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0230 1 20 Years 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0240 0 20 Years 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0250 1 20 Years 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0270 1 20 Years 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0272 1 20 Years 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0273 1 20 Years 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0274 2 20 Years 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0277 2 20 Years 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0310 1 20 Years 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0320 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0321 1 20 Years 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0322 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0330 3 20 Years 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0340 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0350 0 20 Years 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0415 1 20 Years 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0460 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0470 1 20 Years 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0502 1 20 Years 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D0999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1110 13 20 Years 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1120 6 155 Months 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1206 6 251 Months 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1330 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1351 0 20 Years 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1352 5 20 Years 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1510 1 20 Years 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1516 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1517 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1520 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1526 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1527 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1551 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1552 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1553 1 20 Years 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 1/1/2020

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1556 1 20 Years 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 1/1/2020

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1557 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1558 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D1575 3 7 Years 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 10/1/2017

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2140 0 20 Years 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2150 0 20 Years 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2160 1 20 Years 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2161 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2330 0 20 Years 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2331 0 20 Years 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2332 1 20 Years 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2335 1 20 Years 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2390 0 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2391 0 20 Years 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2392 0 20 Years 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2393 1 20 Years 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2394 1 20 Years 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2510 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2520 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2530 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2542 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2543 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2544 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2650 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2651 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2652 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2662 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2663 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2664 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2710 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2720 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2721 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2722 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2740 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2750 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2751 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2752 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2780 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2781 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2782 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2783 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2790 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2791 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2792 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2794 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2910 13 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2915 4 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2920 1 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2930 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2931 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2932 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2933 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2934 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2940 0 20 Years 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2950 4 20 Years 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2951 4 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2952 13 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2953 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2954 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2955 4 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2957 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2960 13 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2961 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2962 13 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2980 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D2999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3110 1 20 Years 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3120 1 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3220 0 20 Years 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3230 1 20 Years 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3240 1 20 Years 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3310 6 20 Years 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3320 6 20 Years 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3330 6 20 Years 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3346 6 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3347 6 20 Years 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3348 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3351 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3352 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3353 6 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3410 6 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3421 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3425 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3426 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3430 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3450 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3460 16 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3470 6 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3910 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3920 6 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3950 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D3999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4210 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4211 13 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4230 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4231 13 20 Years 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4240 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4241 13 20 Years 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4245 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4249 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4260 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4261 13 20 Years 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4266 13 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4267 13 20 Years 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4270 13 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4273 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4274 13 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4275 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4276 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4283 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4285 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4320 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4321 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4341 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4342 13 20 Years 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4355 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4381 13 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4910 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4920 13 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D4999 13 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5110 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5120 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5130 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5140 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5211 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5212 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5213 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5214 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5410 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5411 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5421 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5422 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5511 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5512 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5520 3 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5611 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5612 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5630 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5640 6 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5650 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5660 6 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5670 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5671 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5710 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5711 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5720 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5721 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5730 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5731 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5740 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5741 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5750 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5751 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5760 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5761 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5810 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5811 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5820 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5821 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5850 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5851 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5862 4 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5911 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5912 1 20 Years 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5913 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5914 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5915 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5916 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5919 1 20 Years 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5922 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5923 1 20 Years 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5924 1 20 Years 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5925 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5926 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5927 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5928 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5929 1 20 Years 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5931 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5932 1 20 Years 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5933 1 20 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5934 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5935 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5936 1 20 Years 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5937 1 20 Years 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5951 0 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5952 0 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5953 13 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5954 0 20 Years 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5955 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5958 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5959 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5960 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5982 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5984 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5985 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5986 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5987 1 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5988 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5992 0 999 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5993 0 999 Years 0.00 $0.0000 $1,979.16 9/1/2018 0.00 $1,979.16 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D5999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6210 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6211 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6212 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6240 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6241 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6242 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6245 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6250 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6251 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6252 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6545 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6548 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6720 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6721 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6722 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6740 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6750 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6751 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6752 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6780 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6781 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6782 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6783 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6790 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6791 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6792 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6920 16 20 Years 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6930 16 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6940 16 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6950 16 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6980 16 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D6999 16 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7111 0 20 Years 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7140 0 20 Years 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7210 1 20 Years 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7220 1 20 Years 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7230 1 20 Years 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7240 1 20 Years 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7241 1 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7250 1 20 Years 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7260 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7261 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7270 1 20 Years 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7272 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7280 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7282 4 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7283 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7285 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7286 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7290 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7291 4 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7310 1 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7320 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7340 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7350 1 20 Years 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7410 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7411 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7413 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7414 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7440 1 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7441 1 20 Years 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7450 1 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7451 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7460 0 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7461 0 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7465 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7472 1 20 Years 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7510 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7520 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7530 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7540 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7550 1 20 Years 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7560 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7670 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7820 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7880 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7910 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7911 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7912 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7955 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7960 1 20 Years 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7970 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7971 1 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7972 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7980 1 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7997 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D7999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8050 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8060 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8080 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8210 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8220 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8660 0 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8670 0 20 Years 0.00 $0.0000 $65.07 9/1/2018 0.00 $65.07 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8680 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8690 0 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D8999 0 20 Years 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9110 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9120 13 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9210 1 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9211 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9212 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 1 20 Years 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 UZ 1 20 Years 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9230 1 20 Years 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9239 1 20 Years 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9248 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9310 1 20 Years 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9410 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9420 1 20 Years 0.00 $0.0000 $36.31 9/1/2018 0.00 $36.31 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9430 1 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9440 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9610 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9612 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9630 1 20 Years 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9910 18 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9920 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9930 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9944 16 20 Years 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 1/1/2019

