12/19/2016 TEXAS MEDICAID FEE SCHEDULE - Page 1 of 58...

12/19/2016 Page 1 of 58TEXAS MEDICAID FEE SCHEDULE -

PHYSICIAN - DOCTOR OF DENTISTRY

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7 ANESTHESIA 00100 0 20 Years 5.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 5.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014






7 ANESTHESIA 00162 0 20 Years 7.00 $19.8300 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014






7 ANESTHESIA 00170 EP 0 20 Years 5.00 $27.2760 $0.00 9/1/2007 -2.00 $0.00 12 3 5.00 $27.2760 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014

1st Modifier, if required for pricing determination.

2nd Modifier, if required for pricing determination.

TOS:

TOS Desc:

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.

Last Pricing Review

Date:

Adjusted Fee for Report

Date:

Note Codes:

Proc Code:

Mod 1:

Frm:

Client Age

Thru:

Mod 2:

Adjust %:

Total RVUs/Base Units:

Non-facility/Facility

Fee Effect Date:

Medicaid Fee:

Conversion Factor:


Texas Medicaid Fee Schedule Information

This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the current year’s Texas Medicaid

Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.

Field Descriptions

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Client Age Units:

The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-

20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations.

The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20

years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations.

Medicaid rates are based on the client’s age in days, months or years.

Non-Facility pricing is for services that are rendered in places of service other than an inpatient hospital or an outpatient hospital. Facility pricing is for services that are rendered in an inpatient hospital (place of service [POS] 3), or an outpatient hospital or ambulatory surgical center (POS 5).

The current relative value units (RVUs) for the procedure code, if the fee is a resource-based fee (RBF). The payable amount for RBFs is calculated by multiplying the total RVUs by the applicable conversion factor. For Anesthesia services only, this column shows the base units instead; and

payment is based on the sum of the base units plus actual face-to-face time units multiplied by the applicable conversion factor.

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.

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.

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

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



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TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

7 ANESTHESIA 00170 EP 21 999 Years 5.00 $27.2760 $0.00 9/1/2007 -2.00 $0.00 12 3 5.00 $27.2760 $0.00 9/1/2007 -2.00 $0.00 12 3 10/1/2014







2 SURGERY 10021 0 20 Years 3.49 $28.0672 $97.95 10/1/2016 0.00 $97.95 2.00 $28.0672 $56.13 10/1/2016 0.00 $56.13 10/1/2016

2 SURGERY 10021 21 999 Years 3.49 $26.7305 $93.29 10/1/2016 0.00 $93.29 2.00 $26.7305 $53.46 10/1/2016 0.00 $53.46 10/1/2016

2 SURGERY 10022 0 20 Years 3.94 $28.0672 $110.58 1/1/2015 0.00 $110.58 1.88 $28.0672 $52.77 1/1/2015 0.00 $52.77 1/1/2015

2 SURGERY 10022 21 999 Years 3.94 $26.7305 $105.32 1/1/2015 0.00 $105.32 1.88 $26.7305 $50.25 1/1/2015 0.00 $50.25 1/1/2015

2 SURGERY 10060 0 20 Years 3.32 $28.0672 $93.18 10/1/2016 0.00 $93.18 2.76 $28.0672 $77.47 10/1/2016 0.00 $77.47 10/1/2016

2 SURGERY 10060 21 999 Years 3.32 $26.7305 $88.75 10/1/2016 0.00 $88.75 2.76 $26.7305 $73.78 10/1/2016 0.00 $73.78 10/1/2016

2 SURGERY 10061 0 20 Years 5.85 $28.0672 $164.19 10/1/2016 0.00 $164.19 5.12 $28.0672 $143.70 10/1/2016 0.00 $143.70 10/1/2016

2 SURGERY 10061 21 999 Years 5.85 $26.7305 $156.37 10/1/2016 0.00 $156.37 5.12 $26.7305 $136.86 10/1/2016 0.00 $136.86 10/1/2016

2 SURGERY 10120 0 20 Years 4.30 $28.0672 $120.69 10/1/2016 0.00 $120.69 2.95 $28.0672 $82.80 10/1/2016 0.00 $82.80 10/1/2016

2 SURGERY 10120 21 999 Years 4.30 $26.7305 $114.94 10/1/2016 0.00 $114.94 2.95 $26.7305 $78.85 10/1/2016 0.00 $78.85 10/1/2016

2 SURGERY 10121 0 20 Years 7.77 $28.0672 $218.08 10/1/2016 0.00 $218.08 5.31 $28.0672 $149.04 10/1/2016 0.00 $149.04 10/1/2016

2 SURGERY 10121 21 999 Years 7.77 $26.7305 $207.70 10/1/2016 0.00 $207.70 5.31 $26.7305 $141.94 10/1/2016 0.00 $141.94 10/1/2016

2 SURGERY 10140 0 20 Years 4.62 $28.0672 $129.67 10/1/2016 0.00 $129.67 3.38 $28.0672 $94.87 10/1/2016 0.00 $94.87 10/1/2016

2 SURGERY 10140 21 999 Years 4.62 $26.7305 $123.49 10/1/2016 0.00 $123.49 3.38 $26.7305 $90.35 10/1/2016 0.00 $90.35 10/1/2016

2 SURGERY 10160 0 20 Years 3.69 $28.0672 $103.57 10/1/2016 0.00 $103.57 2.74 $28.0672 $76.90 10/1/2016 0.00 $76.90 10/1/2016

2 SURGERY 10160 21 999 Years 3.69 $26.7305 $98.64 10/1/2016 0.00 $98.64 2.74 $26.7305 $73.24 10/1/2016 0.00 $73.24 10/1/2016

2 SURGERY 10180 0 20 Years 7.01 $28.0672 $196.75 10/1/2016 0.00 $196.75 5.13 $28.0672 $143.98 10/1/2016 0.00 $143.98 10/1/2016

2 SURGERY 10180 21 999 Years 7.01 $26.7305 $187.38 10/1/2016 0.00 $187.38 5.13 $26.7305 $137.13 10/1/2016 0.00 $137.13 10/1/2016

2 SURGERY 11000 0 20 Years 1.54 $28.0672 $43.22 10/1/2016 0.00 $43.22 0.82 $28.0672 $23.02 10/1/2014 0.00 $23.02 10/1/2016

2 SURGERY 11000 21 999 Years 1.54 $26.7305 $41.16 10/1/2016 0.00 $41.16 0.82 $26.7305 $21.92 10/1/2014 0.00 $21.92 10/1/2016

2 SURGERY 11001 0 20 Years 0.61 $28.0672 $17.12 10/1/2016 0.00 $17.12 0.41 $28.0672 $11.51 10/1/2014 0.00 $11.51 10/1/2016

2 SURGERY 11001 21 999 Years 0.61 $26.7305 $16.31 10/1/2016 0.00 $16.31 0.41 $26.7305 $10.96 10/1/2014 0.00 $10.96 10/1/2016

2 SURGERY 11010 0 20 Years 13.99 $28.0672 $392.66 10/1/2016 0.00 $392.66 8.04 $28.0672 $225.66 10/1/2016 0.00 $225.66 10/1/2016

2 SURGERY 11010 21 999 Years 13.99 $26.7305 $373.96 10/1/2016 0.00 $373.96 8.04 $26.7305 $214.91 10/1/2016 0.00 $214.91 10/1/2016

2 SURGERY 11011 0 20 Years 15.21 $28.0672 $426.90 10/1/2016 0.00 $426.90 8.62 $28.0672 $241.94 10/1/2016 0.00 $241.94 10/1/2016

2 SURGERY 11011 21 999 Years 15.21 $26.7305 $406.57 10/1/2016 0.00 $406.57 8.62 $26.7305 $230.42 10/1/2016 0.00 $230.42 10/1/2016

2 SURGERY 11012 0 20 Years 20.32 $28.0672 $570.33 10/1/2016 0.00 $570.33 12.31 $28.0672 $345.51 10/1/2016 0.00 $345.51 10/1/2016

2 SURGERY 11012 21 999 Years 20.32 $26.7305 $543.16 10/1/2016 0.00 $543.16 12.31 $26.7305 $329.05 10/1/2016 0.00 $329.05 10/1/2016

2 SURGERY 11042 0 20 Years 3.30 $28.0672 $92.62 10/1/2016 0.00 $92.62 1.77 $28.0672 $49.68 10/1/2016 0.00 $49.68 10/1/2016

2 SURGERY 11042 21 999 Years 3.30 $26.7305 $88.21 10/1/2016 0.00 $88.21 1.77 $26.7305 $47.31 10/1/2016 0.00 $47.31 10/1/2016

2 SURGERY 11043 0 20 Years 6.49 $28.0672 $182.16 10/1/2014 0.00 $182.16 4.47 $28.0672 $125.46 10/1/2016 0.00 $125.46 10/1/2016

2 SURGERY 11043 21 999 Years 6.49 $26.7305 $173.48 10/1/2014 0.00 $173.48 4.47 $26.7305 $119.49 10/1/2016 0.00 $119.49 10/1/2016

2 SURGERY 11044 0 20 Years 8.96 $28.0672 $251.48 10/1/2016 0.00 $251.48 6.66 $28.0672 $186.93 10/1/2016 0.00 $186.93 10/1/2016




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TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 11044 21 999 Years 8.96 $26.7305 $239.51 10/1/2016 0.00 $239.51 6.66 $26.7305 $178.03 10/1/2016 0.00 $178.03 10/1/2016

2 SURGERY 11045 0 20 Years 1.16 $28.0672 $32.56 10/1/2016 0.00 $32.56 0.75 $28.0672 $21.05 10/1/2016 0.00 $21.05 10/1/2016

2 SURGERY 11045 21 999 Years 1.16 $26.7305 $31.01 10/1/2016 0.00 $31.01 0.75 $26.7305 $20.05 10/1/2016 0.00 $20.05 10/1/2016

2 SURGERY 11046 0 20 Years 2.09 $28.0672 $58.66 10/1/2016 0.00 $58.66 1.61 $28.0672 $45.19 10/1/2014 0.00 $45.19 10/1/2016

2 SURGERY 11046 21 999 Years 2.09 $26.7305 $55.87 10/1/2016 0.00 $55.87 1.61 $26.7305 $43.04 10/1/2014 0.00 $43.04 10/1/2016

2 SURGERY 11047 0 20 Years 3.54 $28.0672 $99.36 10/1/2016 0.00 $99.36 2.87 $28.0672 $80.55 10/1/2016 0.00 $80.55 10/1/2016

2 SURGERY 11047 21 999 Years 3.54 $26.7305 $94.63 10/1/2016 0.00 $94.63 2.87 $26.7305 $76.72 10/1/2016 0.00 $76.72 10/1/2016

2 SURGERY 11100 0 20 Years 2.92 $28.0672 $81.96 10/1/2016 0.00 $81.96 1.40 $28.0672 $39.29 10/1/2016 0.00 $39.29 10/1/2016

2 SURGERY 11100 21 999 Years 2.92 $26.7305 $78.05 10/1/2016 0.00 $78.05 1.40 $26.7305 $37.42 10/1/2016 0.00 $37.42 10/1/2016

2 SURGERY 11101 0 20 Years 0.93 $28.0672 $26.10 10/1/2016 0.00 $26.10 0.72 $28.0672 $20.21 10/1/2016 0.00 $20.21 10/1/2016

2 SURGERY 11101 21 999 Years 0.93 $26.7305 $24.86 10/1/2016 0.00 $24.86 0.72 $26.7305 $19.25 10/1/2016 0.00 $19.25 10/1/2016

2 SURGERY 11200 0 20 Years 2.49 $28.0672 $69.89 10/1/2016 0.00 $69.89 2.09 $28.0672 $58.66 10/1/2016 0.00 $58.66 10/1/2016

2 SURGERY 11200 21 999 Years 2.49 $26.7305 $66.56 10/1/2016 0.00 $66.56 2.09 $26.7305 $55.87 10/1/2016 0.00 $55.87 10/1/2016

2 SURGERY 11201 0 20 Years 0.54 $28.0672 $15.16 10/1/2014 0.00 $15.16 0.48 $28.0672 $13.47 10/1/2014 0.00 $13.47 10/1/2016

2 SURGERY 11201 21 999 Years 0.54 $26.7305 $14.43 10/1/2014 0.00 $14.43 0.48 $26.7305 $12.83 10/1/2014 0.00 $12.83 10/1/2016

2 SURGERY 11305 0 20 Years 2.80 $28.0672 $78.59 10/1/2016 0.00 $78.59 1.13 $28.0672 $31.72 10/1/2016 0.00 $31.72 10/1/2016

2 SURGERY 11305 21 999 Years 2.80 $26.7305 $74.85 10/1/2016 0.00 $74.85 1.13 $26.7305 $30.21 10/1/2016 0.00 $30.21 10/1/2016

2 SURGERY 11306 0 20 Years 3.44 $28.0672 $96.55 10/1/2016 0.00 $96.55 1.49 $28.0672 $41.82 10/1/2016 0.00 $41.82 10/1/2016

2 SURGERY 11306 21 999 Years 3.44 $26.7305 $91.95 10/1/2016 0.00 $91.95 1.49 $26.7305 $39.83 10/1/2016 0.00 $39.83 10/1/2016

2 SURGERY 11307 0 20 Years 4.06 $28.0672 $113.95 10/1/2016 0.00 $113.95 1.92 $28.0672 $53.89 10/1/2016 0.00 $53.89 10/1/2016

2 SURGERY 11307 21 999 Years 4.06 $26.7305 $108.53 10/1/2016 0.00 $108.53 1.92 $26.7305 $51.32 10/1/2016 0.00 $51.32 10/1/2016

2 SURGERY 11308 0 20 Years 4.26 $28.0672 $119.57 10/1/2016 0.00 $119.57 2.12 $28.0672 $59.50 10/1/2016 0.00 $59.50 10/1/2016

2 SURGERY 11308 21 999 Years 4.26 $26.7305 $113.87 10/1/2016 0.00 $113.87 2.12 $26.7305 $56.67 10/1/2016 0.00 $56.67 10/1/2016

2 SURGERY 11310 0 20 Years 3.20 $28.0672 $89.82 10/1/2016 0.00 $89.82 1.36 $28.0672 $38.17 10/1/2016 0.00 $38.17 10/1/2016

2 SURGERY 11310 21 999 Years 3.20 $26.7305 $85.54 10/1/2016 0.00 $85.54 1.36 $26.7305 $36.35 10/1/2016 0.00 $36.35 10/1/2016

2 SURGERY 11311 0 20 Years 3.15 $28.0672 $88.41 10/1/2016 0.00 $88.41 1.89 $28.0672 $53.05 10/1/2016 0.00 $53.05 10/1/2016

2 SURGERY 11311 21 999 Years 3.15 $26.7305 $84.20 10/1/2016 0.00 $84.20 1.89 $26.7305 $50.52 10/1/2016 0.00 $50.52 10/1/2016

2 SURGERY 11312 0 20 Years 4.53 $28.0672 $127.14 10/1/2016 0.00 $127.14 2.25 $28.0672 $63.15 10/1/2016 0.00 $63.15 10/1/2016

2 SURGERY 11312 21 999 Years 4.53 $26.7305 $121.09 10/1/2016 0.00 $121.09 2.25 $26.7305 $60.14 10/1/2016 0.00 $60.14 10/1/2016

2 SURGERY 11313 0 20 Years 5.25 $28.0672 $147.35 10/1/2016 0.00 $147.35 2.89 $28.0672 $81.11 10/1/2016 0.00 $81.11 10/1/2016

2 SURGERY 11313 21 999 Years 5.25 $26.7305 $140.34 10/1/2016 0.00 $140.34 2.89 $26.7305 $77.25 10/1/2016 0.00 $77.25 10/1/2016

2 SURGERY 11420 0 20 Years 3.46 $28.0672 $97.11 10/1/2016 0.00 $97.11 2.33 $28.0672 $65.40 10/1/2016 0.00 $65.40 10/1/2016

2 SURGERY 11420 21 999 Years 3.46 $26.7305 $92.49 10/1/2016 0.00 $92.49 2.33 $26.7305 $62.28 10/1/2016 0.00 $62.28 10/1/2016

2 SURGERY 11421 0 20 Years 4.43 $28.0672 $124.34 10/1/2016 0.00 $124.34 3.14 $28.0672 $88.13 10/1/2014 0.00 $88.13 10/1/2016

2 SURGERY 11421 21 999 Years 4.43 $26.7305 $118.42 10/1/2016 0.00 $118.42 3.14 $26.7305 $83.93 10/1/2014 0.00 $83.93 10/1/2016

2 SURGERY 11422 0 20 Years 4.96 $28.0672 $139.21 10/1/2016 0.00 $139.21 3.87 $28.0672 $108.62 10/1/2016 0.00 $108.62 10/1/2016

2 SURGERY 11422 21 999 Years 4.96 $26.7305 $132.58 10/1/2016 0.00 $132.58 3.87 $26.7305 $103.45 10/1/2016 0.00 $103.45 10/1/2016

2 SURGERY 11423 0 20 Years 5.72 $28.0672 $160.54 10/1/2016 0.00 $160.54 4.50 $28.0672 $126.30 10/1/2016 0.00 $126.30 10/1/2016

2 SURGERY 11423 21 999 Years 5.72 $26.7305 $152.90 10/1/2016 0.00 $152.90 4.50 $26.7305 $120.29 10/1/2016 0.00 $120.29 10/1/2016

2 SURGERY 11424 0 20 Years 6.62 $28.0672 $185.80 10/1/2016 0.00 $185.80 5.15 $28.0672 $144.55 10/1/2016 0.00 $144.55 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 11424 21 999 Years 6.62 $26.7305 $176.96 10/1/2016 0.00 $176.96 5.15 $26.7305 $137.66 10/1/2016 0.00 $137.66 10/1/2016

2 SURGERY 11426 0 20 Years 9.47 $28.0672 $265.80 10/1/2016 0.00 $265.80 7.89 $28.0672 $221.45 10/1/2016 0.00 $221.45 10/1/2016

2 SURGERY 11426 21 999 Years 9.47 $26.7305 $253.14 10/1/2016 0.00 $253.14 7.89 $26.7305 $210.90 10/1/2016 0.00 $210.90 10/1/2016

2 SURGERY 11440 0 20 Years 3.81 $28.0672 $106.94 10/1/2016 0.00 $106.94 2.94 $28.0672 $82.52 10/1/2016 0.00 $82.52 10/1/2016

2 SURGERY 11440 21 999 Years 3.81 $26.7305 $101.84 10/1/2016 0.00 $101.84 2.94 $26.7305 $78.59 10/1/2016 0.00 $78.59 10/1/2016

2 SURGERY 11441 0 20 Years 4.75 $28.0672 $133.32 10/1/2016 0.00 $133.32 3.76 $28.0672 $105.53 10/1/2016 0.00 $105.53 10/1/2016

2 SURGERY 11441 21 999 Years 4.75 $26.7305 $126.97 10/1/2016 0.00 $126.97 3.76 $26.7305 $100.51 10/1/2016 0.00 $100.51 10/1/2016

