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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.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note 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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 4 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 5 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 6 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 7 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 8 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 9 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 10 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 11 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 12 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 13 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 14 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 17 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 18 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 20 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 21 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 22 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 23 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 27 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 28 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 29 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 30 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 31 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 32 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 33 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 34 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 35 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 36 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 37 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 38 of 93TEXAS MEDICAID FEE SCHEDULE -
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
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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
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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
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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
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 43 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 44 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 45 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 46 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 47 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 49 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 50 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 51 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 52 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 53 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 54 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 55 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 56 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 57 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 58 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 59 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 60 of 93TEXAS MEDICAID FEE SCHEDULE -
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
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Note 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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 63 of 93TEXAS MEDICAID FEE SCHEDULE -
DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 64 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 65 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 68 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 69 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 70 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 71 of 93TEXAS MEDICAID FEE SCHEDULE -
DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 72 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 73 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 74 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 75 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 76 of 93TEXAS MEDICAID FEE SCHEDULE -
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 77 of 93TEXAS MEDICAID FEE SCHEDULE -
DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 78 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 79 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 80 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 81 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 82 of 93TEXAS MEDICAID FEE SCHEDULE -
DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 83 of 93TEXAS MEDICAID FEE SCHEDULE -
DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 84 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 85 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 86 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 88 of 93TEXAS MEDICAID FEE SCHEDULE -
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 89 of 93TEXAS MEDICAID FEE SCHEDULE -
DENTAL
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 90 of 93TEXAS MEDICAID FEE SCHEDULE -
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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 91 of 93TEXAS MEDICAID FEE SCHEDULE -
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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
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 92 of 93TEXAS MEDICAID FEE SCHEDULE -
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.
D2 - Fee displayed is for a permanent tooth; a primary tooth is paid at 80.78% applied after the payment amount is calculated and before the payment is processed.
D3 - Fee displayed is for a permanent tooth; a primary tooth is paid at 86.09% applied after the payment amount is calculated and before the payment is processed.
D4 - Fee displayed is for a permanent tooth; a primary tooth is paid at 87.76% applied after the payment amount is calculated and before the payment is processed.
D5 - Fee displayed is for a permanent tooth; a primary tooth is paid at 89.82% applied after the payment amount is calculated and before the payment is processed.
D6 - Fee displayed is for a permanent tooth; a primary tooth is paid at 91.56% applied after the payment amount is calculated and before the payment is processed.
D7 - Fee displayed is for a permanent tooth; a primary tooth is paid at 94.31% applied after the payment amount is calculated and before the payment is processed.
D8 - Fee displayed is for a permanent tooth; a primary tooth is paid at 94.79% applied after the payment amount is calculated and before the payment is processed.
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
9/15/2020 93 of 93TEXAS MEDICAID FEE SCHEDULE -
DENTAL
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.
D2 - Fee displayed is for a permanent tooth; a primary tooth is paid at 80.78% applied after the payment amount is calculated and before the payment is processed.
D3 - Fee displayed is for a permanent tooth; a primary tooth is paid at 86.09% applied after the payment amount is calculated and before the payment is processed.
D4 - Fee displayed is for a permanent tooth; a primary tooth is paid at 87.76% applied after the payment amount is calculated and before the payment is processed.
D5 - Fee displayed is for a permanent tooth; a primary tooth is paid at 89.82% applied after the payment amount is calculated and before the payment is processed.
D6 - Fee displayed is for a permanent tooth; a primary tooth is paid at 91.56% applied after the payment amount is calculated and before the payment is processed.
D7 - Fee displayed is for a permanent tooth; a primary tooth is paid at 94.31% applied after the payment amount is calculated and before the payment is processed.
D8 - Fee displayed is for a permanent tooth; a primary tooth is paid at 94.79% applied after the payment amount is calculated and before the payment is processed.
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.