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9950 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9951 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9952 13 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9974 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

ORTHODONTI

ST W

THSTEPS

DENTAL/ORTHOD

ONTIA D9999 1 20 Years 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0120 0 20 Years 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0140 0 20 Years 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0145 6 35 Months 0.00 $0.0000 $144.97 3/1/2008 -2.00 $142.07 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0150 0 20 Years 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0160 1 20 Years 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0170 0 20 Years 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0180 13 20 Years 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0210 2 20 Years 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0220 1 20 Years 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0230 1 20 Years 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0240 0 20 Years 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0250 1 20 Years 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0270 1 20 Years 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0272 1 20 Years 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0273 1 20 Years 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0274 2 20 Years 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0277 2 20 Years 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0310 1 20 Years 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0320 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0321 1 20 Years 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0322 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0330 3 20 Years 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0340 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0350 0 20 Years 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0415 1 20 Years 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0460 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0470 1 20 Years 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0502 1 20 Years 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D0999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1110 13 20 Years 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1120 6 155 Months 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1206 6 251 Months 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1330 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1351 0 20 Years 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1352 5 20 Years 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1510 1 20 Years 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1516 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1517 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1520 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1526 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1527 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1551 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1552 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1553 1 20 Years 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 1/1/2020

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1556 1 20 Years 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 1/1/2020

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1557 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1558 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D1575 3 7 Years 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 10/1/2017