2 SURGERY 11442 0 20 Years 5.32 $28.0672 $149.32 10/1/2016 0.00 $149.32 4.16 $28.0672 $116.76 10/1/2016 0.00 $116.76 10/1/2016

2 SURGERY 11442 21 999 Years 5.32 $26.7305 $142.21 10/1/2016 0.00 $142.21 4.16 $26.7305 $111.20 10/1/2016 0.00 $111.20 10/1/2016

2 SURGERY 11443 0 20 Years 6.35 $28.0672 $178.23 10/1/2016 0.00 $178.23 5.11 $28.0672 $143.42 10/1/2016 0.00 $143.42 10/1/2016

2 SURGERY 11443 21 999 Years 6.35 $26.7305 $169.74 10/1/2016 0.00 $169.74 5.11 $26.7305 $136.59 10/1/2016 0.00 $136.59 10/1/2016

2 SURGERY 11444 0 20 Years 7.98 $28.0672 $223.98 10/1/2016 0.00 $223.98 6.51 $28.0672 $182.72 10/1/2016 0.00 $182.72 10/1/2016

2 SURGERY 11444 21 999 Years 7.98 $26.7305 $213.31 10/1/2016 0.00 $213.31 6.51 $26.7305 $174.02 10/1/2016 0.00 $174.02 10/1/2016

2 SURGERY 11446 0 20 Years 11.09 $28.0672 $311.27 10/1/2016 0.00 $311.27 9.34 $28.0672 $262.15 10/1/2016 0.00 $262.15 10/1/2016

2 SURGERY 11446 21 999 Years 11.09 $26.7305 $296.44 10/1/2016 0.00 $296.44 9.34 $26.7305 $249.66 10/1/2016 0.00 $249.66 10/1/2016

2 SURGERY 11620 0 20 Years 5.50 $28.0672 $154.37 10/1/2016 0.00 $154.37 3.46 $28.0672 $97.11 10/1/2016 0.00 $97.11 10/1/2016

2 SURGERY 11620 21 999 Years 5.50 $26.7305 $147.02 10/1/2016 0.00 $147.02 3.46 $26.7305 $92.49 10/1/2016 0.00 $92.49 10/1/2016

2 SURGERY 11621 0 20 Years 6.51 $28.0672 $182.72 10/1/2016 0.00 $182.72 4.31 $28.0672 $120.97 10/1/2016 0.00 $120.97 10/1/2016

2 SURGERY 11621 21 999 Years 6.51 $26.7305 $174.02 10/1/2016 0.00 $174.02 4.31 $26.7305 $115.21 10/1/2016 0.00 $115.21 10/1/2016

2 SURGERY 11622 0 20 Years 7.26 $28.0672 $203.77 10/1/2016 0.00 $203.77 4.93 $28.0672 $138.37 10/1/2016 0.00 $138.37 10/1/2016

2 SURGERY 11622 21 999 Years 7.26 $26.7305 $194.06 10/1/2016 0.00 $194.06 4.93 $26.7305 $131.78 10/1/2016 0.00 $131.78 10/1/2016

2 SURGERY 11623 0 20 Years 8.53 $28.0672 $239.41 10/1/2016 0.00 $239.41 6.11 $28.0672 $171.49 10/1/2016 0.00 $171.49 10/1/2016

2 SURGERY 11623 21 999 Years 8.53 $26.7305 $228.01 10/1/2016 0.00 $228.01 6.11 $26.7305 $163.32 10/1/2016 0.00 $163.32 10/1/2016

2 SURGERY 11624 0 20 Years 9.62 $28.0672 $270.01 10/1/2016 0.00 $270.01 6.92 $28.0672 $194.23 10/1/2016 0.00 $194.23 10/1/2016

2 SURGERY 11624 21 999 Years 9.62 $26.7305 $257.15 10/1/2016 0.00 $257.15 6.92 $26.7305 $184.98 10/1/2016 0.00 $184.98 10/1/2016

2 SURGERY 11626 0 20 Years 11.60 $28.0672 $325.58 10/1/2016 0.00 $325.58 8.49 $28.0672 $238.29 10/1/2016 0.00 $238.29 10/1/2016

2 SURGERY 11626 21 999 Years 11.60 $26.7305 $310.07 10/1/2016 0.00 $310.07 8.49 $26.7305 $226.94 10/1/2016 0.00 $226.94 10/1/2016

2 SURGERY 11640 0 20 Years 5.67 $28.0672 $159.14 10/1/2016 0.00 $159.14 3.58 $28.0672 $100.48 10/1/2016 0.00 $100.48 10/1/2016

2 SURGERY 11640 21 999 Years 5.67 $26.7305 $151.56 10/1/2016 0.00 $151.56 3.58 $26.7305 $95.70 10/1/2016 0.00 $95.70 10/1/2016

2 SURGERY 11641 0 20 Years 6.74 $28.0672 $189.17 10/1/2016 0.00 $189.17 4.49 $28.0672 $126.02 10/1/2016 0.00 $126.02 10/1/2016

2 SURGERY 11641 21 999 Years 6.74 $26.7305 $180.16 10/1/2016 0.00 $180.16 4.49 $26.7305 $120.02 10/1/2016 0.00 $120.02 10/1/2016

2 SURGERY 11642 0 20 Years 7.70 $28.0672 $216.12 10/1/2016 0.00 $216.12 5.30 $28.0672 $148.76 10/1/2016 0.00 $148.76 10/1/2016

2 SURGERY 11642 21 999 Years 7.70 $26.7305 $205.82 10/1/2016 0.00 $205.82 5.30 $26.7305 $141.67 10/1/2016 0.00 $141.67 10/1/2016

2 SURGERY 11643 0 20 Years 9.08 $28.0672 $254.85 10/1/2016 0.00 $254.85 6.63 $28.0672 $186.09 10/1/2016 0.00 $186.09 10/1/2016

2 SURGERY 11643 21 999 Years 9.08 $26.7305 $242.71 10/1/2016 0.00 $242.71 6.63 $26.7305 $177.22 10/1/2016 0.00 $177.22 10/1/2016

2 SURGERY 11644 0 20 Years 11.20 $28.0672 $314.35 10/1/2016 0.00 $314.35 8.21 $28.0672 $230.43 10/1/2016 0.00 $230.43 10/1/2016

2 SURGERY 11644 21 999 Years 11.20 $26.7305 $299.38 10/1/2016 0.00 $299.38 8.21 $26.7305 $219.46 10/1/2016 0.00 $219.46 10/1/2016

2 SURGERY 11646 0 20 Years 14.65 $28.0672 $411.18 10/1/2016 0.00 $411.18 11.41 $28.0672 $320.25 10/1/2016 0.00 $320.25 10/1/2016

2 SURGERY 11646 21 999 Years 14.65 $26.7305 $391.60 10/1/2016 0.00 $391.60 11.41 $26.7305 $305.00 10/1/2016 0.00 $305.00 10/1/2016

2 SURGERY 11900 0 20 Years 1.57 $28.0672 $44.07 10/1/2016 0.00 $44.07 0.90 $28.0672 $25.26 10/1/2016 0.00 $25.26 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 11900 21 999 Years 1.57 $26.7305 $41.97 10/1/2016 0.00 $41.97 0.90 $26.7305 $24.06 10/1/2016 0.00 $24.06 10/1/2016

2 SURGERY 11901 0 20 Years 1.98 $28.0672 $55.57 10/1/2016 0.00 $55.57 1.39 $28.0672 $39.01 10/1/2014 0.00 $39.01 10/1/2016

2 SURGERY 11901 21 999 Years 1.98 $26.7305 $52.93 10/1/2016 0.00 $52.93 1.39 $26.7305 $37.16 10/1/2014 0.00 $37.16 10/1/2016

2 SURGERY 11950 0 20 Years 2.08 $28.0672 $58.38 10/1/2016 0.00 $58.38 1.46 $28.0672 $40.98 10/1/2016 0.00 $40.98 10/1/2016

2 SURGERY 11950 21 999 Years 2.08 $26.7305 $55.60 10/1/2016 0.00 $55.60 1.46 $26.7305 $39.03 10/1/2016 0.00 $39.03 10/1/2016

2 SURGERY 11951 0 20 Years 2.76 $28.0672 $77.47 10/1/2016 0.00 $77.47 2.06 $28.0672 $57.82 10/1/2016 0.00 $57.82 10/1/2016

2 SURGERY 11951 21 999 Years 2.76 $26.7305 $73.78 10/1/2016 0.00 $73.78 2.06 $26.7305 $55.06 10/1/2016 0.00 $55.06 10/1/2016

2 SURGERY 11952 0 20 Years 3.71 $28.0672 $104.13 10/1/2016 0.00 $104.13 2.78 $28.0672 $78.03 10/1/2016 0.00 $78.03 10/1/2016

2 SURGERY 11952 21 999 Years 3.71 $26.7305 $99.17 10/1/2016 0.00 $99.17 2.78 $26.7305 $74.31 10/1/2016 0.00 $74.31 10/1/2016

2 SURGERY 11954 0 20 Years 4.47 $28.0672 $125.46 10/1/2016 0.00 $125.46 3.29 $28.0672 $92.34 10/1/2016 0.00 $92.34 10/1/2016

2 SURGERY 11954 21 999 Years 4.47 $26.7305 $119.49 10/1/2016 0.00 $119.49 3.29 $26.7305 $87.94 10/1/2016 0.00 $87.94 10/1/2016

2 SURGERY 11960 0 20 Years 27.05 $28.0672 $759.22 10/1/2016 0.00 $759.22 27.05 $28.0672 $759.22 10/1/2016 0.00 $759.22 10/1/2016

2 SURGERY 11960 21 999 Years 27.05 $26.7305 $723.06 10/1/2016 0.00 $723.06 27.05 $26.7305 $723.06 10/1/2016 0.00 $723.06 10/1/2016

2 SURGERY 11970 18 20 Years 17.44 $28.0672 $489.49 10/1/2016 0.00 $489.49 17.44 $28.0672 $489.49 10/1/2016 0.00 $489.49 10/1/2016

2 SURGERY 11970 21 999 Years 17.44 $26.7305 $466.18 10/1/2016 0.00 $466.18 17.44 $26.7305 $466.18 10/1/2016 0.00 $466.18 10/1/2016

2 SURGERY 11971 18 20 Years 13.30 $28.0672 $373.29 10/1/2016 0.00 $373.29 9.11 $28.0672 $255.69 10/1/2016 0.00 $255.69 10/1/2016

2 SURGERY 11971 21 999 Years 13.30 $26.7305 $355.52 10/1/2016 0.00 $355.52 9.11 $26.7305 $243.51 10/1/2016 0.00 $243.51 10/1/2016

2 SURGERY 12001 0 20 Years 2.52 $28.0672 $70.73 10/1/2014 0.00 $70.73 1.27 $28.0672 $35.65 10/1/2016 0.00 $35.65 10/1/2016

2 SURGERY 12001 21 999 Years 2.52 $26.7305 $67.36 10/1/2014 0.00 $67.36 1.27 $26.7305 $33.95 10/1/2016 0.00 $33.95 10/1/2016

2 SURGERY 12002 0 20 Years 3.07 $28.0672 $86.17 10/1/2016 0.00 $86.17 1.67 $28.0672 $46.87 10/1/2016 0.00 $46.87 10/1/2016

2 SURGERY 12002 21 999 Years 3.07 $26.7305 $82.06 10/1/2016 0.00 $82.06 1.67 $26.7305 $44.64 10/1/2016 0.00 $44.64 10/1/2016

2 SURGERY 12004 0 20 Years 3.62 $28.0672 $101.60 10/1/2016 0.00 $101.60 2.09 $28.0672 $58.66 10/1/2016 0.00 $58.66 10/1/2016

2 SURGERY 12004 21 999 Years 3.62 $26.7305 $96.76 10/1/2016 0.00 $96.76 2.09 $26.7305 $55.87 10/1/2016 0.00 $55.87 10/1/2016

2 SURGERY 12005 0 20 Years 4.57 $28.0672 $128.27 10/1/2016 0.00 $128.27 2.72 $28.0672 $76.34 10/1/2016 0.00 $76.34 10/1/2016

2 SURGERY 12005 21 999 Years 4.57 $26.7305 $122.16 10/1/2016 0.00 $122.16 2.72 $26.7305 $72.71 10/1/2016 0.00 $72.71 10/1/2016

2 SURGERY 12006 0 20 Years 5.42 $28.0672 $152.12 10/1/2016 0.00 $152.12 3.34 $28.0672 $93.74 10/1/2016 0.00 $93.74 10/1/2016

2 SURGERY 12006 21 999 Years 5.42 $26.7305 $144.88 10/1/2016 0.00 $144.88 3.34 $26.7305 $89.28 10/1/2016 0.00 $89.28 10/1/2016

2 SURGERY 12007 0 20 Years 6.33 $28.0672 $177.67 10/1/2016 0.00 $177.67 4.22 $28.0672 $118.44 10/1/2016 0.00 $118.44 10/1/2016

2 SURGERY 12007 21 999 Years 6.33 $26.7305 $169.20 10/1/2016 0.00 $169.20 4.22 $26.7305 $112.80 10/1/2016 0.00 $112.80 10/1/2016

2 SURGERY 12011 0 20 Years 3.09 $28.0672 $86.73 10/1/2016 0.00 $86.73 1.58 $28.0672 $44.35 10/1/2016 0.00 $44.35 10/1/2016

2 SURGERY 12011 21 999 Years 3.09 $26.7305 $82.60 10/1/2016 0.00 $82.60 1.58 $26.7305 $42.23 10/1/2016 0.00 $42.23 10/1/2016

2 SURGERY 12013 0 20 Years 3.23 $28.0672 $90.66 10/1/2016 0.00 $90.66 1.66 $28.0672 $46.59 10/1/2016 0.00 $46.59 10/1/2016

2 SURGERY 12013 21 999 Years 3.23 $26.7305 $86.34 10/1/2016 0.00 $86.34 1.66 $26.7305 $44.37 10/1/2016 0.00 $44.37 10/1/2016

2 SURGERY 12014 0 20 Years 3.78 $28.0672 $106.09 10/1/2016 0.00 $106.09 2.14 $28.0672 $60.06 10/1/2016 0.00 $60.06 10/1/2016

2 SURGERY 12014 21 999 Years 3.78 $26.7305 $101.04 10/1/2016 0.00 $101.04 2.14 $26.7305 $57.20 10/1/2016 0.00 $57.20 10/1/2016

2 SURGERY 12015 0 20 Years 4.58 $28.0672 $128.55 10/1/2016 0.00 $128.55 2.69 $28.0672 $75.50 10/1/2016 0.00 $75.50 10/1/2016

2 SURGERY 12015 21 999 Years 4.58 $26.7305 $122.43 10/1/2016 0.00 $122.43 2.69 $26.7305 $71.91 10/1/2016 0.00 $71.91 10/1/2016

2 SURGERY 12016 0 20 Years 5.82 $28.0672 $163.35 10/1/2016 0.00 $163.35 3.68 $28.0672 $103.29 10/1/2016 0.00 $103.29 10/1/2016

2 SURGERY 12016 21 999 Years 5.82 $26.7305 $155.57 10/1/2016 0.00 $155.57 3.68 $26.7305 $98.37 10/1/2016 0.00 $98.37 10/1/2016

2 SURGERY 12017 0 20 Years 4.41 $28.0672 $123.78 10/1/2016 0.00 $123.78 4.41 $28.0672 $123.78 10/1/2016 0.00 $123.78 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 12017 21 999 Years 4.41 $26.7305 $117.88 10/1/2016 0.00 $117.88 4.41 $26.7305 $117.88 10/1/2016 0.00 $117.88 10/1/2016

2 SURGERY 12018 0 20 Years 5.00 $28.0672 $140.34 10/1/2016 0.00 $140.34 10 5.00 $28.0672 $140.34 10/1/2016 0.00 $140.34 10 10/1/2016

2 SURGERY 12018 21 999 Years 5.00 $26.7305 $133.65 10/1/2016 0.00 $133.65 10 5.00 $26.7305 $133.65 10/1/2016 0.00 $133.65 10 10/1/2016

2 SURGERY 12020 0 20 Years 8.23 $28.0672 $230.99 10/1/2016 0.00 $230.99 5.59 $28.0672 $156.90 10/1/2016 0.00 $156.90 10/1/2016

2 SURGERY 12020 21 999 Years 8.23 $26.7305 $219.99 10/1/2016 0.00 $219.99 5.59 $26.7305 $149.42 10/1/2016 0.00 $149.42 10/1/2016

2 SURGERY 12021 0 20 Years 4.75 $28.0672 $133.32 10/1/2016 0.00 $133.32 4.05 $28.0672 $113.67 10/1/2016 0.00 $113.67 10/1/2016

2 SURGERY 12021 21 999 Years 4.75 $26.7305 $126.97 10/1/2016 0.00 $126.97 4.05 $26.7305 $108.26 10/1/2016 0.00 $108.26 10/1/2016

2 SURGERY 12031 0 20 Years 6.70 $28.0672 $188.05 10/1/2016 0.00 $188.05 4.39 $28.0672 $123.22 10/1/2016 0.00 $123.22 10/1/2016

2 SURGERY 12031 21 999 Years 6.70 $26.7305 $179.09 10/1/2016 0.00 $179.09 4.39 $26.7305 $117.35 10/1/2016 0.00 $117.35 10/1/2016

2 SURGERY 12032 0 20 Years 8.58 $28.0672 $240.82 10/1/2016 0.00 $240.82 5.60 $28.0672 $157.18 10/1/2016 0.00 $157.18 10/1/2016

2 SURGERY 12032 21 999 Years 8.58 $26.7305 $229.35 10/1/2016 0.00 $229.35 5.60 $26.7305 $149.69 10/1/2016 0.00 $149.69 10/1/2016

2 SURGERY 12034 0 20 Years 8.82 $28.0672 $247.55 10/1/2016 0.00 $247.55 5.94 $28.0672 $166.72 10/1/2016 0.00 $166.72 10/1/2016

2 SURGERY 12034 21 999 Years 8.82 $26.7305 $235.76 10/1/2016 0.00 $235.76 5.94 $26.7305 $158.78 10/1/2016 0.00 $158.78 10/1/2016

2 SURGERY 12035 0 20 Years 10.84 $28.0672 $304.25 10/1/2016 0.00 $304.25 6.91 $28.0672 $193.94 10/1/2014 0.00 $193.94 10/1/2016

2 SURGERY 12035 21 999 Years 10.84 $26.7305 $289.76 10/1/2016 0.00 $289.76 6.91 $26.7305 $184.71 10/1/2014 0.00 $184.71 10/1/2016

2 SURGERY 12036 0 20 Years 11.95 $28.0672 $335.40 10/1/2016 0.00 $335.40 8.03 $28.0672 $225.38 10/1/2016 0.00 $225.38 10/1/2016

2 SURGERY 12036 21 999 Years 11.95 $26.7305 $319.43 10/1/2016 0.00 $319.43 8.03 $26.7305 $214.65 10/1/2016 0.00 $214.65 10/1/2016