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2140 0 20 Years 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2150 0 20 Years 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2160 1 20 Years 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2161 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2330 0 20 Years 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2331 0 20 Years 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2332 1 20 Years 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2335 1 20 Years 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2390 0 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2391 0 20 Years 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2392 0 20 Years 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2393 1 20 Years 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2394 1 20 Years 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2510 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2520 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2530 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2542 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2543 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2544 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2650 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2651 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2652 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2662 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2663 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2664 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2710 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2720 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2721 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2722 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2740 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2750 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2751 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2752 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2780 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2781 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2782 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2783 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2790 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2791 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2792 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2794 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2910 13 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2915 4 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2920 1 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2930 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2931 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2932 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2933 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2934 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2940 0 20 Years 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2950 4 20 Years 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2951 4 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2952 13 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2953 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2954 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2955 4 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2957 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2960 13 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2961 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2962 13 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2971 13 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2980 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D2999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3110 1 20 Years 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3120 1 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3220 0 20 Years 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3230 1 20 Years 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3240 1 20 Years 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3310 6 20 Years 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3320 6 20 Years 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3330 6 20 Years 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3346 6 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3347 6 20 Years 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3348 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3351 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3352 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3353 6 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3410 6 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3421 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3425 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3426 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3430 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3450 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3460 16 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3470 6 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3910 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3920 6 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3950 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D3999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4210 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4211 13 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4230 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4231 13 20 Years 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4240 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4241 13 20 Years 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4245 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4249 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4260 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4261 13 20 Years 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4266 13 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4267 13 20 Years 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4270 13 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4273 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4274 13 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4275 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4276 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4283 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4285 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4320 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4321 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4341 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4342 13 20 Years 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4355 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4381 13 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4910 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4920 13 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D4999 13 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5110 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5120 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5130 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5140 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5211 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5212 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5213 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5214 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5410 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5411 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5421 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5422 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5511 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5512 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5520 3 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5611 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5612 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5630 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5640 6 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5650 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5660 6 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5670 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5671 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5710 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5711 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5720 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5721 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5730 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5731 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5740 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5741 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5750 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5751 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5760 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5761 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5810 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5811 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5820 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5821 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5850 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5851 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5862 4 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5911 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5912 1 20 Years 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5913 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5914 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5915 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5916 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5919 1 20 Years 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5922 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5923 1 20 Years 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5924 1 20 Years 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5925 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5926 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5927 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5928 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5929 1 20 Years 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5931 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5932 1 20 Years 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5933 1 20 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5934 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5935 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5936 1 20 Years 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5937 1 20 Years 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5951 0 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5952 0 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5953 13 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5954 0 20 Years 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5955 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5958 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5959 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5960 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5982 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5984 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5985 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5986 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5987 1 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5988 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5992 0 999 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5993 0 999 Years 0.00 $0.0000 $1,979.16 9/1/2018 0.00 $1,979.16 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D5999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6210 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6211 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6212 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6240 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6241 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6242 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6245 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6250 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6251 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6252 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6545 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6548 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6720 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6721 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6722 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6740 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6750 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6751 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6752 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6780 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6781 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6782 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6783 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6790 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6791 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6792 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6920 16 20 Years 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6930 16 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6940 16 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6950 16 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6980 16 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D6999 16 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7111 0 20 Years 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7140 0 20 Years 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7210 1 20 Years 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7220 1 20 Years 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7230 1 20 Years 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7240 1 20 Years 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7241 1 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7250 1 20 Years 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7260 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7261 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7270 1 20 Years 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7272 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7280 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7282 4 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7283 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7285 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7286 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7290 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7291 4 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7310 1 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7320 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7340 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7350 1 20 Years 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7410 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7411 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7413 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7414 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7440 1 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7441 1 20 Years 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7450 1 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7451 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7460 0 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7461 0 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7465 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7472 1 20 Years 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7510 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7520 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7530 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7540 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7550 1 20 Years 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7560 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7670 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7820 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7880 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7910 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7911 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7912 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7955 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7960 1 20 Years 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7970 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7971 1 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7972 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7980 1 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7997 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D7999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8050 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8060 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8080 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8210 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8220 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8660 0 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8670 0 20 Years 0.00 $0.0000 $65.07 9/1/2018 0.00 $65.07 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8680 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8690 0 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D8999 0 20 Years 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9110 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9120 13 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9210 1 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9211 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9212 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 1 20 Years 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 UZ 1 20 Years 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9230 1 20 Years 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9239 1 20 Years 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9248 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9310 1 20 Years 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9410 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9420 1 20 Years 0.00 $0.0000 $36.31 9/1/2018 0.00 $36.31 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9430 1 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9440 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9610 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9612 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9630 1 20 Years 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9910 18 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9920 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9930 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9944 16 20 Years 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 1/1/2019

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9950 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9951 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9952 13 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9970 1 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9974 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS -

DENTAL W

THSTEPS

DENTAL/ORTHOD

ONTIA D9999 1 20 Years 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0120 0 20 Years 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 0.00 $0.0000 $29.44 9/1/2007 -2.00 $28.85 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0140 0 20 Years 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 0.00 $0.0000 $19.16 10/1/2001 -2.00 $18.78 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0145 6 35 Months 0.00 $0.0000 $144.97 3/1/2008 -2.00 $142.07 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0150 0 20 Years 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 0.00 $0.0000 $36.04 9/1/2007 -2.00 $35.32 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0160 1 20 Years 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 0.00 $0.0000 $15.25 1/1/1997 -2.00 $14.95 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0170 0 20 Years 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 0.00 $0.0000 $16.88 1/1/2000 -2.00 $16.54 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0180 13 20 Years 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 0.00 $0.0000 $8.02 10/16/2003 -2.00 $7.86 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0210 2 20 Years 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 0.00 $0.0000 $72.08 9/1/2007 -2.00 $70.64 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0220 1 20 Years 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 0.00 $0.0000 $12.82 9/1/2007 -2.00 $12.56 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0230 1 20 Years 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 0.00 $0.0000 $11.74 9/1/2007 -2.00 $11.51 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0240 0 20 Years 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 0.00 $0.0000 $10.00 12/1/1992 -2.00 $9.80 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0250 1 20 Years 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 0.00 $0.0000 $18.75 12/1/1992 -2.00 $18.38 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0270 1 20 Years 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 0.00 $0.0000 $5.00 12/1/1992 -2.00 $4.90 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0272 1 20 Years 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 0.00 $0.0000 $23.86 9/1/2007 -2.00 $23.38 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0273 1 20 Years 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 0.00 $0.0000 $29.60 9/1/2007 -2.00 $29.01 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0274 2 20 Years 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 0.00 $0.0000 $35.32 9/1/2007 -2.00 $34.61 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0277 2 20 Years 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 0.00 $0.0000 $31.75 1/1/2000 -2.00 $31.12 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0310 1 20 Years 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 0.00 $0.0000 $45.00 12/1/1992 -2.00 $44.10 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0320 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0321 1 20 Years 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 0.00 $0.0000 $35.00 12/1/1992 -2.00 $34.30 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0322 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0330 3 20 Years 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 0.00 $0.0000 $65.08 9/1/2007 -2.00 $63.78 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0340 1 20 Years 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 0.00 $0.0000 $33.75 12/1/1992 -2.00 $33.08 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0350 0 20 Years 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 0.00 $0.0000 $18.75 1/1/2000 -2.00 $18.38 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0415 1 20 Years 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 0.00 $0.0000 $25.00 12/1/1992 -2.00 $24.50 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0460 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0470 1 20 Years 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 0.00 $0.0000 $22.50 12/1/1992 -2.00 $22.05 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0502 1 20 Years 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 0.00 $0.0000 $57.50 12/1/1992 -2.00 $56.35 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D0999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1110 13 20 Years 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 0.00 $0.0000 $56.00 9/1/2007 -2.00 $54.88 10/1/2017



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1120 6 155 Months 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 0.00 $0.0000 $37.50 9/1/2007 -2.00 $36.75 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1206 6 251 Months 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1330 1 20 Years 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 0.00 $0.0000 $12.50 12/1/1992 -2.00 $12.25 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1351 0 20 Years 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 0.00 $0.0000 $28.82 9/1/2007 -2.00 $28.24 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1352 5 20 Years 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 0.00 $0.0000 $38.20 1/1/2011 -2.00 $37.44 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1510 1 20 Years 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 0.00 $0.0000 $160.00 9/1/2007 -2.00 $156.80 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1516 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1517 1 20 Years 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 0.00 $0.0000 $232.75 1/1/2019 0.00 $232.75 1/1/2019

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1520 1 20 Years 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 0.00 $0.0000 $75.00 12/1/1992 -2.00 $73.50 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1526 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1527 1 20 Years 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 0.00 $0.0000 $104.13 1/1/2019 0.00 $104.13 1/1/2019

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1551 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1552 1 20 Years 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 0.00 $0.0000 $18.38 1/1/2020 0.00 $18.38 1/1/2020