2 SURGERY 12037 0 20 Years 13.55 $28.0672 $380.31 10/1/2016 0.00 $380.31 9.40 $28.0672 $263.83 10/1/2016 0.00 $263.83 10/1/2016

2 SURGERY 12037 21 999 Years 13.55 $26.7305 $362.20 10/1/2016 0.00 $362.20 9.40 $26.7305 $251.27 10/1/2016 0.00 $251.27 10/1/2016

2 SURGERY 12051 0 20 Years 7.31 $28.0672 $205.17 10/1/2016 0.00 $205.17 4.93 $28.0672 $138.37 10/1/2016 0.00 $138.37 10/1/2016

2 SURGERY 12051 21 999 Years 7.31 $26.7305 $195.40 10/1/2016 0.00 $195.40 4.93 $26.7305 $131.78 10/1/2016 0.00 $131.78 10/1/2016

2 SURGERY 12052 0 20 Years 8.33 $28.0672 $233.80 10/1/2016 0.00 $233.80 5.86 $28.0672 $164.47 10/1/2016 0.00 $164.47 10/1/2016

2 SURGERY 12052 21 999 Years 8.33 $26.7305 $222.67 10/1/2016 0.00 $222.67 5.86 $26.7305 $156.64 10/1/2016 0.00 $156.64 10/1/2016

2 SURGERY 12053 0 20 Years 9.77 $28.0672 $274.22 10/1/2016 0.00 $274.22 6.26 $28.0672 $175.70 10/1/2016 0.00 $175.70 10/1/2016

2 SURGERY 12053 21 999 Years 9.77 $26.7305 $261.16 10/1/2016 0.00 $261.16 6.26 $26.7305 $167.33 10/1/2016 0.00 $167.33 10/1/2016

2 SURGERY 12054 0 20 Years 10.21 $28.0672 $286.57 10/1/2016 0.00 $286.57 6.40 $28.0672 $179.63 10/1/2016 0.00 $179.63 10/1/2016

2 SURGERY 12054 21 999 Years 10.21 $26.7305 $272.92 10/1/2016 0.00 $272.92 6.40 $26.7305 $171.08 10/1/2016 0.00 $171.08 10/1/2016

2 SURGERY 12055 0 20 Years 13.26 $28.0672 $372.17 10/1/2016 0.00 $372.17 8.81 $28.0672 $247.27 10/1/2016 0.00 $247.27 10/1/2016

2 SURGERY 12055 21 999 Years 13.26 $26.7305 $354.45 10/1/2016 0.00 $354.45 8.81 $26.7305 $235.50 10/1/2016 0.00 $235.50 10/1/2016

2 SURGERY 12056 0 20 Years 15.49 $28.0672 $434.76 10/1/2016 0.00 $434.76 10.87 $28.0672 $305.09 10/1/2016 0.00 $305.09 10/1/2016

2 SURGERY 12056 21 999 Years 15.49 $26.7305 $414.06 10/1/2016 0.00 $414.06 10.87 $26.7305 $290.56 10/1/2016 0.00 $290.56 10/1/2016

2 SURGERY 12057 0 20 Years 15.98 $28.0672 $448.51 10/1/2016 0.00 $448.51 10 11.71 $28.0672 $328.67 10/1/2016 0.00 $328.67 10 10/1/2016

2 SURGERY 12057 21 999 Years 15.98 $26.7305 $427.15 10/1/2016 0.00 $427.15 10 11.71 $26.7305 $313.01 10/1/2016 0.00 $313.01 10 10/1/2016

2 SURGERY 13120 0 20 Years 9.91 $28.0672 $278.15 10/1/2016 0.00 $278.15 6.80 $28.0672 $190.86 10/1/2016 0.00 $190.86 10/1/2016

2 SURGERY 13120 21 999 Years 9.91 $26.7305 $264.90 10/1/2016 0.00 $264.90 6.80 $26.7305 $181.77 10/1/2016 0.00 $181.77 10/1/2016

2 SURGERY 13121 0 20 Years 12.10 $28.0672 $339.61 10/1/2016 0.00 $339.61 7.71 $28.0672 $216.40 10/1/2016 0.00 $216.40 10/1/2016

2 SURGERY 13121 21 999 Years 12.10 $26.7305 $323.44 10/1/2016 0.00 $323.44 7.71 $26.7305 $206.09 10/1/2016 0.00 $206.09 10/1/2016

2 SURGERY 13122 0 20 Years 3.78 $28.0672 $106.09 10/1/2016 0.00 $106.09 2.47 $28.0672 $69.33 10/1/2016 0.00 $69.33 10/1/2016

2 SURGERY 13122 21 999 Years 3.78 $26.7305 $101.04 10/1/2016 0.00 $101.04 2.47 $26.7305 $66.02 10/1/2016 0.00 $66.02 10/1/2016

2 SURGERY 13131 0 20 Years 10.91 $28.0672 $306.21 10/1/2016 0.00 $306.21 7.20 $28.0672 $202.08 10/1/2016 0.00 $202.08 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 13131 21 999 Years 10.91 $26.7305 $291.63 10/1/2016 0.00 $291.63 7.20 $26.7305 $192.46 10/1/2016 0.00 $192.46 10/1/2016

2 SURGERY 13132 0 20 Years 13.50 $28.0672 $378.91 10/1/2016 0.00 $378.91 9.08 $28.0672 $254.85 10/1/2016 0.00 $254.85 10/1/2016

2 SURGERY 13132 21 999 Years 13.50 $26.7305 $360.86 10/1/2016 0.00 $360.86 9.08 $26.7305 $242.71 10/1/2016 0.00 $242.71 10/1/2016

2 SURGERY 13133 0 20 Years 5.08 $28.0672 $142.58 10/1/2016 0.00 $142.58 3.79 $28.0672 $106.37 10/1/2016 0.00 $106.37 10/1/2016

2 SURGERY 13133 21 999 Years 5.08 $26.7305 $135.79 10/1/2016 0.00 $135.79 3.79 $26.7305 $101.31 10/1/2016 0.00 $101.31 10/1/2016

2 SURGERY 13151 0 20 Years 11.96 $28.0672 $335.68 10/1/2016 0.00 $335.68 8.28 $28.0672 $232.40 10/1/2016 0.00 $232.40 10/1/2016

2 SURGERY 13151 21 999 Years 11.96 $26.7305 $319.70 10/1/2016 0.00 $319.70 8.28 $26.7305 $221.33 10/1/2016 0.00 $221.33 10/1/2016

2 SURGERY 13152 0 20 Years 14.38 $28.0672 $403.61 10/1/2016 0.00 $403.61 10.05 $28.0672 $282.08 10/1/2016 0.00 $282.08 10/1/2016

2 SURGERY 13152 21 999 Years 14.38 $26.7305 $384.38 10/1/2016 0.00 $384.38 10.05 $26.7305 $268.64 10/1/2016 0.00 $268.64 10/1/2016

2 SURGERY 13153 0 20 Years 5.51 $28.0672 $154.65 10/1/2016 0.00 $154.65 4.09 $28.0672 $114.79 10/1/2016 0.00 $114.79 10/1/2016

2 SURGERY 13153 21 999 Years 5.51 $26.7305 $147.29 10/1/2016 0.00 $147.29 4.09 $26.7305 $109.33 10/1/2016 0.00 $109.33 10/1/2016

2 SURGERY 13160 0 20 Years 23.18 $28.0672 $650.60 10/1/2016 0.00 $650.60 23.18 $28.0672 $650.60 10/1/2016 0.00 $650.60 10/1/2016

2 SURGERY 13160 21 999 Years 23.18 $26.7305 $619.61 10/1/2016 0.00 $619.61 23.18 $26.7305 $619.61 10/1/2016 0.00 $619.61 10/1/2016

2 SURGERY 14020 0 20 Years 19.77 $28.0672 $554.89 10/1/2016 0.00 $554.89 16.32 $28.0672 $458.06 10/1/2016 0.00 $458.06 10/1/2016

2 SURGERY 14020 21 999 Years 19.77 $26.7305 $528.46 10/1/2016 0.00 $528.46 16.32 $26.7305 $436.24 10/1/2016 0.00 $436.24 10/1/2016

2 SURGERY 14021 0 20 Years 24.75 $28.0672 $694.66 10/1/2016 0.00 $694.66 20.66 $28.0672 $579.87 10/1/2016 0.00 $579.87 10/1/2016

2 SURGERY 14021 21 999 Years 24.75 $26.7305 $661.58 10/1/2016 0.00 $661.58 20.66 $26.7305 $552.25 10/1/2016 0.00 $552.25 10/1/2016

2 SURGERY 14040 0 20 Years 21.65 $28.0672 $607.65 10/1/2016 0.00 $607.65 18.18 $28.0672 $510.26 10/1/2016 0.00 $510.26 10/1/2016

2 SURGERY 14040 21 999 Years 21.65 $26.7305 $578.72 10/1/2016 0.00 $578.72 18.18 $26.7305 $485.96 10/1/2016 0.00 $485.96 10/1/2016

2 SURGERY 14041 0 20 Years 26.81 $28.0672 $752.48 10/1/2016 0.00 $752.48 22.38 $28.0672 $628.14 10/1/2016 0.00 $628.14 10/1/2016

2 SURGERY 14041 21 999 Years 26.81 $26.7305 $716.64 10/1/2016 0.00 $716.64 22.38 $26.7305 $598.23 10/1/2016 0.00 $598.23 10/1/2016

2 SURGERY 14060 0 20 Years 22.09 $28.0672 $620.00 10/1/2016 0.00 $620.00 19.36 $28.0672 $543.38 10/1/2016 0.00 $543.38 10/1/2016

2 SURGERY 14060 21 999 Years 22.09 $26.7305 $590.48 10/1/2016 0.00 $590.48 19.36 $26.7305 $517.50 10/1/2016 0.00 $517.50 10/1/2016

2 SURGERY 14061 0 20 Years 28.84 $28.0672 $809.46 10/1/2016 0.00 $809.46 23.95 $28.0672 $672.21 10/1/2016 0.00 $672.21 10/1/2016

2 SURGERY 14061 21 999 Years 28.84 $26.7305 $770.91 10/1/2016 0.00 $770.91 23.95 $26.7305 $640.20 10/1/2016 0.00 $640.20 10/1/2016

2 SURGERY 14301 0 20 Years 30.66 $28.0672 $860.54 10/1/2016 0.00 $860.54 10 25.40 $28.0672 $712.91 10/1/2016 0.00 $712.91 10 10/1/2016

2 SURGERY 14301 21 999 Years 30.66 $26.7305 $819.56 10/1/2016 0.00 $819.56 10 25.40 $26.7305 $678.95 10/1/2016 0.00 $678.95 10 10/1/2016

2 SURGERY 14302 0 20 Years 6.40 $28.0672 $179.63 10/1/2016 0.00 $179.63 6.40 $28.0672 $179.63 10/1/2016 0.00 $179.63 10/1/2016

2 SURGERY 14302 21 999 Years 6.40 $26.7305 $171.08 10/1/2016 0.00 $171.08 6.40 $26.7305 $171.08 10/1/2016 0.00 $171.08 10/1/2016

2 SURGERY 15004 0 20 Years 11.40 $28.0672 $319.97 10/1/2016 0.00 $319.97 7.79 $28.0672 $218.64 10/1/2016 0.00 $218.64 10/1/2016

2 SURGERY 15004 21 999 Years 11.40 $26.7305 $304.73 10/1/2016 0.00 $304.73 7.79 $26.7305 $208.23 10/1/2016 0.00 $208.23 10/1/2016

2 SURGERY 15005 0 20 Years 3.55 $28.0672 $99.64 10/1/2014 0.00 $99.64 2.63 $28.0672 $73.82 10/1/2014 0.00 $73.82 10/1/2016

2 SURGERY 15005 21 999 Years 3.55 $26.7305 $94.89 10/1/2014 0.00 $94.89 2.63 $26.7305 $70.30 10/1/2014 0.00 $70.30 10/1/2016

2 SURGERY 15115 0 20 Years 23.48 $28.0672 $659.02 10/1/2016 0.00 $659.02 20.58 $28.0672 $577.62 10/1/2016 0.00 $577.62 10/1/2016

2 SURGERY 15115 21 999 Years 23.48 $26.7305 $627.63 10/1/2016 0.00 $627.63 20.58 $26.7305 $550.11 10/1/2016 0.00 $550.11 10/1/2016

2 SURGERY 15116 0 20 Years 4.40 $28.0672 $123.50 10/1/2016 0.00 $123.50 3.98 $28.0672 $111.71 10/1/2016 0.00 $111.71 10/1/2016

2 SURGERY 15116 21 999 Years 4.40 $26.7305 $117.61 10/1/2016 0.00 $117.61 3.98 $26.7305 $106.39 10/1/2016 0.00 $106.39 10/1/2016

2 SURGERY 15120 0 20 Years 24.25 $28.0672 $680.63 10/1/2016 0.00 $680.63 20.09 $28.0672 $563.87 10/1/2016 0.00 $563.87 10/1/2016

2 SURGERY 15120 21 999 Years 24.25 $26.7305 $648.21 10/1/2016 0.00 $648.21 20.09 $26.7305 $537.02 10/1/2016 0.00 $537.02 10/1/2016

2 SURGERY 15121 0 20 Years 5.93 $28.0672 $166.44 10/1/2016 0.00 $166.44 3.83 $28.0672 $107.50 10/1/2016 0.00 $107.50 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 15121 21 999 Years 5.93 $26.7305 $158.51 10/1/2016 0.00 $158.51 3.83 $26.7305 $102.38 10/1/2016 0.00 $102.38 10/1/2016

2 SURGERY 15135 0 20 Years 24.06 $28.0672 $675.30 10/1/2016 0.00 $675.30 21.17 $28.0672 $594.18 10/1/2016 0.00 $594.18 10/1/2016

2 SURGERY 15135 21 999 Years 24.06 $26.7305 $643.14 10/1/2016 0.00 $643.14 21.17 $26.7305 $565.88 10/1/2016 0.00 $565.88 10/1/2016

2 SURGERY 15136 0 20 Years 2.71 $28.0672 $76.06 10/1/2016 0.00 $76.06 2.54 $28.0672 $71.29 10/1/2016 0.00 $71.29 10/1/2016

2 SURGERY 15136 21 999 Years 2.71 $26.7305 $72.44 10/1/2016 0.00 $72.44 2.54 $26.7305 $67.90 10/1/2016 0.00 $67.90 10/1/2016

2 SURGERY 15155 0 20 Years 20.62 $28.0672 $578.75 10/1/2016 0.00 $578.75 19.11 $28.0672 $536.36 10/1/2016 0.00 $536.36 10/1/2016

2 SURGERY 15155 21 999 Years 20.62 $26.7305 $551.18 10/1/2016 0.00 $551.18 19.11 $26.7305 $510.82 10/1/2016 0.00 $510.82 10/1/2016

2 SURGERY 15156 0 20 Years 4.54 $28.0672 $127.43 10/1/2016 0.00 $127.43 4.31 $28.0672 $120.97 10/1/2014 0.00 $120.97 10/1/2016

2 SURGERY 15156 21 999 Years 4.54 $26.7305 $121.36 10/1/2016 0.00 $121.36 4.31 $26.7305 $115.21 10/1/2014 0.00 $115.21 10/1/2016

2 SURGERY 15157 0 20 Years 4.99 $28.0672 $140.06 10/1/2016 0.00 $140.06 4.67 $28.0672 $131.07 10/1/2016 0.00 $131.07 10/1/2016

2 SURGERY 15157 21 999 Years 4.99 $26.7305 $133.39 10/1/2016 0.00 $133.39 4.67 $26.7305 $124.83 10/1/2016 0.00 $124.83 10/1/2016

2 SURGERY 15240 0 20 Years 26.55 $28.0672 $745.18 10/1/2016 0.00 $745.18 23.03 $28.0672 $646.39 10/1/2016 0.00 $646.39 10/1/2016

2 SURGERY 15240 21 999 Years 26.55 $26.7305 $709.69 10/1/2016 0.00 $709.69 23.03 $26.7305 $615.60 10/1/2016 0.00 $615.60 10/1/2016

2 SURGERY 15241 0 20 Years 5.25 $28.0672 $147.35 10/1/2016 0.00 $147.35 3.22 $28.0672 $90.38 10/1/2016 0.00 $90.38 10/1/2016

2 SURGERY 15241 21 999 Years 5.25 $26.7305 $140.34 10/1/2016 0.00 $140.34 3.22 $26.7305 $86.07 10/1/2016 0.00 $86.07 10/1/2016

2 SURGERY 15260 0 20 Years 28.80 $28.0672 $808.34 10/1/2016 0.00 $808.34 24.71 $28.0672 $693.54 10/1/2016 0.00 $693.54 10/1/2016

2 SURGERY 15260 21 999 Years 28.80 $26.7305 $769.84 10/1/2016 0.00 $769.84 24.71 $26.7305 $660.51 10/1/2016 0.00 $660.51 10/1/2016

2 SURGERY 15261 0 20 Years 6.14 $28.0672 $172.33 10/1/2016 0.00 $172.33 4.05 $28.0672 $113.67 10/1/2016 0.00 $113.67 10/1/2016

2 SURGERY 15261 21 999 Years 6.14 $26.7305 $164.13 10/1/2016 0.00 $164.13 4.05 $26.7305 $108.26 10/1/2016 0.00 $108.26 10/1/2016

2 SURGERY 15275 0 20 Years 4.23 $28.0672 $118.72 10/1/2016 0.00 $118.72 2.75 $28.0672 $77.18 10/1/2016 0.00 $77.18 10/1/2016

2 SURGERY 15275 21 999 Years 4.23 $26.7305 $113.07 10/1/2016 0.00 $113.07 2.75 $26.7305 $73.51 10/1/2016 0.00 $73.51 10/1/2016

2 SURGERY 15276 0 20 Years 0.98 $28.0672 $27.51 10/1/2016 0.00 $27.51 0.72 $28.0672 $20.21 10/1/2014 0.00 $20.21 10/1/2016

2 SURGERY 15276 21 999 Years 0.98 $26.7305 $26.20 10/1/2016 0.00 $26.20 0.72 $26.7305 $19.25 10/1/2014 0.00 $19.25 10/1/2016

2 SURGERY 15277 0 20 Years 9.17 $28.0672 $257.38 10/1/2016 0.00 $257.38 6.49 $28.0672 $182.16 10/1/2016 0.00 $182.16 10/1/2016

2 SURGERY 15277 21 999 Years 9.17 $26.7305 $245.12 10/1/2016 0.00 $245.12 6.49 $26.7305 $173.48 10/1/2016 0.00 $173.48 10/1/2016

2 SURGERY 15278 0 20 Years 2.42 $28.0672 $67.92 10/1/2016 0.00 $67.92 1.65 $28.0672 $46.31 10/1/2016 0.00 $46.31 10/1/2016