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1553 1 20 Years 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 0.00 $0.0000 $13.79 1/1/2020 0.00 $13.79 1/1/2020

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1556 1 20 Years 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 0.00 $0.0000 $36.75 1/1/2020 0.00 $36.75 1/1/2020

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1557 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1558 1 20 Years 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 0.00 $0.0000 $49.00 1/1/2020 0.00 $49.00 1/1/2020

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D1575 3 7 Years 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 0.00 $0.0000 $200.00 1/1/2017 0.00 $200.00 10/1/2017

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2140 0 20 Years 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 0.00 $0.0000 $62.80 9/1/2018 0.00 $62.80 D7 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2150 0 20 Years 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 0.00 $0.0000 $83.57 9/1/2018 0.00 $83.57 D8 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2160 1 20 Years 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 0.00 $0.0000 $106.46 9/1/2018 0.00 $106.46 D2 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2161 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 D4 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2330 0 20 Years 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 0.00 $0.0000 $75.81 9/1/2018 0.00 $75.81 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2331 0 20 Years 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 0.00 $0.0000 $100.46 9/1/2018 0.00 $100.46 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2332 1 20 Years 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 0.00 $0.0000 $131.17 9/1/2018 0.00 $131.17 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2335 1 20 Years 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 0.00 $0.0000 $162.80 9/1/2018 0.00 $162.80 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2390 0 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 D1 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2391 0 20 Years 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 0.00 $0.0000 $80.34 9/1/2018 0.00 $80.34 D6 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2392 0 20 Years 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 0.00 $0.0000 $105.30 9/1/2018 0.00 $105.30 D5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2393 1 20 Years 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 0.00 $0.0000 $117.98 9/1/2018 0.00 $117.98 D3 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2394 1 20 Years 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 0.00 $0.0000 $131.63 9/1/2018 0.00 $131.63 D3 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2510 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2520 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2530 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2542 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2543 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2544 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2650 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2651 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2652 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2662 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2663 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2664 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2710 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2720 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2721 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2722 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2740 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2750 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2751 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2752 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2780 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2781 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2782 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2783 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2790 13 20 Years 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 0.00 $0.0000 $504.50 9/1/2018 0.00 $504.50 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2791 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2792 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2794 13 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2910 13 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2915 4 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2920 1 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2930 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2931 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2932 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2933 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2934 0 20 Years 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 0.00 $0.0000 $149.12 9/1/2018 0.00 $149.12 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2940 0 20 Years 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 0.00 $0.0000 $34.95 9/1/2018 0.00 $34.95 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2950 4 20 Years 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 0.00 $0.0000 $43.00 9/1/2018 0.00 $43.00 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2951 4 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2952 13 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2953 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2954 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2955 4 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2957 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2960 13 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2961 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2962 13 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2971 13 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2980 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D2999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3110 1 20 Years 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 0.00 $0.0000 $15.53 9/1/2018 0.00 $15.53 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3120 1 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3220 0 20 Years 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 0.00 $0.0000 $84.05 9/1/2018 0.00 $84.05 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3230 1 20 Years 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 0.00 $0.0000 $37.03 9/1/2018 0.00 $37.03 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3240 1 20 Years 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 0.00 $0.0000 $42.02 9/1/2018 0.00 $42.02 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3310 6 20 Years 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 0.00 $0.0000 $340.14 9/1/2018 0.00 $340.14 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3320 6 20 Years 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 0.00 $0.0000 $394.14 9/1/2018 0.00 $394.14 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3330 6 20 Years 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 0.00 $0.0000 $596.48 9/1/2018 0.00 $596.48 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3346 6 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3347 6 20 Years 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 0.00 $0.0000 $197.08 9/1/2018 0.00 $197.08 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3348 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3351 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3352 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3353 6 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3410 6 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3421 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3425 6 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3426 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3430 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3450 6 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3460 16 20 Years 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 0.00 $0.0000 $203.04 9/1/2018 0.00 $203.04 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3470 6 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3910 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3920 6 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3950 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D3999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4210 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4211 13 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4230 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4231 13 20 Years 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 0.00 $0.0000 $93.16 9/1/2018 0.00 $93.16 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4240 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4241 13 20 Years 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 0.00 $0.0000 $52.55 9/1/2018 0.00 $52.