2 SURGERY 15278 21 999 Years 2.42 $26.7305 $64.69 10/1/2016 0.00 $64.69 1.65 $26.7305 $44.11 10/1/2016 0.00 $44.11 10/1/2016

2 SURGERY 15574 0 20 Years 26.01 $28.0672 $730.03 10/1/2016 0.00 $730.03 22.05 $28.0672 $618.88 10/1/2016 0.00 $618.88 10/1/2016

2 SURGERY 15574 21 999 Years 26.01 $26.7305 $695.26 10/1/2016 0.00 $695.26 22.05 $26.7305 $589.41 10/1/2016 0.00 $589.41 10/1/2016

2 SURGERY 15576 0 20 Years 22.94 $28.0672 $643.86 10/1/2016 0.00 $643.86 19.28 $28.0672 $541.14 10/1/2016 0.00 $541.14 10/1/2016

2 SURGERY 15576 21 999 Years 22.94 $26.7305 $613.20 10/1/2016 0.00 $613.20 19.28 $26.7305 $515.36 10/1/2016 0.00 $515.36 10/1/2016

2 SURGERY 15620 0 20 Years 12.47 $28.0672 $350.00 10/1/2016 0.00 $350.00 9.35 $28.0672 $262.43 10/1/2016 0.00 $262.43 10/1/2016

2 SURGERY 15620 21 999 Years 12.47 $26.7305 $333.33 10/1/2016 0.00 $333.33 9.35 $26.7305 $249.93 10/1/2016 0.00 $249.93 10/1/2016

2 SURGERY 15630 0 20 Years 13.03 $28.0672 $365.72 10/1/2016 0.00 $365.72 9.94 $28.0672 $278.99 10/1/2016 0.00 $278.99 10/1/2016

2 SURGERY 15630 21 999 Years 13.03 $26.7305 $348.30 10/1/2016 0.00 $348.30 9.94 $26.7305 $265.70 10/1/2016 0.00 $265.70 10/1/2016

2 SURGERY 15732 0 20 Years 36.66 $28.0672 $1,028.94 10/1/2016 0.00 $1,028.94 32.08 $28.0672 $900.40 10/1/2016 0.00 $900.40 10/1/2016

2 SURGERY 15732 21 999 Years 36.66 $26.7305 $979.94 10/1/2016 0.00 $979.94 32.08 $26.7305 $857.51 10/1/2016 0.00 $857.51 10/1/2016

2 SURGERY 15740 0 20 Years 29.00 $28.0672 $813.95 10/1/2016 0.00 $813.95 24.55 $28.0672 $689.05 10/1/2016 0.00 $689.05 10/1/2016

2 SURGERY 15740 21 999 Years 29.00 $26.7305 $775.18 10/1/2016 0.00 $775.18 24.55 $26.7305 $656.23 10/1/2016 0.00 $656.23 10/1/2016

2 SURGERY 15750 0 20 Years 26.38 $28.0672 $740.41 10/1/2016 0.00 $740.41 26.38 $28.0672 $740.41 10/1/2016 0.00 $740.41 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 15750 21 999 Years 26.38 $26.7305 $705.15 10/1/2016 0.00 $705.15 26.38 $26.7305 $705.15 10/1/2016 0.00 $705.15 10/1/2016

2 SURGERY 15756 0 20 Years 67.03 $28.0672 $1,881.34 10/1/2016 0.00 $1,881.34 10 67.03 $28.0672 $1,881.34 10/1/2016 0.00 $1,881.34 10 10/1/2016

2 SURGERY 15756 21 999 Years 67.03 $26.7305 $1,791.75 10/1/2016 0.00 $1,791.75 10 67.03 $26.7305 $1,791.75 10/1/2016 0.00 $1,791.75 10 10/1/2016

2 SURGERY 15757 0 20 Years 66.22 $28.0672 $1,858.61 10/1/2016 0.00 $1,858.61 10 66.22 $28.0672 $1,858.61 10/1/2016 0.00 $1,858.61 10 10/1/2016

2 SURGERY 15757 21 999 Years 66.22 $26.7305 $1,770.09 10/1/2016 0.00 $1,770.09 10 66.22 $26.7305 $1,770.09 10/1/2016 0.00 $1,770.09 10 10/1/2016

2 SURGERY 15758 0 20 Years 66.32 $28.0672 $1,861.42 10/1/2016 0.00 $1,861.42 10 66.32 $28.0672 $1,861.42 10/1/2016 0.00 $1,861.42 10 10/1/2016

2 SURGERY 15758 21 999 Years 66.32 $26.7305 $1,772.77 10/1/2016 0.00 $1,772.77 10 66.32 $26.7305 $1,772.77 10/1/2016 0.00 $1,772.77 10 10/1/2016

2 SURGERY 15760 0 20 Years 24.30 $28.0672 $682.03 10/1/2016 0.00 $682.03 20.38 $28.0672 $572.01 10/1/2016 0.00 $572.01 10/1/2016

2 SURGERY 15760 21 999 Years 24.30 $26.7305 $649.55 10/1/2016 0.00 $649.55 20.38 $26.7305 $544.77 10/1/2016 0.00 $544.77 10/1/2016

2 SURGERY 15770 0 20 Years 19.28 $28.0672 $541.14 10/1/2016 0.00 $541.14 19.28 $28.0672 $541.14 10/1/2016 0.00 $541.14 10/1/2016

2 SURGERY 15770 21 999 Years 19.28 $26.7305 $515.36 10/1/2016 0.00 $515.36 19.28 $26.7305 $515.36 10/1/2016 0.00 $515.36 10/1/2016

2 SURGERY 15780 0 20 Years 23.92 $28.0672 $671.37 10/1/2016 0.00 $671.37 18.15 $28.0672 $509.42 10/1/2016 0.00 $509.42 10/1/2016

2 SURGERY 15780 21 999 Years 23.92 $26.7305 $639.39 10/1/2016 0.00 $639.39 18.15 $26.7305 $485.16 10/1/2016 0.00 $485.16 10/1/2016

2 SURGERY 15781 0 20 Years 15.77 $28.0672 $442.62 10/1/2016 0.00 $442.62 12.44 $28.0672 $349.16 10/1/2016 0.00 $349.16 10/1/2016

2 SURGERY 15781 21 999 Years 15.77 $26.7305 $421.54 10/1/2016 0.00 $421.54 12.44 $26.7305 $332.53 10/1/2016 0.00 $332.53 10/1/2016

2 SURGERY 15782 0 20 Years 18.04 $28.0672 $506.33 10/1/2016 0.00 $506.33 12.78 $28.0672 $358.70 10/1/2016 0.00 $358.70 10/1/2016

2 SURGERY 15782 21 999 Years 18.04 $26.7305 $482.22 10/1/2016 0.00 $482.22 12.78 $26.7305 $341.62 10/1/2016 0.00 $341.62 10/1/2016

2 SURGERY 15783 0 20 Years 13.24 $28.0672 $371.61 10/1/2016 0.00 $371.61 10.34 $28.0672 $290.21 10/1/2016 0.00 $290.21 10/1/2016

2 SURGERY 15783 21 999 Years 13.24 $26.7305 $353.91 10/1/2016 0.00 $353.91 10.34 $26.7305 $276.39 10/1/2016 0.00 $276.39 10/1/2016

2 SURGERY 15786 0 20 Years 6.93 $28.0672 $194.51 10/1/2016 0.00 $194.51 3.89 $28.0672 $109.18 10/1/2016 0.00 $109.18 10/1/2016

2 SURGERY 15786 21 999 Years 6.93 $26.7305 $185.24 10/1/2016 0.00 $185.24 3.89 $26.7305 $103.98 10/1/2016 0.00 $103.98 10/1/2016

2 SURGERY 15787 0 20 Years 1.39 $28.0672 $39.01 10/1/2014 0.00 $39.01 0.50 $28.0672 $14.03 10/1/2016 0.00 $14.03 10/1/2016

2 SURGERY 15787 21 999 Years 1.39 $26.7305 $37.16 10/1/2014 0.00 $37.16 0.50 $26.7305 $13.37 10/1/2016 0.00 $13.37 10/1/2016

2 SURGERY 15788 0 20 Years 13.06 $28.0672 $366.56 10/1/2016 0.00 $366.56 7.07 $28.0672 $198.44 10/1/2016 0.00 $198.44 10/1/2016

2 SURGERY 15788 21 999 Years 13.06 $26.7305 $349.10 10/1/2016 0.00 $349.10 7.07 $26.7305 $188.98 10/1/2016 0.00 $188.98 10/1/2016

2 SURGERY 15789 0 20 Years 15.59 $28.0672 $437.57 10/1/2016 0.00 $437.57 11.86 $28.0672 $332.88 10/1/2016 0.00 $332.88 10/1/2016

2 SURGERY 15789 21 999 Years 15.59 $26.7305 $416.73 10/1/2016 0.00 $416.73 11.86 $26.7305 $317.02 10/1/2016 0.00 $317.02 10/1/2016

2 SURGERY 15792 0 20 Years 12.57 $28.0672 $352.80 10/1/2016 0.00 $352.80 7.53 $28.0672 $211.35 10/1/2016 0.00 $211.35 10/1/2016

2 SURGERY 15792 21 999 Years 12.57 $26.7305 $336.00 10/1/2016 0.00 $336.00 7.53 $26.7305 $201.28 10/1/2016 0.00 $201.28 10/1/2016

2 SURGERY 15793 0 20 Years 13.99 $28.0672 $392.66 10/1/2016 0.00 $392.66 10.52 $28.0672 $295.27 10/1/2016 0.00 $295.27 10/1/2016

2 SURGERY 15793 21 999 Years 13.99 $26.7305 $373.96 10/1/2016 0.00 $373.96 10.52 $26.7305 $281.20 10/1/2016 0.00 $281.20 10/1/2016

2 SURGERY 15819 0 20 Years 21.11 $28.0672 $592.50 10/1/2016 0.00 $592.50 21.11 $28.0672 $592.50 10/1/2016 0.00 $592.50 10/1/2016

2 SURGERY 15819 21 999 Years 21.11 $26.7305 $564.28 10/1/2016 0.00 $564.28 21.11 $26.7305 $564.28 10/1/2016 0.00 $564.28 10/1/2016

2 SURGERY 15820 0 20 Years 15.95 $28.0672 $447.67 10/1/2016 0.00 $447.67 14.41 $28.0672 $404.45 10/1/2016 0.00 $404.45 10/1/2016

2 SURGERY 15820 21 999 Years 15.95 $26.7305 $426.35 10/1/2016 0.00 $426.35 14.41 $26.7305 $385.19 10/1/2016 0.00 $385.19 10/1/2016

2 SURGERY 15821 0 20 Years 17.19 $28.0672 $482.48 10/1/2016 0.00 $482.48 15.47 $28.0672 $434.20 10/1/2016 0.00 $434.20 10/1/2016

2 SURGERY 15821 21 999 Years 17.19 $26.7305 $459.50 10/1/2016 0.00 $459.50 15.47 $26.7305 $413.52 10/1/2016 0.00 $413.52 10/1/2016

2 SURGERY 15822 0 20 Years 12.62 $28.0672 $354.21 10/1/2016 0.00 $354.21 11.10 $28.0672 $311.55 10/1/2016 0.00 $311.55 10/1/2016

2 SURGERY 15822 21 999 Years 12.62 $26.7305 $337.34 10/1/2016 0.00 $337.34 11.10 $26.7305 $296.71 10/1/2016 0.00 $296.71 10/1/2016

2 SURGERY 15823 0 20 Years 17.19 $28.0672 $482.48 10/1/2016 0.00 $482.48 15.44 $28.0672 $433.36 10/1/2016 0.00 $433.36 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 15823 21 999 Years 17.19 $26.7305 $459.50 10/1/2016 0.00 $459.50 15.44 $26.7305 $412.72 10/1/2016 0.00 $412.72 10/1/2016

2 SURGERY 15838 0 20 Years 16.44 $28.0672 $461.42 10/1/2016 0.00 $461.42 16.44 $28.0672 $461.42 10/1/2016 0.00 $461.42 10/1/2016

2 SURGERY 15838 21 999 Years 16.44 $26.7305 $439.45 10/1/2016 0.00 $439.45 16.44 $26.7305 $439.45 10/1/2016 0.00 $439.45 10/1/2016

2 SURGERY 15850 0 20 Years 2.52 $28.0672 $70.73 10/1/2016 0.00 $70.73 1.19 $28.0672 $33.40 10/1/2016 0.00 $33.40 10/1/2016

2 SURGERY 15850 21 999 Years 2.52 $26.7305 $67.36 10/1/2016 0.00 $67.36 1.19 $26.7305 $31.81 10/1/2016 0.00 $31.81 10/1/2016

2 SURGERY 15851 0 20 Years 2.80 $28.0672 $78.59 10/1/2016 0.00 $78.59 1.31 $28.0672 $36.77 10/1/2016 0.00 $36.77 10/1/2016

2 SURGERY 15851 21 999 Years 2.80 $26.7305 $74.85 10/1/2016 0.00 $74.85 1.31 $26.7305 $35.02 10/1/2016 0.00 $35.02 10/1/2016

2 SURGERY 15852 0 20 Years 1.35 $28.0672 $37.89 10/1/2016 0.00 $37.89 1.35 $28.0672 $37.89 10/1/2016 0.00 $37.89 10/1/2016

2 SURGERY 15852 21 999 Years 1.35 $26.7305 $36.09 10/1/2016 0.00 $36.09 1.35 $26.7305 $36.09 10/1/2016 0.00 $36.09 10/1/2016

2 SURGERY 15876 0 20 Years 0.00 $0.0000 $164.19 10/1/2016 0.00 $164.19 0.00 $0.0000 $143.70 10/1/2016 0.00 $143.70 10/1/2016

2 SURGERY 15876 21 999 Years 0.00 $0.0000 $156.37 10/1/2016 0.00 $156.37 0.00 $0.0000 $136.86 10/1/2016 0.00 $136.86 10/1/2016

2 SURGERY 16020 0 20 Years 2.31 $28.0672 $64.84 10/1/2016 0.00 $64.84 1.55 $28.0672 $43.50 10/1/2014 0.00 $43.50 10/1/2016

2 SURGERY 16020 21 999 Years 2.31 $26.7305 $61.75 10/1/2016 0.00 $61.75 1.55 $26.7305 $41.43 10/1/2014 0.00 $41.43 10/1/2016

2 SURGERY 16025 0 20 Years 4.18 $28.0672 $117.32 10/1/2016 0.00 $117.32 3.19 $28.0672 $89.53 10/1/2016 0.00 $89.53 10/1/2016

2 SURGERY 16025 21 999 Years 4.18 $26.7305 $111.73 10/1/2016 0.00 $111.73 3.19 $26.7305 $85.27 10/1/2016 0.00 $85.27 10/1/2016

2 SURGERY 16030 0 20 Years 5.27 $28.0672 $147.91 10/1/2016 0.00 $147.91 3.84 $28.0672 $107.78 10/1/2016 0.00 $107.78 10/1/2016

2 SURGERY 16030 21 999 Years 5.27 $26.7305 $140.87 10/1/2016 0.00 $140.87 3.84 $26.7305 $102.65 10/1/2016 0.00 $102.65 10/1/2016

2 SURGERY 17000 0 20 Years 1.89 $28.0672 $53.05 10/1/2016 0.00 $53.05 1.52 $28.0672 $42.66 10/1/2016 0.00 $42.66 10/1/2016

2 SURGERY 17000 21 999 Years 1.89 $26.7305 $50.52 10/1/2016 0.00 $50.52 1.52 $26.7305 $40.63 10/1/2016 0.00 $40.63 10/1/2016

2 SURGERY 17003 0 20 Years 0.16 $28.0672 $4.49 10/1/2016 0.00 $4.49 0.07 $28.0672 $1.96 10/1/2014 0.00 $1.96 10/1/2016

2 SURGERY 17003 21 999 Years 0.16 $26.7305 $4.28 10/1/2016 0.00 $4.28 0.07 $26.7305 $1.87 10/1/2014 0.00 $1.87 10/1/2016

2 SURGERY 17004 0 20 Years 4.25 $28.0672 $119.29 10/1/2016 0.00 $119.29 2.86 $28.0672 $80.27 10/1/2016 0.00 $80.27 10/1/2016

2 SURGERY 17004 21 999 Years 4.25 $26.7305 $113.60 10/1/2016 0.00 $113.60 2.86 $26.7305 $76.45 10/1/2016 0.00 $76.45 10/1/2016

2 SURGERY 17106 0 20 Years 9.68 $28.0672 $271.69 10/1/2016 0.00 $271.69 7.90 $28.0672 $221.73 10/1/2016 0.00 $221.73 10/1/2016

2 SURGERY 17106 21 999 Years 9.68 $26.7305 $258.75 10/1/2016 0.00 $258.75 7.90 $26.7305 $211.17 10/1/2016 0.00 $211.17 10/1/2016

2 SURGERY 17107 0 20 Years 12.31 $28.0672 $345.51 10/1/2016 0.00 $345.51 9.94 $28.0672 $278.99 10/1/2016 0.00 $278.99 10/1/2016

2 SURGERY 17107 21 999 Years 12.31 $26.7305 $329.05 10/1/2016 0.00 $329.05 9.94 $26.7305 $265.70 10/1/2016 0.00 $265.70 10/1/2016

2 SURGERY 17108 0 20 Years 18.15 $28.0672 $509.42 10/1/2016 0.00 $509.42 15.08 $28.0672 $423.25 10/1/2016 0.00 $423.25 10/1/2016

2 SURGERY 17108 21 999 Years 18.15 $26.7305 $485.16 10/1/2016 0.00 $485.16 15.08 $26.7305 $403.10 10/1/2016 0.00 $403.10 10/1/2016

2 SURGERY 17110 0 20 Years 3.13 $28.0672 $87.85 10/1/2016 0.00 $87.85 1.99 $28.0672 $55.85 10/1/2016 0.00 $55.85 10/1/2016

2 SURGERY 17110 21 999 Years 3.13 $26.7305 $83.67 10/1/2016 0.00 $83.67 1.99 $26.7305 $53.19 10/1/2016 0.00 $53.19 10/1/2016

2 SURGERY 17111 0 20 Years 3.71 $28.0672 $104.13 10/1/2016 0.00 $104.13 2.45 $28.0672 $68.76 10/1/2016 0.00 $68.76 10/1/2016

2 SURGERY 17111 21 999 Years 3.71 $26.7305 $99.17 10/1/2016 0.00 $99.17 2.45 $26.7305 $65.49 10/1/2016 0.00 $65.49 10/1/2016

2 SURGERY 17250 0 20 Years 2.24 $28.0672 $62.87 10/1/2016 0.00 $62.87 1.06 $28.0672 $29.75 10/1/2014 0.00 $29.75 10/1/2016

2 SURGERY 17250 21 999 Years 2.24 $26.7305 $59.88 10/1/2016 0.00 $59.88 1.06 $26.7305 $28.33 10/1/2014 0.00 $28.33 10/1/2016