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4245 13 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4249 13 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4260 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4261 13 20 Years 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 0.00 $0.0000 $64.02 9/1/2018 0.00 $64.02 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4266 13 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4267 13 20 Years 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 0.00 $0.0000 $310.54 9/1/2018 0.00 $310.54 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4270 13 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4273 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4274 13 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4275 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4276 13 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4283 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4285 13 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4320 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4321 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4341 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4342 13 20 Years 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 0.00 $0.0000 $6.69 9/1/2018 0.00 $6.69 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4355 13 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4381 13 20 Years 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 0.00 $0.0000 $28.67 9/1/2018 0.00 $28.67 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4910 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4920 13 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D4999 13 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5110 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5120 3 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5130 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5140 13 20 Years 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 0.00 $0.0000 $370.26 9/1/2018 0.00 $370.26 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5211 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5212 6 20 Years 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 0.00 $0.0000 $262.76 9/1/2018 0.00 $262.76 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5213 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5214 9 20 Years 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 0.00 $0.0000 $382.20 9/1/2018 0.00 $382.20 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5410 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5411 3 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5421 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5422 6 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5511 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5512 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5520 3 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5611 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5612 3 20 Years 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 0.00 $0.0000 $68.00 9/1/2018 0.00 $68.00 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5630 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5640 6 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5650 6 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5660 6 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5670 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5671 6 20 Years 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 0.00 $0.0000 $167.21 9/1/2018 0.00 $167.21 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5710 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5711 4 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5720 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5721 7 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5730 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5731 4 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5740 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5741 7 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5750 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5751 4 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5760 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5761 7 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5810 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5811 3 20 Years 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 0.00 $0.0000 $191.10 9/1/2018 0.00 $191.10 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5820 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5821 3 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5850 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5851 3 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5862 4 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5911 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5912 1 20 Years 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 0.00 $0.0000 $86.00 9/1/2018 0.00 $86.00 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5913 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5914 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5915 1 20 Years 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 0.00 $0.0000 $836.06 9/1/2018 0.00 $836.06 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5916 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5919 1 20 Years 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 0.00 $0.0000 $1,074.94 9/1/2018 0.00 $1,074.94 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5922 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5923 1 20 Years 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 0.00 $0.0000 $322.48 9/1/2018 0.00 $322.48 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5924 1 20 Years 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 0.00 $0.0000 $418.03 9/1/2018 0.00 $418.03 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5925 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5926 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5927 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5928 1 20 Years 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 0.00 $0.0000 $429.98 9/1/2018 0.00 $429.98 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5929 1 20 Years 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 0.00 $0.0000 $859.95 9/1/2018 0.00 $859.95 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5931 1 20 Years 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 0.00 $0.0000 $358.31 9/1/2018 0.00 $358.31 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5932 1 20 Years 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 0.00 $0.0000 $1,242.15 9/1/2018 0.00 $1,242.15 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5933 1 20 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5934 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5935 1 20 Years 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 0.00 $0.0000 $537.47 9/1/2018 0.00 $537.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5936 1 20 Years 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 0.00 $0.0000 $597.19 9/1/2018 0.00 $597.19 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5937 1 20 Years 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 0.00 $0.0000 $250.82 9/1/2018 0.00 $250.82 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5951 0 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5952 0 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5953 13 20 Years 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 0.00 $0.0000 $806.21 9/1/2018 0.00 $806.21 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5954 0 20 Years 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 0.00 $0.0000 $424.01 9/1/2018 0.00 $424.01 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5955 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5958 0 20 Years 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 0.00 $0.0000 $214.99 9/1/2018 0.00 $214.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5959 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5960 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5982 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5984 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5985 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5986 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5987 1 20 Years 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 0.00 $0.0000 $125.41 9/1/2018 0.00 $125.41 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5988 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5992 0 999 Years 0.00 $0.0000 $268.74 9/1/2018 0.00 $268.74 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5993 0 999 Years 0.00 $0.0000 $1,979.16 9/1/2018 0.00 $1,979.16 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D5999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6210 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6211 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6212 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6240 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6241 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6242 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6245 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6250 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6251 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6252 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6545 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6548 16 20 Years 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 0.00 $0.0000 $257.40 9/1/2018 0.00 $257.40 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6720 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6721 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6722 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6740 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6750 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6751 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6752 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6780 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6781 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6782 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6783 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6790 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6791 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6792 16 20 Years 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 0.00 $0.0000 $252.25 9/1/2018 0.00 $252.25 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6920 16 20 Years 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 0.00 $0.0000 $128.99 9/1/2018 0.00 $128.