2 SURGERY 17270 0 20 Years 4.26 $28.0672 $119.57 10/1/2016 0.00 $119.57 2.86 $28.0672 $80.27 10/1/2016 0.00 $80.27 10/1/2016

2 SURGERY 17270 21 999 Years 4.26 $26.7305 $113.87 10/1/2016 0.00 $113.87 2.86 $26.7305 $76.45 10/1/2016 0.00 $76.45 10/1/2016

2 SURGERY 17271 0 20 Years 4.61 $28.0672 $129.39 10/1/2016 0.00 $129.39 3.18 $28.0672 $89.25 10/1/2016 0.00 $89.25 10/1/2016

2 SURGERY 17271 21 999 Years 4.61 $26.7305 $123.23 10/1/2016 0.00 $123.23 3.18 $26.7305 $85.00 10/1/2016 0.00 $85.00 10/1/2016

2 SURGERY 17272 0 20 Years 5.27 $28.0672 $147.91 10/1/2016 0.00 $147.91 3.68 $28.0672 $103.29 10/1/2016 0.00 $103.29 10/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 17272 21 999 Years 5.27 $26.7305 $140.87 10/1/2016 0.00 $140.87 3.68 $26.7305 $98.37 10/1/2016 0.00 $98.37 10/1/2016

2 SURGERY 17273 0 20 Years 5.88 $28.0672 $165.04 10/1/2016 0.00 $165.04 4.15 $28.0672 $116.48 10/1/2016 0.00 $116.48 10/1/2016

2 SURGERY 17273 21 999 Years 5.88 $26.7305 $157.18 10/1/2016 0.00 $157.18 4.15 $26.7305 $110.93 10/1/2016 0.00 $110.93 10/1/2016

2 SURGERY 17274 0 20 Years 6.95 $28.0672 $195.07 10/1/2016 0.00 $195.07 5.07 $28.0672 $142.30 10/1/2016 0.00 $142.30 10/1/2016

2 SURGERY 17274 21 999 Years 6.95 $26.7305 $185.78 10/1/2016 0.00 $185.78 5.07 $26.7305 $135.52 10/1/2016 0.00 $135.52 10/1/2016

2 SURGERY 17276 0 20 Years 8.05 $28.0672 $225.94 10/1/2016 0.00 $225.94 6.09 $28.0672 $170.93 10/1/2016 0.00 $170.93 10/1/2016

2 SURGERY 17276 21 999 Years 8.05 $26.7305 $215.18 10/1/2016 0.00 $215.18 6.09 $26.7305 $162.79 10/1/2016 0.00 $162.79 10/1/2016

2 SURGERY 17280 0 20 Years 3.98 $28.0672 $111.71 10/1/2016 0.00 $111.71 2.60 $28.0672 $72.97 10/1/2016 0.00 $72.97 10/1/2016

2 SURGERY 17280 21 999 Years 3.98 $26.7305 $106.39 10/1/2016 0.00 $106.39 2.60 $26.7305 $69.50 10/1/2016 0.00 $69.50 10/1/2016

2 SURGERY 17281 0 20 Years 5.03 $28.0672 $141.18 10/1/2016 0.00 $141.18 3.58 $28.0672 $100.48 10/1/2016 0.00 $100.48 10/1/2016

2 SURGERY 17281 21 999 Years 5.03 $26.7305 $134.45 10/1/2016 0.00 $134.45 3.58 $26.7305 $95.70 10/1/2016 0.00 $95.70 10/1/2016

2 SURGERY 17282 0 20 Years 5.79 $28.0672 $162.51 10/1/2016 0.00 $162.51 4.14 $28.0672 $116.20 10/1/2016 0.00 $116.20 10/1/2016

2 SURGERY 17282 21 999 Years 5.79 $26.7305 $154.77 10/1/2016 0.00 $154.77 4.14 $26.7305 $110.66 10/1/2016 0.00 $110.66 10/1/2016

2 SURGERY 17283 0 20 Years 6.93 $28.0672 $194.51 10/1/2016 0.00 $194.51 5.17 $28.0672 $145.11 10/1/2016 0.00 $145.11 10/1/2016

2 SURGERY 17283 21 999 Years 6.93 $26.7305 $185.24 10/1/2016 0.00 $185.24 5.17 $26.7305 $138.20 10/1/2016 0.00 $138.20 10/1/2016

2 SURGERY 17284 0 20 Years 7.92 $28.0672 $222.29 10/1/2016 0.00 $222.29 6.03 $28.0672 $169.25 10/1/2016 0.00 $169.25 10/1/2016

2 SURGERY 17284 21 999 Years 7.92 $26.7305 $211.71 10/1/2016 0.00 $211.71 6.03 $26.7305 $161.18 10/1/2016 0.00 $161.18 10/1/2016

2 SURGERY 17286 0 20 Years 10.17 $28.0672 $285.44 10/1/2016 0.00 $285.44 8.09 $28.0672 $227.06 10/1/2016 0.00 $227.06 10/1/2016

2 SURGERY 17286 21 999 Years 10.17 $26.7305 $271.85 10/1/2016 0.00 $271.85 8.09 $26.7305 $216.25 10/1/2016 0.00 $216.25 10/1/2016

2 SURGERY 20005 0 20 Years 8.76 $28.0672 $245.87 1/1/2016 0.00 $245.87 6.69 $28.0672 $187.77 1/1/2016 0.00 $187.77 1/1/2016

2 SURGERY 20005 21 999 Years 8.76 $26.7305 $234.16 1/1/2016 0.00 $234.16 6.69 $26.7305 $178.83 1/1/2016 0.00 $178.83 1/1/2016

2 SURGERY 20100 0 20 Years 17.56 $28.0672 $492.86 1/1/2016 0.00 $492.86 17.56 $28.0672 $492.86 1/1/2016 0.00 $492.86 1/1/2016

2 SURGERY 20100 21 999 Years 17.56 $26.7305 $469.39 1/1/2016 0.00 $469.39 17.56 $26.7305 $469.39 1/1/2016 0.00 $469.39 1/1/2016

2 SURGERY 20200 0 20 Years 5.91 $28.0672 $165.88 1/1/2016 0.00 $165.88 2.76 $28.0672 $77.47 1/1/2016 0.00 $77.47 1/1/2016

2 SURGERY 20200 21 999 Years 5.91 $26.7305 $157.98 1/1/2016 0.00 $157.98 2.76 $26.7305 $73.78 1/1/2016 0.00 $73.78 1/1/2016

2 SURGERY 20205 0 20 Years 8.24 $28.0672 $231.27 1/1/2016 0.00 $231.27 4.51 $28.0672 $126.58 1/1/2016 0.00 $126.58 1/1/2016

2 SURGERY 20205 21 999 Years 8.24 $26.7305 $220.26 1/1/2016 0.00 $220.26 4.51 $26.7305 $120.55 1/1/2016 0.00 $120.55 1/1/2016

2 SURGERY 20206 0 20 Years 6.71 $28.0672 $188.33 1/1/2016 0.00 $188.33 1.71 $28.0672 $47.99 4/1/2014 0.00 $47.99 1/1/2016

2 SURGERY 20206 21 999 Years 6.71 $26.7305 $179.36 1/1/2016 0.00 $179.36 1.71 $26.7305 $45.71 4/1/2014 0.00 $45.71 1/1/2016

2 SURGERY 20220 0 20 Years 4.79 $28.0672 $134.44 1/1/2016 0.00 $134.44 2.10 $28.0672 $58.94 1/1/2016 0.00 $58.94 1/1/2016

2 SURGERY 20220 21 999 Years 4.79 $26.7305 $128.04 1/1/2016 0.00 $128.04 2.10 $26.7305 $56.13 1/1/2016 0.00 $56.13 1/1/2016

2 SURGERY 20240 0 20 Years 6.23 $28.0672 $174.86 1/1/2016 0.00 $174.86 6.23 $28.0672 $174.86 1/1/2016 0.00 $174.86 1/1/2016

2 SURGERY 20240 21 999 Years 6.23 $26.7305 $166.53 1/1/2016 0.00 $166.53 6.23 $26.7305 $166.53 1/1/2016 0.00 $166.53 1/1/2016

2 SURGERY 20520 0 20 Years 5.79 $28.0672 $162.51 1/1/2016 0.00 $162.51 4.21 $28.0672 $118.16 1/1/2016 0.00 $118.16 1/1/2016

2 SURGERY 20520 21 999 Years 5.79 $26.7305 $154.77 1/1/2016 0.00 $154.77 4.21 $26.7305 $112.54 1/1/2016 0.00 $112.54 1/1/2016

2 SURGERY 20525 0 20 Years 13.70 $28.0672 $384.52 1/1/2016 0.00 $384.52 7.18 $28.0672 $201.52 1/1/2016 0.00 $201.52 1/1/2016

2 SURGERY 20525 21 999 Years 13.70 $26.7305 $366.21 1/1/2016 0.00 $366.21 7.18 $26.7305 $191.92 1/1/2016 0.00 $191.92 1/1/2016

2 SURGERY 20550 0 20 Years 1.68 $28.0672 $47.15 1/1/2016 0.00 $47.15 1.20 $28.0672 $33.68 1/1/2016 0.00 $33.68 1/1/2016

2 SURGERY 20550 21 999 Years 1.68 $26.7305 $44.91 1/1/2016 0.00 $44.91 1.20 $26.7305 $32.08 1/1/2016 0.00 $32.08 1/1/2016

2 SURGERY 20551 0 20 Years 1.72 $28.0672 $48.28 1/1/2016 0.00 $48.28 1.23 $28.0672 $34.52 1/1/2016 0.00 $34.52 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 20551 21 999 Years 1.72 $26.7305 $45.98 1/1/2016 0.00 $45.98 1.23 $26.7305 $32.88 1/1/2016 0.00 $32.88 1/1/2016

2 SURGERY 20552 0 20 Years 1.56 $28.0672 $43.78 4/1/2014 0.00 $43.78 1.08 $28.0672 $30.31 1/1/2016 0.00 $30.31 1/1/2016

2 SURGERY 20552 21 999 Years 1.56 $26.7305 $41.70 4/1/2014 0.00 $41.70 1.08 $26.7305 $28.87 1/1/2016 0.00 $28.87 1/1/2016

2 SURGERY 20600 0 20 Years 1.35 $28.0672 $37.89 4/1/2014 0.00 $37.89 1.02 $28.0672 $28.63 4/1/2014 0.00 $28.63 1/1/2016

2 SURGERY 20600 21 999 Years 1.35 $26.7305 $36.09 4/1/2014 0.00 $36.09 1.02 $26.7305 $27.27 4/1/2014 0.00 $27.27 1/1/2016

2 SURGERY 20604 0 20 Years 2.05 $28.0672 $57.54 1/1/2016 0.00 $57.54 1.32 $28.0672 $37.05 1/1/2016 0.00 $37.05 1/1/2016

2 SURGERY 20604 21 999 Years 2.05 $26.7305 $54.80 1/1/2016 0.00 $54.80 1.32 $26.7305 $35.28 1/1/2016 0.00 $35.28 1/1/2016

2 SURGERY 20605 0 20 Years 1.41 $28.0672 $39.57 4/1/2014 0.00 $39.57 1.06 $28.0672 $29.75 1/1/2016 0.00 $29.75 1/1/2016

2 SURGERY 20605 21 999 Years 1.41 $26.7305 $37.69 4/1/2014 0.00 $37.69 1.06 $26.7305 $28.33 1/1/2016 0.00 $28.33 1/1/2016

2 SURGERY 20606 0 20 Years 2.27 $28.0672 $63.71 1/1/2016 0.00 $63.71 1.51 $28.0672 $42.38 1/1/2016 0.00 $42.38 1/1/2016

2 SURGERY 20606 21 999 Years 2.27 $26.7305 $60.68 1/1/2016 0.00 $60.68 1.51 $26.7305 $40.36 1/1/2016 0.00 $40.36 1/1/2016

2 SURGERY 20611 0 20 Years 2.62 $28.0672 $73.54 1/1/2016 0.00 $73.54 1.78 $28.0672 $49.96 1/1/2016 0.00 $49.96 1/1/2016

2 SURGERY 20611 21 999 Years 2.62 $26.7305 $70.03 1/1/2016 0.00 $70.03 1.78 $26.7305 $47.58 1/1/2016 0.00 $47.58 1/1/2016

2 SURGERY 20615 0 20 Years 7.03 $28.0672 $197.31 1/1/2016 0.00 $197.31 4.74 $28.0672 $133.04 1/1/2016 0.00 $133.04 1/1/2016

2 SURGERY 20615 21 999 Years 7.03 $26.7305 $187.92 1/1/2016 0.00 $187.92 4.74 $26.7305 $126.70 1/1/2016 0.00 $126.70 1/1/2016

2 SURGERY 20650 0 20 Years 5.87 $28.0672 $164.75 1/1/2016 0.00 $164.75 4.48 $28.0672 $125.74 1/1/2016 0.00 $125.74 1/1/2016

2 SURGERY 20650 21 999 Years 5.87 $26.7305 $156.91 1/1/2016 0.00 $156.91 4.48 $26.7305 $119.75 1/1/2016 0.00 $119.75 1/1/2016

2 SURGERY 20660 0 20 Years 7.19 $28.0672 $201.80 1/1/2016 0.00 $201.80 7.19 $28.0672 $201.80 1/1/2016 0.00 $201.80 1/1/2016

2 SURGERY 20660 21 999 Years 7.19 $26.7305 $192.19 1/1/2016 0.00 $192.19 7.19 $26.7305 $192.19 1/1/2016 0.00 $192.19 1/1/2016

2 SURGERY 20661 0 20 Years 14.64 $28.0672 $410.90 1/1/2016 0.00 $410.90 14.64 $28.0672 $410.90 1/1/2016 0.00 $410.90 1/1/2016

2 SURGERY 20661 21 999 Years 14.64 $26.7305 $391.33 1/1/2016 0.00 $391.33 14.64 $26.7305 $391.33 1/1/2016 0.00 $391.33 1/1/2016

2 SURGERY 20670 0 20 Years 10.82 $28.0672 $303.69 1/1/2016 0.00 $303.69 4.24 $28.0672 $119.00 1/1/2016 0.00 $119.00 1/1/2016

2 SURGERY 20670 21 999 Years 10.82 $26.7305 $289.22 1/1/2016 0.00 $289.22 4.24 $26.7305 $113.34 1/1/2016 0.00 $113.34 1/1/2016

2 SURGERY 20680 0 20 Years 17.66 $28.0672 $495.67 1/1/2016 0.00 $495.67 10 12.17 $28.0672 $341.58 1/1/2016 0.00 $341.58 10 1/1/2016

2 SURGERY 20680 21 999 Years 17.66 $26.7305 $472.06 1/1/2016 0.00 $472.06 10 12.17 $26.7305 $325.31 1/1/2016 0.00 $325.31 10 1/1/2016

2 SURGERY 20690 0 20 Years 17.14 $28.0672 $481.07 1/1/2016 0.00 $481.07 17.14 $28.0672 $481.07 1/1/2016 0.00 $481.07 1/1/2016

2 SURGERY 20690 21 999 Years 17.14 $26.7305 $458.16 1/1/2016 0.00 $458.16 17.14 $26.7305 $458.16 1/1/2016 0.00 $458.16 1/1/2016

2 SURGERY 20692 0 20 Years 32.19 $28.0672 $903.48 1/1/2016 0.00 $903.48 32.19 $28.0672 $903.48 1/1/2016 0.00 $903.48 1/1/2016

2 SURGERY 20692 21 999 Years 32.19 $26.7305 $860.45 1/1/2016 0.00 $860.45 32.19 $26.7305 $860.45 1/1/2016 0.00 $860.45 1/1/2016

2 SURGERY 20693 0 20 Years 12.87 $28.0672 $361.22 1/1/2016 0.00 $361.22 12.87 $28.0672 $361.22 1/1/2016 0.00 $361.22 1/1/2016

2 SURGERY 20693 21 999 Years 12.87 $26.7305 $344.02 1/1/2016 0.00 $344.02 12.87 $26.7305 $344.02 1/1/2016 0.00 $344.02 1/1/2016

2 SURGERY 20694 0 20 Years 12.15 $28.0672 $341.02 1/1/2016 0.00 $341.02 9.70 $28.0672 $272.25 1/1/2016 0.00 $272.25 1/1/2016

2 SURGERY 20694 21 999 Years 12.15 $26.7305 $324.78 1/1/2016 0.00 $324.78 9.70 $26.7305 $259.29 1/1/2016 0.00 $259.29 1/1/2016

2 SURGERY 20696 0 20 Years 34.86 $28.0672 $978.42 1/1/2016 0.00 $978.42 34.86 $28.0672 $978.42 1/1/2016 0.00 $978.42 1/1/2016

2 SURGERY 20696 21 999 Years 34.86 $26.7305 $931.83 1/1/2016 0.00 $931.83 34.86 $26.7305 $931.83 1/1/2016 0.00 $931.83 1/1/2016

2 SURGERY 20697 0 20 Years 59.98 $28.0672 $1,683.47 1/1/2016 0.00 $1,683.47 59.98 $28.0672 $1,683.47 1/1/2016 0.00 $1,683.47 1/1/2016

2 SURGERY 20697 21 999 Years 59.98 $26.7305 $1,603.30 1/1/2016 0.00 $1,603.30 59.98 $26.7305 $1,603.30 1/1/2016 0.00 $1,603.30 1/1/2016

2 SURGERY 20900 0 20 Years 11.98 $28.0672 $336.25 1/1/2016 0.00 $336.25 5.49 $28.0672 $154.09 4/1/2014 0.00 $154.09 1/1/2016

2 SURGERY 20900 21 999 Years 11.98 $26.7305 $320.23 1/1/2016 0.00 $320.23 5.49 $26.7305 $146.75 4/1/2014 0.00 $146.75 1/1/2016

2 SURGERY 20902 0 20 Years 8.28 $28.0672 $232.40 1/1/2016 0.00 $232.40 10 8.28 $28.0672 $232.40 1/1/2016 0.00 $232.40 10 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 20902 21 999 Years 8.28 $26.7305 $221.33 1/1/2016 0.00 $221.33 10 8.28 $26.7305 $221.33 1/1/2016 0.00 $221.33 10 1/1/2016

2 SURGERY 20910 0 20 Years 13.11 $28.0672 $367.96 1/1/2016 0.00 $367.96 13.11 $28.0672 $367.96 1/1/2016 0.00 $367.96 1/1/2016

2 SURGERY 20910 21 999 Years 13.11 $26.7305 $350.44 1/1/2016 0.00 $350.44 13.11 $26.7305 $350.44 1/1/2016 0.00 $350.44 1/1/2016

2 SURGERY 20912 0 20 Years 13.75 $28.0672 $385.92 1/1/2016 0.00 $385.92 13.75 $28.0672 $385.92 1/1/2016 0.00 $385.92 1/1/2016

2 SURGERY 20912 21 999 Years 13.75 $26.7305 $367.54 1/1/2016 0.00 $367.54 13.75 $26.7305 $367.54 1/1/2016 0.00 $367.54 1/1/2016