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6930 16 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6940 16 20 Years 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 0.00 $0.0000 $83.61 9/1/2018 0.00 $83.61 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6950 16 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6980 16 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D6999 16 20 Years 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1990 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7111 0 20 Years 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 0.00 $0.0000 $11.47 9/1/2018 0.00 $11.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7140 0 20 Years 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 0.00 $0.0000 $64.06 9/1/2018 0.00 $64.06 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7210 1 20 Years 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 0.00 $0.0000 $98.23 9/1/2018 0.00 $98.23 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7220 1 20 Years 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 0.00 $0.0000 $150.49 9/1/2018 0.00 $150.49 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7230 1 20 Years 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 0.00 $0.0000 $171.99 9/1/2018 0.00 $171.99 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7240 1 20 Years 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 0.00 $0.0000 $286.65 9/1/2018 0.00 $286.65 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7241 1 20 Years 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 0.00 $0.0000 $149.30 9/1/2018 0.00 $149.30 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7250 1 20 Years 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 0.00 $0.0000 $88.38 9/1/2018 0.00 $88.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7260 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7261 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7270 1 20 Years 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 0.00 $0.0000 $105.11 9/1/2018 0.00 $105.11 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7272 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7280 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7282 4 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7283 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7285 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7286 1 20 Years 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 0.00 $0.0000 $59.72 9/1/2018 0.00 $59.72 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7290 1 20 Years 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 0.00 $0.0000 $131.38 9/1/2018 0.00 $131.38 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7291 4 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7310 1 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7320 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7340 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7350 1 20 Years 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 0.00 $0.0000 $238.88 9/1/2018 0.00 $238.88 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7410 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7411 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7413 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7414 1 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7440 1 20 Years 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 0.00 $0.0000 $173.19 9/1/2018 0.00 $173.19 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7441 1 20 Years 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 0.00 $0.0000 $226.93 9/1/2018 0.00 $226.93 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7450 1 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7451 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7460 0 20 Years 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 0.00 $0.0000 $113.47 9/1/2018 0.00 $113.47 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7461 0 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7465 1 20 Years 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 0.00 $0.0000 $65.70 9/1/2018 0.00 $65.70 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7472 1 20 Years 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 0.00 $0.0000 $152.88 9/1/2018 0.00 $152.88 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7510 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7520 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7530 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7540 1 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7550 1 20 Years 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 0.00 $0.0000 $101.53 9/1/2018 0.00 $101.53 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7560 1 20 Years 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 0.00 $0.0000 $119.44 9/1/2018 0.00 $119.44 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7670 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7820 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7880 1 20 Years 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 0.00 $0.0000 $133.77 9/1/2018 0.00 $133.77 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7899 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7910 1 20 Years 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 0.00 $0.0000 $71.66 9/1/2018 0.00 $71.66 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7911 1 20 Years 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 0.00 $0.0000 $77.64 9/1/2018 0.00 $77.64 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7912 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7955 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7960 1 20 Years 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 0.00 $0.0000 $100.33 9/1/2018 0.00 $100.33 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7970 1 20 Years 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 0.00 $0.0000 $107.49 9/1/2018 0.00 $107.49 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7971 1 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7972 13 20 Years 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 0.00 $0.0000 $41.81 9/1/2018 0.00 $41.81 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7980 1 20 Years 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 0.00 $0.0000 $185.13 9/1/2018 0.00 $185.13 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7983 1 20 Years 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 0.00 $0.0000 $155.27 9/1/2018 0.00 $155.27 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7997 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D7999 1 20 Years 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/1/1992 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8050 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8060 0 20 Years 0.00 $0.0000 $324.87 9/1/2018 0.00 $324.87 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8080 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8210 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8220 0 20 Years 0.00 $0.0000 $0.00 10/16/2003 -2.00 $0.00 5 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8660 0 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8670 0 20 Years 0.00 $0.0000 $65.07 9/1/2018 0.00 $65.07 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8680 0 20 Years 0.00 $0.0000 $95.55 9/1/2018 0.00 $95.55 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8690 0 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D8999 0 20 Years 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 0.00 $0.0000 $0.00 5/1/1988 -2.00 $0.00 5 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9110 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9120 13 20 Years 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 0.00 $0.0000 $19.11 9/1/2018 0.00 $19.11 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9210 1 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9211 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9212 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 1 20 Years 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 0.00 $0.0000 $58.50 9/1/2018 0.00 $58.50 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9222 UZ 1 20 Years 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 0.00 $0.0000 $81.76 9/1/2018 0.00 $81.76 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9230 1 20 Years 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 0.00 $0.0000 $27.11 9/1/2018 0.00 $27.11 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9239 1 20 Years 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 0.00 $0.0000 $57.04 9/1/2018 0.00 $57.04 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9248 1 20 Years 0.00 $0.0000 $121.88 9/1/2018 0.00 $121.88 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9310 1 20 Years 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 0.00 $0.0000 $14.58 9/1/2018 0.00 $14.58 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9410 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9420 1 20 Years 0.00 $0.0000 $36.31 9/1/2018 0.00 $36.31 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9430 1 20 Years 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 0.00 $0.0000 $14.33 9/1/2018 0.00 $14.33 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9440 1 20 Years 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 0.00 $0.0000 $29.86 9/1/2018 0.00 $29.86 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9610 1 20 Years 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 0.00 $0.0000 $17.92 9/1/2018 0.00 $17.92 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9612 1 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9630 1 20 Years 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 0.00 $0.0000 $8.60 9/1/2018 0.00 $8.60 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9910 18 20 Years 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 0.00 $0.0000 $11.94 9/1/2018 0.00 $11.94 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9920 1 20 Years 0.00 $0.0000 $47.78 9/1/2018 0.00 $47.78 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9930 1 20 Years 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 0.00 $0.0000 $23.89 9/1/2018 0.00 $23.89 9/1/2018