2 SURGERY 20920 0 20 Years 11.31 $28.0672 $317.44 4/1/2014 0.00 $317.44 11.31 $28.0672 $317.44 4/1/2014 0.00 $317.44 1/1/2016

2 SURGERY 20920 21 999 Years 11.31 $26.7305 $302.32 4/1/2014 0.00 $302.32 11.31 $26.7305 $302.32 4/1/2014 0.00 $302.32 1/1/2016

2 SURGERY 20922 0 20 Years 17.31 $28.0672 $485.84 1/1/2016 0.00 $485.84 14.34 $28.0672 $402.48 1/1/2016 0.00 $402.48 1/1/2016

2 SURGERY 20922 21 999 Years 17.31 $26.7305 $462.70 1/1/2016 0.00 $462.70 14.34 $26.7305 $383.32 1/1/2016 0.00 $383.32 1/1/2016

2 SURGERY 20926 0 20 Years 12.35 $28.0672 $346.63 1/1/2016 0.00 $346.63 12.35 $28.0672 $346.63 1/1/2016 0.00 $346.63 1/1/2016

2 SURGERY 20926 21 999 Years 12.35 $26.7305 $330.12 1/1/2016 0.00 $330.12 12.35 $26.7305 $330.12 1/1/2016 0.00 $330.12 1/1/2016

2 SURGERY 20955 0 20 Years 72.71 $28.0672 $2,040.77 1/1/2016 0.00 $2,040.77 72.71 $28.0672 $2,040.77 1/1/2016 0.00 $2,040.77 1/1/2016

2 SURGERY 20955 21 999 Years 72.71 $26.7305 $1,943.57 1/1/2016 0.00 $1,943.57 72.71 $26.7305 $1,943.57 1/1/2016 0.00 $1,943.57 1/1/2016

2 SURGERY 20956 0 20 Years 76.74 $28.0672 $2,153.88 1/1/2016 0.00 $2,153.88 76.74 $28.0672 $2,153.88 1/1/2016 0.00 $2,153.88 1/1/2016

2 SURGERY 20956 21 999 Years 76.74 $26.7305 $2,051.30 1/1/2016 0.00 $2,051.30 76.74 $26.7305 $2,051.30 1/1/2016 0.00 $2,051.30 1/1/2016

2 SURGERY 20957 0 20 Years 60.69 $28.0672 $1,703.40 1/1/2016 0.00 $1,703.40 60.69 $28.0672 $1,703.40 1/1/2016 0.00 $1,703.40 1/1/2016

2 SURGERY 20957 21 999 Years 60.69 $26.7305 $1,622.27 1/1/2016 0.00 $1,622.27 60.69 $26.7305 $1,622.27 1/1/2016 0.00 $1,622.27 1/1/2016

2 SURGERY 20962 0 20 Years 58.38 $28.0672 $1,638.56 1/1/2016 0.00 $1,638.56 58.38 $28.0672 $1,638.56 1/1/2016 0.00 $1,638.56 1/1/2016

2 SURGERY 20962 21 999 Years 58.38 $26.7305 $1,560.53 1/1/2016 0.00 $1,560.53 58.38 $26.7305 $1,560.53 1/1/2016 0.00 $1,560.53 1/1/2016

2 SURGERY 20969 0 20 Years 79.50 $28.0672 $2,231.34 1/1/2016 0.00 $2,231.34 79.50 $28.0672 $2,231.34 1/1/2016 0.00 $2,231.34 1/1/2016

2 SURGERY 20969 21 999 Years 79.50 $26.7305 $2,125.07 1/1/2016 0.00 $2,125.07 79.50 $26.7305 $2,125.07 1/1/2016 0.00 $2,125.07 1/1/2016

2 SURGERY 20970 0 20 Years 83.02 $28.0672 $2,330.14 1/1/2016 0.00 $2,330.14 83.02 $28.0672 $2,330.14 1/1/2016 0.00 $2,330.14 1/1/2016

2 SURGERY 20970 21 999 Years 83.02 $26.7305 $2,219.17 1/1/2016 0.00 $2,219.17 83.02 $26.7305 $2,219.17 1/1/2016 0.00 $2,219.17 1/1/2016

2 SURGERY 20972 0 20 Years 66.11 $28.0672 $1,855.52 1/1/2016 0.00 $1,855.52 5 66.11 $28.0672 $1,855.52 1/1/2016 0.00 $1,855.52 5 1/1/2016

2 SURGERY 20972 21 999 Years 66.11 $26.7305 $1,767.15 1/1/2016 0.00 $1,767.15 5 66.11 $26.7305 $1,767.15 1/1/2016 0.00 $1,767.15 5 1/1/2016

2 SURGERY 20973 0 20 Years 72.90 $28.0672 $2,046.10 1/1/2016 0.00 $2,046.10 72.90 $28.0672 $2,046.10 1/1/2016 0.00 $2,046.10 1/1/2016

2 SURGERY 20973 21 999 Years 72.90 $26.7305 $1,948.65 1/1/2016 0.00 $1,948.65 72.90 $26.7305 $1,948.65 1/1/2016 0.00 $1,948.65 1/1/2016

2 SURGERY 20999 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 10 5 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 10 5 1/1/2016

2 SURGERY 21010 0 20 Years 21.93 $28.0672 $615.51 1/1/2016 0.00 $615.51 21.93 $28.0672 $615.51 1/1/2016 0.00 $615.51 1/1/2016

2 SURGERY 21010 21 999 Years 21.93 $26.7305 $586.20 1/1/2016 0.00 $586.20 21.93 $26.7305 $586.20 1/1/2016 0.00 $586.20 1/1/2016

2 SURGERY 21011 0 20 Years 9.93 $28.0672 $278.71 1/1/2016 0.00 $278.71 10 7.42 $28.0672 $208.26 1/1/2016 0.00 $208.26 10 1/1/2016

2 SURGERY 21011 21 999 Years 9.93 $26.7305 $265.43 1/1/2016 0.00 $265.43 10 7.42 $26.7305 $198.34 1/1/2016 0.00 $198.34 10 1/1/2016

2 SURGERY 21012 0 20 Years 9.70 $28.0672 $272.25 1/1/2016 0.00 $272.25 10 9.70 $28.0672 $272.25 1/1/2016 0.00 $272.25 10 1/1/2016

2 SURGERY 21012 21 999 Years 9.70 $26.7305 $259.29 1/1/2016 0.00 $259.29 10 9.70 $26.7305 $259.29 1/1/2016 0.00 $259.29 10 1/1/2016

2 SURGERY 21013 0 20 Years 14.81 $28.0672 $415.68 1/1/2016 0.00 $415.68 10 11.51 $28.0672 $323.05 1/1/2016 0.00 $323.05 10 1/1/2016

2 SURGERY 21013 21 999 Years 14.81 $26.7305 $395.88 1/1/2016 0.00 $395.88 10 11.51 $26.7305 $307.67 1/1/2016 0.00 $307.67 10 1/1/2016

2 SURGERY 21014 0 20 Years 14.94 $28.0672 $419.32 1/1/2016 0.00 $419.32 10 14.94 $28.0672 $419.32 1/1/2016 0.00 $419.32 10 1/1/2016

2 SURGERY 21014 21 999 Years 14.94 $26.7305 $399.35 1/1/2016 0.00 $399.35 10 14.94 $26.7305 $399.35 1/1/2016 0.00 $399.35 10 1/1/2016

2 SURGERY 21015 0 20 Years 20.30 $28.0672 $569.76 1/1/2016 0.00 $569.76 1/1/2016

2 SURGERY 21015 21 999 Years 20.30 $26.7305 $542.63 1/1/2016 0.00 $542.63 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21016 0 20 Years 29.39 $28.0672 $824.90 1/1/2016 0.00 $824.90 10 1/1/2016

2 SURGERY 21016 21 999 Years 29.39 $26.7305 $785.61 1/1/2016 0.00 $785.61 10 1/1/2016

2 SURGERY 21025 0 20 Years 25.76 $28.0672 $723.01 1/1/2016 0.00 $723.01 21.80 $28.0672 $611.86 1/1/2016 0.00 $611.86 1/1/2016

2 SURGERY 21025 21 999 Years 25.76 $26.7305 $688.58 1/1/2016 0.00 $688.58 21.80 $26.7305 $582.72 1/1/2016 0.00 $582.72 1/1/2016

2 SURGERY 21026 0 20 Years 17.83 $28.0672 $500.44 1/1/2016 0.00 $500.44 14.45 $28.0672 $405.57 1/1/2016 0.00 $405.57 1/1/2016

2 SURGERY 21026 21 999 Years 17.83 $26.7305 $476.60 1/1/2016 0.00 $476.60 14.45 $26.7305 $386.26 1/1/2016 0.00 $386.26 1/1/2016

2 SURGERY 21029 0 20 Years 21.96 $28.0672 $616.36 1/1/2016 0.00 $616.36 18.34 $28.0672 $514.75 1/1/2016 0.00 $514.75 1/1/2016

2 SURGERY 21029 21 999 Years 21.96 $26.7305 $587.00 1/1/2016 0.00 $587.00 18.34 $26.7305 $490.24 1/1/2016 0.00 $490.24 1/1/2016

2 SURGERY 21030 0 20 Years 14.97 $28.0672 $420.17 1/1/2016 0.00 $420.17 12.09 $28.0672 $339.33 1/1/2016 0.00 $339.33 1/1/2016

2 SURGERY 21030 21 999 Years 14.97 $26.7305 $400.16 1/1/2016 0.00 $400.16 12.09 $26.7305 $323.17 1/1/2016 0.00 $323.17 1/1/2016

2 SURGERY 21031 0 20 Years 11.40 $28.0672 $319.97 1/1/2016 0.00 $319.97 8.55 $28.0672 $239.97 1/1/2016 0.00 $239.97 1/1/2016

2 SURGERY 21031 21 999 Years 11.40 $26.7305 $304.73 1/1/2016 0.00 $304.73 8.55 $26.7305 $228.55 1/1/2016 0.00 $228.55 1/1/2016

2 SURGERY 21032 0 20 Years 11.56 $28.0672 $324.46 1/1/2016 0.00 $324.46 8.46 $28.0672 $237.45 1/1/2016 0.00 $237.45 1/1/2016

2 SURGERY 21032 21 999 Years 11.56 $26.7305 $309.00 1/1/2016 0.00 $309.00 8.46 $26.7305 $226.14 1/1/2016 0.00 $226.14 1/1/2016

2 SURGERY 21034 0 20 Years 38.09 $28.0672 $1,069.08 1/1/2016 0.00 $1,069.08 10 33.60 $28.0672 $943.06 1/1/2016 0.00 $943.06 10 1/1/2016

2 SURGERY 21034 21 999 Years 38.09 $26.7305 $1,018.16 1/1/2016 0.00 $1,018.16 10 33.60 $26.7305 $898.14 1/1/2016 0.00 $898.14 10 1/1/2016

2 SURGERY 21040 0 20 Years 15.11 $28.0672 $424.10 1/1/2016 0.00 $424.10 12.14 $28.0672 $340.74 1/1/2016 0.00 $340.74 1/1/2016

2 SURGERY 21040 21 999 Years 15.11 $26.7305 $403.90 1/1/2016 0.00 $403.90 12.14 $26.7305 $324.51 1/1/2016 0.00 $324.51 1/1/2016

2 SURGERY 21044 0 20 Years 25.41 $28.0672 $713.19 1/1/2016 0.00 $713.19 10 25.41 $28.0672 $713.19 1/1/2016 0.00 $713.19 10 1/1/2016

2 SURGERY 21044 21 999 Years 25.41 $26.7305 $679.22 1/1/2016 0.00 $679.22 10 25.41 $26.7305 $679.22 1/1/2016 0.00 $679.22 10 1/1/2016

2 SURGERY 21045 0 20 Years 35.41 $28.0672 $993.86 1/1/2016 0.00 $993.86 10 1/1/2016

2 SURGERY 21045 21 999 Years 35.41 $26.7305 $946.53 1/1/2016 0.00 $946.53 10 1/1/2016

2 SURGERY 21046 0 20 Years 32.44 $28.0672 $910.50 1/1/2016 0.00 $910.50 10 32.44 $28.0672 $910.50 1/1/2016 0.00 $910.50 10 1/1/2016

2 SURGERY 21046 21 999 Years 32.44 $26.7305 $867.14 1/1/2016 0.00 $867.14 10 32.44 $26.7305 $867.14 1/1/2016 0.00 $867.14 10 1/1/2016

2 SURGERY 21047 0 20 Years 38.26 $28.0672 $1,073.85 1/1/2016 0.00 $1,073.85 10 38.26 $28.0672 $1,073.85 1/1/2016 0.00 $1,073.85 10 1/1/2016

2 SURGERY 21047 21 999 Years 38.26 $26.7305 $1,022.71 1/1/2016 0.00 $1,022.71 10 38.26 $26.7305 $1,022.71 1/1/2016 0.00 $1,022.71 10 1/1/2016

2 SURGERY 21048 0 20 Years 33.31 $28.0672 $934.92 1/1/2016 0.00 $934.92 33.31 $28.0672 $934.92 1/1/2016 0.00 $934.92 1/1/2016

2 SURGERY 21048 21 999 Years 33.31 $26.7305 $890.39 1/1/2016 0.00 $890.39 33.31 $26.7305 $890.39 1/1/2016 0.00 $890.39 1/1/2016

2 SURGERY 21049 0 20 Years 35.00 $28.0672 $982.35 1/1/2016 0.00 $982.35 35.00 $28.0672 $982.35 1/1/2016 0.00 $982.35 1/1/2016

2 SURGERY 21049 21 999 Years 35.00 $26.7305 $935.57 1/1/2016 0.00 $935.57 35.00 $26.7305 $935.57 1/1/2016 0.00 $935.57 1/1/2016

2 SURGERY 21050 0 20 Years 24.29 $28.0672 $681.75 1/1/2016 0.00 $681.75 10 24.29 $28.0672 $681.75 1/1/2016 0.00 $681.75 10 1/1/2016

2 SURGERY 21050 21 999 Years 24.29 $26.7305 $649.28 1/1/2016 0.00 $649.28 10 24.29 $26.7305 $649.28 1/1/2016 0.00 $649.28 10 1/1/2016

2 SURGERY 21060 0 20 Years 23.45 $28.0672 $658.18 1/1/2016 0.00 $658.18 10 23.45 $28.0672 $658.18 1/1/2016 0.00 $658.18 10 1/1/2016

2 SURGERY 21060 21 999 Years 23.45 $26.7305 $626.83 1/1/2016 0.00 $626.83 10 23.45 $26.7305 $626.83 1/1/2016 0.00 $626.83 10 1/1/2016

2 SURGERY 21070 0 20 Years 17.81 $28.0672 $499.88 1/1/2016 0.00 $499.88 17.81 $28.0672 $499.88 1/1/2016 0.00 $499.88 1/1/2016

2 SURGERY 21070 21 999 Years 17.81 $26.7305 $476.07 1/1/2016 0.00 $476.07 17.81 $26.7305 $476.07 1/1/2016 0.00 $476.07 1/1/2016

2 SURGERY 21073 0 20 Years 11.38 $28.0672 $319.40 1/1/2016 0.00 $319.40 7.35 $28.0672 $206.29 1/1/2016 0.00 $206.29 1/1/2016

2 SURGERY 21073 21 999 Years 11.38 $26.7305 $304.19 1/1/2016 0.00 $304.19 7.35 $26.7305 $196.47 1/1/2016 0.00 $196.47 1/1/2016

2 SURGERY 21076 0 20 Years 29.09 $28.0672 $816.47 1/1/2016 0.00 $816.47 24.43 $28.0672 $685.68 1/1/2016 0.00 $685.68 1/1/2016

2 SURGERY 21077 0 20 Years 73.03 $28.0672 $2,049.75 1/1/2016 0.00 $2,049.75 61.64 $28.0672 $1,730.06 1/1/2016 0.00 $1,730.06 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21079 0 20 Years 49.11 $28.0672 $1,378.38 1/1/2016 0.00 $1,378.38 40.81 $28.0672 $1,145.42 1/1/2016 0.00 $1,145.42 1/1/2016

2 SURGERY 21079 21 999 Years 49.11 $26.7305 $1,312.73 1/1/2016 0.00 $1,312.73 40.81 $26.7305 $1,090.87 1/1/2016 0.00 $1,090.87 1/1/2016

2 SURGERY 21080 0 20 Years 54.97 $28.0672 $1,542.85 1/1/2016 0.00 $1,542.85 45.28 $28.0672 $1,270.88 1/1/2016 0.00 $1,270.88 1/1/2016

2 SURGERY 21080 21 999 Years 54.97 $26.7305 $1,469.38 1/1/2016 0.00 $1,469.38 45.28 $26.7305 $1,210.36 1/1/2016 0.00 $1,210.36 1/1/2016

2 SURGERY 21081 0 20 Years 50.87 $28.0672 $1,427.78 1/1/2016 0.00 $1,427.78 41.80 $28.0672 $1,173.21 1/1/2016 0.00 $1,173.21 1/1/2016

2 SURGERY 21081 21 999 Years 50.87 $26.7305 $1,359.78 1/1/2016 0.00 $1,359.78 41.80 $26.7305 $1,117.33 1/1/2016 0.00 $1,117.33 1/1/2016

2 SURGERY 21082 0 20 Years 48.21 $28.0672 $1,353.12 1/1/2016 0.00 $1,353.12 39.33 $28.0672 $1,103.88 1/1/2016 0.00 $1,103.88 1/1/2016

2 SURGERY 21083 0 20 Years 45.93 $28.0672 $1,289.13 1/1/2016 0.00 $1,289.13 36.52 $28.0672 $1,025.01 1/1/2016 0.00 $1,025.01 1/1/2016

2 SURGERY 21084 0 20 Years 52.55 $28.0672 $1,474.93 1/1/2016 0.00 $1,474.93 42.25 $28.0672 $1,185.84 1/1/2016 0.00 $1,185.84 1/1/2016

2 SURGERY 21084 21 999 Years 52.55 $26.7305 $1,404.69 1/1/2016 0.00 $1,404.69 42.25 $26.7305 $1,129.36 1/1/2016 0.00 $1,129.36 1/1/2016

2 SURGERY 21085 0 20 Years 22.08 $28.0672 $619.72 1/1/2016 0.00 $619.72 16.57 $28.0672 $465.07 1/1/2016 0.00 $465.07 1/1/2016

2 SURGERY 21085 21 999 Years 22.08 $26.7305 $590.21 1/1/2016 0.00 $590.21 16.57 $26.7305 $442.92 1/1/2016 0.00 $442.92 1/1/2016

2 SURGERY 21086 0 20 Years 54.27 $28.0672 $1,523.21 1/1/2016 0.00 $1,523.21 45.45 $28.0672 $1,275.65 1/1/2016 0.00 $1,275.65 1/1/2016

2 SURGERY 21086 21 999 Years 54.27 $26.7305 $1,450.66 1/1/2016 0.00 $1,450.66 45.45 $26.7305 $1,214.90 1/1/2016 0.00 $1,214.90 1/1/2016

2 SURGERY 21087 0 20 Years 54.27 $28.0672 $1,523.21 1/1/2016 0.00 $1,523.21 45.45 $28.0672 $1,275.65 1/1/2016 0.00 $1,275.65 1/1/2016

2 SURGERY 21087 21 999 Years 54.27 $26.7305 $1,450.66 1/1/2016 0.00 $1,450.66 45.45 $26.7305 $1,214.90 1/1/2016 0.00 $1,214.90 1/1/2016

2 SURGERY 21088 0 20 Years 0.00 $0.0000 $1,523.21 1/1/2016 0.00 $1,523.21 0.00 $0.0000 $1,275.65 1/1/2016 0.00 $1,275.65 1/1/2016

2 SURGERY 21088 21 999 Years 0.00 $0.0000 $1,450.66 1/1/2016 0.00 $1,450.66 0.00 $0.0000 $1,214.90 1/1/2016 0.00 $1,214.90 1/1/2016

2 SURGERY 21089 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 5 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 5 1/1/2016

2 SURGERY 21100 0 20 Years 33.16 $28.0672 $930.71 1/1/2016 0.00 $930.71 15.07 $28.0672 $422.97 1/1/2016 0.00 $422.97 1/1/2016

2 SURGERY 21110 0 20 Years 23.35 $28.0672 $655.37 1/1/2016 0.00 $655.37 19.55 $28.0672 $548.71 1/1/2016 0.00 $548.71 1/1/2016

2 SURGERY 21116 0 20 Years 4.23 $28.0672 $118.72 1/1/2016 0.00 $118.72 1.28 $28.0672 $35.93 1/1/2016 0.00 $35.93 1/1/2016

2 SURGERY 21116 21 999 Years 4.23 $26.7305 $113.07 1/1/2016 0.00 $113.07 1.28 $26.7305 $34.22 1/1/2016 0.00 $34.22 1/1/2016

2 SURGERY 21120 0 20 Years 17.24 $28.0672 $483.88 1/1/2016 0.00 $483.88 10 13.80 $28.0672 $387.33 1/1/2016 0.00 $387.33 10 1/1/2016

2 SURGERY 21120 21 999 Years 17.24 $26.7305 $460.83 1/1/2016 0.00 $460.83 10 13.80 $26.7305 $368.88 1/1/2016 0.00 $368.88 10 1/1/2016

2 SURGERY 21121 0 20 Years 23.07 $28.0672 $647.51 1/1/2016 0.00 $647.51 10 19.25 $28.0672 $540.29 1/1/2016 0.00 $540.29 10 1/1/2016

2 SURGERY 21121 21 999 Years 23.07 $26.7305 $616.67 1/1/2016 0.00 $616.67 10 19.25 $26.7305 $514.56 1/1/2016 0.00 $514.56 10 1/1/2016

2 SURGERY 21122 0 20 Years 18.42 $28.0672 $517.00 1/1/2016 0.00 $517.00 10 1/1/2016

2 SURGERY 21122 21 999 Years 18.42 $26.7305 $492.38 1/1/2016 0.00 $492.38 10 1/1/2016

2 SURGERY 21123 0 20 Years 22.22 $28.0672 $623.65 1/1/2016 0.00 $623.65 10 1/1/2016

2 SURGERY 21123 21 999 Years 22.22 $26.7305 $593.95 1/1/2016 0.00 $593.95 10 1/1/2016

2 SURGERY 21125 0 20 Years 89.96 $28.0672 $2,524.93 1/1/2016 0.00 $2,524.93 10 21.16 $28.0672 $593.90 1/1/2016 0.00 $593.90 10 1/1/2016

2 SURGERY 21125 21 999 Years 89.96 $26.7305 $2,404.68 1/1/2016 0.00 $2,404.68 10 21.16 $26.7305 $565.62 1/1/2016 0.00 $565.62 10 1/1/2016

2 SURGERY 21127 0 20 Years 124.47 $28.0672 $3,493.52 1/1/2016 0.00 $3,493.52 10 25.58 $28.0672 $717.96 1/1/2016 0.00 $717.96 10 1/1/2016

2 SURGERY 21127 21 999 Years 124.47 $26.7305 $3,327.15 1/1/2016 0.00 $3,327.15 10 25.58 $26.7305 $683.77 1/1/2016 0.00 $683.77 10 1/1/2016

2 SURGERY 21137 0 20 Years 19.94 $28.0672 $559.66 1/1/2016 0.00 $559.66 10 1/1/2016

2 SURGERY 21137 21 999 Years 19.94 $26.7305 $533.01 1/1/2016 0.00 $533.01 10 1/1/2016

2 SURGERY 21138 0 20 Years 25.30 $28.0672 $710.10 1/1/2016 0.00 $710.10 10 1/1/2016

2 SURGERY 21138 21 999 Years 25.30 $26.7305 $676.28 1/1/2016 0.00 $676.28 10 1/1/2016

2 SURGERY 21139 0 20 Years 32.35 $28.0672 $907.97 1/1/2016 0.00 $907.97 10 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21139 21 999 Years 32.35 $26.7305 $864.73 1/1/2016 0.00 $864.73 10 1/1/2016

2 SURGERY 21141 0 20 Years 38.98 $28.0672 $1,094.06 1/1/2016 0.00 $1,094.06 10 1/1/2016

2 SURGERY 21141 21 999 Years 38.98 $26.7305 $1,041.95 1/1/2016 0.00 $1,041.95 10 1/1/2016

2 SURGERY 21142 0 20 Years 41.69 $28.0672 $1,170.12 1/1/2016 0.00 $1,170.12 10 1/1/2016

2 SURGERY 21142 21 999 Years 41.69 $26.7305 $1,114.39 1/1/2016 0.00 $1,114.39 10 1/1/2016

2 SURGERY 21143 0 20 Years 42.06 $28.0672 $1,180.51 1/1/2016 0.00 $1,180.51 10 1/1/2016

2 SURGERY 21143 21 999 Years 42.06 $26.7305 $1,124.28 1/1/2016 0.00 $1,124.28 10 1/1/2016

2 SURGERY 21145 0 20 Years 47.24 $28.0672 $1,325.89 1/1/2016 0.00 $1,325.89 10 1/1/2016

2 SURGERY 21145 21 999 Years 47.24 $26.7305 $1,262.75 1/1/2016 0.00 $1,262.75 10 1/1/2016

2 SURGERY 21146 0 20 Years 49.20 $28.0672 $1,380.91 1/1/2016 0.00 $1,380.91 10 1/1/2016

2 SURGERY 21146 21 999 Years 49.20 $26.7305 $1,315.14 1/1/2016 0.00 $1,315.14 10 1/1/2016

2 SURGERY 21147 0 20 Years 52.00 $28.0672 $1,459.49 1/1/2016 0.00 $1,459.49 10 1/1/2016

2 SURGERY 21147 21 999 Years 52.00 $26.7305 $1,389.99 1/1/2016 0.00 $1,389.99 10 1/1/2016

2 SURGERY 21150 0 20 Years 48.48 $28.0672 $1,360.70 1/1/2016 0.00 $1,360.70 10 1/1/2016

2 SURGERY 21150 21 999 Years 48.48 $26.7305 $1,295.89 1/1/2016 0.00 $1,295.89 10 1/1/2016

2 SURGERY 21151 0 20 Years 59.29 $28.0672 $1,664.10 1/1/2016 0.00 $1,664.10 10 1/1/2016

2 SURGERY 21151 21 999 Years 59.29 $26.7305 $1,584.85 1/1/2016 0.00 $1,584.85 10 1/1/2016

2 SURGERY 21154 0 20 Years 63.78 $28.0672 $1,790.13 1/1/2016 0.00 $1,790.13 10 1/1/2016

2 SURGERY 21154 21 999 Years 63.78 $26.7305 $1,704.87 1/1/2016 0.00 $1,704.87 10 1/1/2016

2 SURGERY 21155 0 20 Years 67.82 $28.0672 $1,903.52 1/1/2016 0.00 $1,903.52 10 1/1/2016

2 SURGERY 21155 21 999 Years 67.82 $26.7305 $1,812.86 1/1/2016 0.00 $1,812.86 10 1/1/2016

2 SURGERY 21159 0 20 Years 69.37 $28.0672 $1,947.02 1/1/2016 0.00 $1,947.02 10 1/1/2016

2 SURGERY 21159 21 999 Years 69.37 $26.7305 $1,854.29 1/1/2016 0.00 $1,854.29 10 1/1/2016

2 SURGERY 21160 0 20 Years 75.27 $28.0672 $2,112.62 1/1/2016 0.00 $2,112.62 10 1/1/2016

2 SURGERY 21160 21 999 Years 75.27 $26.7305 $2,012.00 1/1/2016 0.00 $2,012.00 10 1/1/2016

2 SURGERY 21172 0 20 Years 50.90 $28.0672 $1,428.62 1/1/2016 0.00 $1,428.62 10 1/1/2016

2 SURGERY 21172 21 999 Years 50.90 $26.7305 $1,360.58 1/1/2016 0.00 $1,360.58 10 1/1/2016

2 SURGERY 21175 0 20 Years 66.81 $28.0672 $1,875.17 1/1/2016 0.00 $1,875.17 10 1/1/2016

2 SURGERY 21175 21 999 Years 66.81 $26.7305 $1,785.86 1/1/2016 0.00 $1,785.86 10 1/1/2016

2 SURGERY 21179 0 20 Years 37.67 $28.0672 $1,057.29 1/1/2016 0.00 $1,057.29 10 1/1/2016

2 SURGERY 21179 21 999 Years 37.67 $26.7305 $1,006.94 1/1/2016 0.00 $1,006.94 10 1/1/2016

2 SURGERY 21180 0 20 Years 44.10 $28.0672 $1,237.76 1/1/2016 0.00 $1,237.76 10 1/1/2016

2 SURGERY 21180 21 999 Years 44.10 $26.7305 $1,178.82 1/1/2016 0.00 $1,178.82 10 1/1/2016

2 SURGERY 21181 0 20 Years 21.25 $28.0672 $596.43 1/1/2016 0.00 $596.43 10 1/1/2016

2 SURGERY 21181 21 999 Years 21.25 $26.7305 $568.02 1/1/2016 0.00 $568.02 10 1/1/2016

2 SURGERY 21182 0 20 Years 55.19 $28.0672 $1,549.03 1/1/2016 0.00 $1,549.03 10 1/1/2016

2 SURGERY 21182 21 999 Years 55.19 $26.7305 $1,475.26 1/1/2016 0.00 $1,475.26 10 1/1/2016

2 SURGERY 21183 0 20 Years 64.13 $28.0672 $1,799.95 1/1/2016 0.00 $1,799.95 10 1/1/2016

2 SURGERY 21183 21 999 Years 64.13 $26.7305 $1,714.23 1/1/2016 0.00 $1,714.23 10 1/1/2016

2 SURGERY 21184 0 20 Years 69.36 $28.0672 $1,946.74 1/1/2016 0.00 $1,946.74 10 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21184 21 999 Years 69.36 $26.7305 $1,854.03 1/1/2016 0.00 $1,854.03 10 1/1/2016

2 SURGERY 21188 0 20 Years 45.09 $28.0672 $1,265.55 1/1/2016 0.00 $1,265.55 10 1/1/2016

2 SURGERY 21188 21 999 Years 45.09 $26.7305 $1,205.28 1/1/2016 0.00 $1,205.28 10 1/1/2016

2 SURGERY 21193 0 20 Years 34.26 $28.0672 $961.58 1/1/2016 0.00 $961.58 10 1/1/2016

2 SURGERY 21193 21 999 Years 34.26 $26.7305 $915.79 1/1/2016 0.00 $915.79 10 1/1/2016

2 SURGERY 21194 0 20 Years 43.24 $28.0672 $1,213.63 1/1/2016 0.00 $1,213.63 10 1/1/2016

2 SURGERY 21194 21 999 Years 43.24 $26.7305 $1,155.83 1/1/2016 0.00 $1,155.83 10 1/1/2016

2 SURGERY 21195 0 20 Years 38.70 $28.0672 $1,086.20 1/1/2016 0.00 $1,086.20 10 1/1/2016

2 SURGERY 21195 21 999 Years 38.70 $26.7305 $1,034.47 1/1/2016 0.00 $1,034.47 10 1/1/2016

2 SURGERY 21196 0 20 Years 42.66 $28.0672 $1,197.35 1/1/2016 0.00 $1,197.35 10 1/1/2016

2 SURGERY 21196 21 999 Years 42.66 $26.7305 $1,140.32 1/1/2016 0.00 $1,140.32 10 1/1/2016

2 SURGERY 21198 0 20 Years 33.60 $28.0672 $943.06 1/1/2016 0.00 $943.06 10 1/1/2016

2 SURGERY 21198 21 999 Years 33.60 $26.7305 $898.14 1/1/2016 0.00 $898.14 10 1/1/2016

2 SURGERY 21199 0 20 Years 28.97 $28.0672 $813.11 1/1/2016 0.00 $813.11 10 1/1/2016

2 SURGERY 21199 21 999 Years 28.97 $26.7305 $774.38 1/1/2016 0.00 $774.38 10 1/1/2016

2 SURGERY 21206 0 20 Years 35.73 $28.0672 $1,002.84 1/1/2016 0.00 $1,002.84 10 1/1/2016

2 SURGERY 21206 21 999 Years 35.73 $26.7305 $955.08 1/1/2016 0.00 $955.08 10 1/1/2016

2 SURGERY 21208 0 20 Years 24.40 $28.0672 $684.84 1/1/2016 0.00 $684.84 1/1/2016

2 SURGERY 21208 21 999 Years 24.40 $26.7305 $652.22 1/1/2016 0.00 $652.22 1/1/2016

2 SURGERY 21209 0 20 Years 17.76 $28.0672 $498.47 1/1/2016 0.00 $498.47 10 1/1/2016

2 SURGERY 21209 21 999 Years 17.76 $26.7305 $474.73 1/1/2016 0.00 $474.73 10 1/1/2016

2 SURGERY 21210 0 20 Years 66.10 $28.0672 $1,855.24 1/1/2016 0.00 $1,855.24 10 25.20 $28.0672 $707.29 1/1/2016 0.00 $707.29 10 1/1/2016

2 SURGERY 21210 21 999 Years 66.10 $26.7305 $1,766.89 1/1/2016 0.00 $1,766.89 10 25.20 $26.7305 $673.61 1/1/2016 0.00 $673.61 10 1/1/2016

2 SURGERY 21215 0 20 Years 118.03 $28.0672 $3,312.77 1/1/2016 0.00 $3,312.77 26.15 $28.0672 $733.96 1/1/2016 0.00 $733.96 1/1/2016

2 SURGERY 21215 21 999 Years 118.03 $26.7305 $3,155.00 1/1/2016 0.00 $3,155.00 26.15 $26.7305 $699.00 1/1/2016 0.00 $699.00 1/1/2016

2 SURGERY 21230 0 20 Years 21.93 $28.0672 $615.51 1/1/2016 0.00 $615.51 1/1/2016

2 SURGERY 21230 21 999 Years 21.93 $26.7305 $586.20 1/1/2016 0.00 $586.20 1/1/2016

2 SURGERY 21235 0 20 Years 16.30 $28.0672 $457.50 1/1/2016 0.00 $457.50 1/1/2016

2 SURGERY 21235 21 999 Years 16.30 $26.7305 $435.71 1/1/2016 0.00 $435.71 1/1/2016

2 SURGERY 21240 0 20 Years 32.44 $28.0672 $910.50 1/1/2016 0.00 $910.50 10 32.44 $28.0672 $910.50 1/1/2016 0.00 $910.50 10 1/1/2016

2 SURGERY 21240 21 999 Years 32.44 $26.7305 $867.14 1/1/2016 0.00 $867.14 10 32.44 $26.7305 $867.14 1/1/2016 0.00 $867.14 10 1/1/2016

2 SURGERY 21242 0 20 Years 29.72 $28.0672 $834.16 1/1/2016 0.00 $834.16 10 29.72 $28.0672 $834.16 1/1/2016 0.00 $834.16 10 1/1/2016

2 SURGERY 21242 21 999 Years 29.72 $26.7305 $794.43 1/1/2016 0.00 $794.43 10 29.72 $26.7305 $794.43 1/1/2016 0.00 $794.43 10 1/1/2016

2 SURGERY 21243 0 20 Years 49.26 $28.0672 $1,382.59 1/1/2016 0.00 $1,382.59 10 49.26 $28.0672 $1,382.59 1/1/2016 0.00 $1,382.59 10 1/1/2016

2 SURGERY 21243 21 999 Years 49.26 $26.7305 $1,316.74 1/1/2016 0.00 $1,316.74 10 49.26 $26.7305 $1,316.74 1/1/2016 0.00 $1,316.74 10 1/1/2016

2 SURGERY 21244 0 20 Years 30.80 $28.0672 $864.47 1/1/2016 0.00 $864.47 10 1/1/2016

2 SURGERY 21244 21 999 Years 30.80 $26.7305 $823.30 1/1/2016 0.00 $823.30 10 1/1/2016

2 SURGERY 21245 0 20 Years 25.46 $28.0672 $714.59 1/1/2016 0.00 $714.59 10 1/1/2016

2 SURGERY 21245 21 999 Years 25.46 $26.7305 $680.56 1/1/2016 0.00 $680.56 10 1/1/2016

2 SURGERY 21246 0 20 Years 25.94 $28.0672 $728.06 1/1/2016 0.00 $728.06 10 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21246 21 999 Years 25.94 $26.7305 $693.39 1/1/2016 0.00 $693.39 10 1/1/2016