DENTAL

1 2 3 1 2 3

Note CodesTotal

RVUs/

Base Units

Conversion

Factor

Change

IndTOS TOS Desc

Proc

Code

Last Pricing

Review Date

Mod

1

Mod

2

FacilityClient Age

Frm Thru Units

Total

RVUs/

Base Units

Conversion

Factor

Non-facility

Provider

Type Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report Date

Medicaid

Fee

Note Codes

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9944 16 20 Years 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 0.00 $0.0000 $113.47 1/1/2019 0.00 $113.47 1/1/2019

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9950 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9951 13 20 Years 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 0.00 $0.0000 $35.83 9/1/2018 0.00 $35.83 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9952 13 20 Years 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 0.00 $0.0000 $143.33 9/1/2018 0.00 $143.33 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9970 1 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9974 13 20 Years 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 0.00 $0.0000 $53.75 9/1/2018 0.00 $53.75 9/1/2018

TEXAS

HEALTH

STEPS

DENTAL -

GROUP W

THSTEPS

DENTAL/ORTHOD

ONTIA D9999 1 20 Years 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 0.00 $0.0000 $0.00 1/1/1977 -2.00 $0.00 5 9/1/2018



DENTAL

Note Code(s): 5 - This procedure is manually reviewed to determine pricing.

D1 - Fee displayed is for a permanent tooth; a primary tooth is paid at 45.83% applied after the payment amount is calculated and before the payment is processed.










DENTAL










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