2 SURGERY 21247 0 20 Years 43.97 $28.0672 $1,234.11 1/1/2016 0.00 $1,234.11 10 1/1/2016

2 SURGERY 21247 21 999 Years 43.97 $26.7305 $1,175.34 1/1/2016 0.00 $1,175.34 10 1/1/2016

2 SURGERY 21255 0 20 Years 37.96 $28.0672 $1,065.43 1/1/2016 0.00 $1,065.43 1/1/2016

2 SURGERY 21255 21 999 Years 37.96 $26.7305 $1,014.69 1/1/2016 0.00 $1,014.69 1/1/2016

2 SURGERY 21256 0 20 Years 34.32 $28.0672 $963.27 1/1/2016 0.00 $963.27 10 1/1/2016

2 SURGERY 21256 21 999 Years 34.32 $26.7305 $917.39 1/1/2016 0.00 $917.39 10 1/1/2016

2 SURGERY 21260 0 20 Years 32.95 $28.0672 $924.81 1/1/2016 0.00 $924.81 10 1/1/2016

2 SURGERY 21260 21 999 Years 32.95 $26.7305 $880.77 1/1/2016 0.00 $880.77 10 1/1/2016

2 SURGERY 21261 0 20 Years 58.47 $28.0672 $1,641.09 1/1/2016 0.00 $1,641.09 10 1/1/2016

2 SURGERY 21261 21 999 Years 58.47 $26.7305 $1,562.93 1/1/2016 0.00 $1,562.93 10 1/1/2016

2 SURGERY 21263 0 20 Years 54.04 $28.0672 $1,516.75 1/1/2016 0.00 $1,516.75 10 1/1/2016

2 SURGERY 21263 21 999 Years 54.04 $26.7305 $1,444.52 1/1/2016 0.00 $1,444.52 10 1/1/2016

2 SURGERY 21267 0 20 Years 45.23 $28.0672 $1,269.48 1/1/2016 0.00 $1,269.48 10 1/1/2016

2 SURGERY 21267 21 999 Years 45.23 $26.7305 $1,209.02 1/1/2016 0.00 $1,209.02 10 1/1/2016

2 SURGERY 21268 0 20 Years 53.14 $28.0672 $1,491.49 1/1/2016 0.00 $1,491.49 10 1/1/2016

2 SURGERY 21268 21 999 Years 53.14 $26.7305 $1,420.46 1/1/2016 0.00 $1,420.46 10 1/1/2016

2 SURGERY 21270 0 20 Years 20.77 $28.0672 $582.96 1/1/2016 0.00 $582.96 10 1/1/2016

2 SURGERY 21270 21 999 Years 20.77 $26.7305 $555.19 1/1/2016 0.00 $555.19 10 1/1/2016

2 SURGERY 21275 0 20 Years 24.04 $28.0672 $674.74 1/1/2016 0.00 $674.74 10 1/1/2016

2 SURGERY 21275 21 999 Years 24.04 $26.7305 $642.60 1/1/2016 0.00 $642.60 10 1/1/2016

2 SURGERY 21280 0 20 Years 16.24 $28.0672 $455.81 1/1/2016 0.00 $455.81 16.24 $28.0672 $455.81 1/1/2016 0.00 $455.81 1/1/2016

2 SURGERY 21280 21 999 Years 16.24 $26.7305 $434.10 1/1/2016 0.00 $434.10 16.24 $26.7305 $434.10 1/1/2016 0.00 $434.10 1/1/2016

2 SURGERY 21282 0 20 Years 10.84 $28.0672 $304.25 1/1/2016 0.00 $304.25 10.84 $28.0672 $304.25 1/1/2016 0.00 $304.25 1/1/2016

2 SURGERY 21282 21 999 Years 10.84 $26.7305 $289.76 1/1/2016 0.00 $289.76 10.84 $26.7305 $289.76 1/1/2016 0.00 $289.76 1/1/2016

2 SURGERY 21295 0 20 Years 5.41 $28.0672 $151.84 1/1/2016 0.00 $151.84 1/1/2016

2 SURGERY 21295 21 999 Years 5.41 $26.7305 $144.61 1/1/2016 0.00 $144.61 1/1/2016

2 SURGERY 21296 0 20 Years 12.06 $28.0672 $338.49 1/1/2016 0.00 $338.49 1/1/2016

2 SURGERY 21296 21 999 Years 12.06 $26.7305 $322.37 1/1/2016 0.00 $322.37 1/1/2016

2 SURGERY 21299 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 10 5 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 10 5 1/1/2016

2 SURGERY 21310 0 20 Years 3.75 $28.0672 $105.25 1/1/2016 0.00 $105.25 0.77 $28.0672 $21.61 1/1/2016 0.00 $21.61 1/1/2016

2 SURGERY 21310 21 999 Years 3.75 $26.7305 $100.24 1/1/2016 0.00 $100.24 0.77 $26.7305 $20.58 1/1/2016 0.00 $20.58 1/1/2016

2 SURGERY 21315 0 20 Years 7.97 $28.0672 $223.70 1/1/2016 0.00 $223.70 4.39 $28.0672 $123.22 1/1/2016 0.00 $123.22 1/1/2016

2 SURGERY 21315 21 999 Years 7.97 $26.7305 $213.04 1/1/2016 0.00 $213.04 4.39 $26.7305 $117.35 1/1/2016 0.00 $117.35 1/1/2016

2 SURGERY 21320 0 20 Years 7.34 $28.0672 $206.01 1/1/2016 0.00 $206.01 3.90 $28.0672 $109.46 1/1/2016 0.00 $109.46 1/1/2016

2 SURGERY 21320 21 999 Years 7.34 $26.7305 $196.20 1/1/2016 0.00 $196.20 3.90 $26.7305 $104.25 1/1/2016 0.00 $104.25 1/1/2016

2 SURGERY 21325 0 20 Years 13.70 $28.0672 $384.52 1/1/2016 0.00 $384.52 13.70 $28.0672 $384.52 1/1/2016 0.00 $384.52 1/1/2016

2 SURGERY 21325 21 999 Years 13.70 $26.7305 $366.21 1/1/2016 0.00 $366.21 13.70 $26.7305 $366.21 1/1/2016 0.00 $366.21 1/1/2016

2 SURGERY 21330 0 20 Years 16.46 $28.0672 $461.99 1/1/2016 0.00 $461.99 16.46 $28.0672 $461.99 1/1/2016 0.00 $461.99 1/1/2016

2 SURGERY 21330 21 999 Years 16.46 $26.7305 $439.98 1/1/2016 0.00 $439.98 16.46 $26.7305 $439.98 1/1/2016 0.00 $439.98 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21335 0 20 Years 20.85 $28.0672 $585.20 1/1/2016 0.00 $585.20 20.85 $28.0672 $585.20 1/1/2016 0.00 $585.20 1/1/2016

2 SURGERY 21335 21 999 Years 20.85 $26.7305 $557.33 1/1/2016 0.00 $557.33 20.85 $26.7305 $557.33 1/1/2016 0.00 $557.33 1/1/2016

2 SURGERY 21336 0 20 Years 18.51 $28.0672 $519.52 1/1/2016 0.00 $519.52 18.51 $28.0672 $519.52 1/1/2016 0.00 $519.52 1/1/2016

2 SURGERY 21336 21 999 Years 18.51 $26.7305 $494.78 1/1/2016 0.00 $494.78 18.51 $26.7305 $494.78 1/1/2016 0.00 $494.78 1/1/2016

2 SURGERY 21337 0 20 Years 11.63 $28.0672 $326.42 1/1/2016 0.00 $326.42 8.50 $28.0672 $238.57 1/1/2016 0.00 $238.57 1/1/2016

2 SURGERY 21337 21 999 Years 11.63 $26.7305 $310.88 1/1/2016 0.00 $310.88 8.50 $26.7305 $227.21 1/1/2016 0.00 $227.21 1/1/2016

2 SURGERY 21338 0 20 Years 21.60 $28.0672 $606.25 1/1/2016 0.00 $606.25 21.60 $28.0672 $606.25 1/1/2016 0.00 $606.25 1/1/2016

2 SURGERY 21338 21 999 Years 21.60 $26.7305 $577.38 1/1/2016 0.00 $577.38 21.60 $26.7305 $577.38 1/1/2016 0.00 $577.38 1/1/2016

2 SURGERY 21339 0 20 Years 24.48 $28.0672 $687.09 1/1/2016 0.00 $687.09 24.48 $28.0672 $687.09 1/1/2016 0.00 $687.09 1/1/2016

2 SURGERY 21339 21 999 Years 24.48 $26.7305 $654.36 1/1/2016 0.00 $654.36 24.48 $26.7305 $654.36 1/1/2016 0.00 $654.36 1/1/2016

2 SURGERY 21340 0 20 Years 22.95 $28.0672 $644.14 1/1/2016 0.00 $644.14 10 22.95 $28.0672 $644.14 1/1/2016 0.00 $644.14 10 1/1/2016

2 SURGERY 21340 21 999 Years 22.95 $26.7305 $613.46 1/1/2016 0.00 $613.46 10 22.95 $26.7305 $613.46 1/1/2016 0.00 $613.46 10 1/1/2016

2 SURGERY 21343 0 20 Years 34.94 $28.0672 $980.67 1/1/2016 0.00 $980.67 10 1/1/2016

2 SURGERY 21343 21 999 Years 34.94 $26.7305 $933.96 1/1/2016 0.00 $933.96 10 1/1/2016

2 SURGERY 21344 0 20 Years 40.06 $28.0672 $1,124.37 1/1/2016 0.00 $1,124.37 10 1/1/2016

2 SURGERY 21344 21 999 Years 40.06 $26.7305 $1,070.82 1/1/2016 0.00 $1,070.82 10 1/1/2016

2 SURGERY 21345 0 20 Years 18.07 $28.0672 $507.17 1/1/2016 0.00 $507.17 1/1/2016

2 SURGERY 21345 21 999 Years 18.07 $26.7305 $483.02 1/1/2016 0.00 $483.02 1/1/2016

2 SURGERY 21346 0 20 Years 26.00 $28.0672 $729.75 1/1/2016 0.00 $729.75 1/1/2016

2 SURGERY 21346 21 999 Years 26.00 $26.7305 $694.99 1/1/2016 0.00 $694.99 1/1/2016

2 SURGERY 21347 0 20 Years 32.72 $28.0672 $918.36 1/1/2016 0.00 $918.36 10 1/1/2016

2 SURGERY 21347 21 999 Years 32.72 $26.7305 $874.62 1/1/2016 0.00 $874.62 10 1/1/2016

2 SURGERY 21348 0 20 Years 34.73 $28.0672 $974.77 1/1/2016 0.00 $974.77 10 1/1/2016

2 SURGERY 21348 21 999 Years 34.73 $26.7305 $928.35 1/1/2016 0.00 $928.35 10 1/1/2016

2 SURGERY 21355 0 20 Years 10.31 $28.0672 $289.37 1/1/2016 0.00 $289.37 1/1/2016

2 SURGERY 21355 21 999 Years 10.31 $26.7305 $275.59 1/1/2016 0.00 $275.59 1/1/2016

2 SURGERY 21356 0 20 Years 10.89 $28.0672 $305.65 1/1/2016 0.00 $305.65 10 1/1/2016

2 SURGERY 21356 21 999 Years 10.89 $26.7305 $291.10 1/1/2016 0.00 $291.10 10 1/1/2016

2 SURGERY 21360 0 20 Years 15.47 $28.0672 $434.20 1/1/2016 0.00 $434.20 10 1/1/2016

2 SURGERY 21360 21 999 Years 15.47 $26.7305 $413.52 1/1/2016 0.00 $413.52 10 1/1/2016

2 SURGERY 21365 0 20 Years 32.02 $28.0672 $898.71 1/1/2016 0.00 $898.71 10 1/1/2016

2 SURGERY 21365 21 999 Years 32.02 $26.7305 $855.91 1/1/2016 0.00 $855.91 10 1/1/2016

2 SURGERY 21366 0 20 Years 33.39 $28.0672 $937.16 1/1/2016 0.00 $937.16 10 1/1/2016

2 SURGERY 21366 21 999 Years 33.39 $26.7305 $892.53 1/1/2016 0.00 $892.53 10 1/1/2016

2 SURGERY 21385 0 20 Years 19.61 $28.0672 $550.40 1/1/2016 0.00 $550.40 10 1/1/2016

2 SURGERY 21385 21 999 Years 19.61 $26.7305 $524.19 1/1/2016 0.00 $524.19 10 1/1/2016

2 SURGERY 21386 0 20 Years 20.00 $28.0672 $561.34 1/1/2016 0.00 $561.34 1/1/2016

2 SURGERY 21386 21 999 Years 20.00 $26.7305 $534.61 1/1/2016 0.00 $534.61 1/1/2016

2 SURGERY 21387 0 20 Years 20.47 $28.0672 $574.54 1/1/2016 0.00 $574.54 1/1/2016

2 SURGERY 21387 21 999 Years 20.47 $26.7305 $547.17 1/1/2016 0.00 $547.17 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21390 0 20 Years 22.77 $28.0672 $639.09 1/1/2016 0.00 $639.09 10 1/1/2016

2 SURGERY 21390 21 999 Years 22.77 $26.7305 $608.65 1/1/2016 0.00 $608.65 10 1/1/2016

2 SURGERY 21395 0 20 Years 28.98 $28.0672 $813.39 1/1/2016 0.00 $813.39 10 1/1/2016

2 SURGERY 21395 21 999 Years 28.98 $26.7305 $774.65 1/1/2016 0.00 $774.65 10 1/1/2016

2 SURGERY 21400 0 20 Years 5.55 $28.0672 $155.77 1/1/2016 0.00 $155.77 4.52 $28.0672 $126.86 1/1/2016 0.00 $126.86 1/1/2016

2 SURGERY 21400 21 999 Years 5.55 $26.7305 $148.35 1/1/2016 0.00 $148.35 4.52 $26.7305 $120.82 1/1/2016 0.00 $120.82 1/1/2016

2 SURGERY 21401 0 20 Years 14.11 $28.0672 $396.03 1/1/2016 0.00 $396.03 8.82 $28.0672 $247.55 1/1/2016 0.00 $247.55 1/1/2016

2 SURGERY 21401 21 999 Years 14.11 $26.7305 $377.17 1/1/2016 0.00 $377.17 8.82 $26.7305 $235.76 1/1/2016 0.00 $235.76 1/1/2016

2 SURGERY 21406 0 20 Years 16.44 $28.0672 $461.42 1/1/2016 0.00 $461.42 16.44 $28.0672 $461.42 1/1/2016 0.00 $461.42 1/1/2016

2 SURGERY 21406 21 999 Years 16.44 $26.7305 $439.45 1/1/2016 0.00 $439.45 16.44 $26.7305 $439.45 1/1/2016 0.00 $439.45 1/1/2016

2 SURGERY 21407 0 20 Years 18.51 $28.0672 $519.52 1/1/2016 0.00 $519.52 10 18.51 $28.0672 $519.52 1/1/2016 0.00 $519.52 10 1/1/2016

2 SURGERY 21407 21 999 Years 18.51 $26.7305 $494.78 1/1/2016 0.00 $494.78 10 18.51 $26.7305 $494.78 1/1/2016 0.00 $494.78 10 1/1/2016

2 SURGERY 21408 0 20 Years 25.84 $28.0672 $725.26 1/1/2016 0.00 $725.26 10 25.84 $28.0672 $725.26 1/1/2016 0.00 $725.26 10 1/1/2016

2 SURGERY 21408 21 999 Years 25.84 $26.7305 $690.72 1/1/2016 0.00 $690.72 10 25.84 $26.7305 $690.72 1/1/2016 0.00 $690.72 10 1/1/2016

2 SURGERY 21421 0 20 Years 24.22 $28.0672 $679.79 1/1/2016 0.00 $679.79 20.05 $28.0672 $562.75 1/1/2016 0.00 $562.75 1/1/2016

2 SURGERY 21421 21 999 Years 24.22 $26.7305 $647.41 1/1/2016 0.00 $647.41 20.05 $26.7305 $535.95 1/1/2016 0.00 $535.95 1/1/2016

2 SURGERY 21422 0 20 Years 19.44 $28.0672 $545.63 1/1/2016 0.00 $545.63 10 19.44 $28.0672 $545.63 1/1/2016 0.00 $545.63 10 1/1/2016

2 SURGERY 21422 21 999 Years 19.44 $26.7305 $519.64 1/1/2016 0.00 $519.64 10 19.44 $26.7305 $519.64 1/1/2016 0.00 $519.64 10 1/1/2016

2 SURGERY 21423 0 20 Years 22.79 $28.0672 $639.65 1/1/2016 0.00 $639.65 10 1/1/2016

2 SURGERY 21423 21 999 Years 22.79 $26.7305 $609.19 1/1/2016 0.00 $609.19 10 1/1/2016

2 SURGERY 21431 0 20 Years 22.68 $28.0672 $636.56 1/1/2016 0.00 $636.56 10 1/1/2016

2 SURGERY 21431 21 999 Years 22.68 $26.7305 $606.25 1/1/2016 0.00 $606.25 10 1/1/2016

2 SURGERY 21432 0 20 Years 18.45 $28.0672 $517.84 1/1/2016 0.00 $517.84 10 1/1/2016

2 SURGERY 21432 21 999 Years 18.45 $26.7305 $493.18 1/1/2016 0.00 $493.18 10 1/1/2016

2 SURGERY 21433 0 20 Years 50.06 $28.0672 $1,405.04 1/1/2016 0.00 $1,405.04 10 1/1/2016

2 SURGERY 21433 21 999 Years 50.06 $26.7305 $1,338.13 1/1/2016 0.00 $1,338.13 10 1/1/2016

2 SURGERY 21435 0 20 Years 36.34 $28.0672 $1,019.96 4/1/2014 0.00 $1,019.96 10 1/1/2016

2 SURGERY 21435 21 999 Years 36.34 $26.7305 $971.39 4/1/2014 0.00 $971.39 10 1/1/2016

2 SURGERY 21436 0 20 Years 58.75 $28.0672 $1,648.95 1/1/2016 0.00 $1,648.95 10 1/1/2016

2 SURGERY 21436 21 999 Years 58.75 $26.7305 $1,570.42 1/1/2016 0.00 $1,570.42 10 1/1/2016

2 SURGERY 21440 0 20 Years 16.66 $28.0672 $467.60 1/1/2016 0.00 $467.60 13.52 $28.0672 $379.47 1/1/2016 0.00 $379.47 1/1/2016

2 SURGERY 21440 21 999 Years 16.66 $26.7305 $445.33 1/1/2016 0.00 $445.33 13.52 $26.7305 $361.40 1/1/2016 0.00 $361.40 1/1/2016

2 SURGERY 21445 0 20 Years 22.34 $28.0672 $627.02 1/1/2016 0.00 $627.02 18.19 $28.0672 $510.54 1/1/2016 0.00 $510.54 1/1/2016

2 SURGERY 21445 21 999 Years 22.34 $26.7305 $597.16 1/1/2016 0.00 $597.16 18.19 $26.7305 $486.23 1/1/2016 0.00 $486.23 1/1/2016

2 SURGERY 21450 0 20 Years 18.03 $28.0672 $506.05 1/1/2016 0.00 $506.05 14.41 $28.0672 $404.45 1/1/2016 0.00 $404.45 1/1/2016

2 SURGERY 21450 21 999 Years 18.03 $26.7305 $481.95 1/1/2016 0.00 $481.95 14.41 $26.7305 $385.19 1/1/2016 0.00 $385.19 1/1/2016

2 SURGERY 21451 0 20 Years 23.74 $28.0672 $666.32 1/1/2016 0.00 $666.32 19.56 $28.0672 $548.99 1/1/2016 0.00 $548.99 1/1/2016

2 SURGERY 21451 21 999 Years 23.74 $26.7305 $634.58 1/1/2016 0.00 $634.58 19.56 $26.7305 $522.85 1/1/2016 0.00 $522.85 1/1/2016

2 SURGERY 21452 0 20 Years 16.57 $28.0672 $465.07 1/1/2016 0.00 $465.07 9.80 $28.0672 $275.06 1/1/2016 0.00 $275.06 1/1/2016

2 SURGERY 21452 21 999 Years 16.57 $26.7305 $442.92 1/1/2016 0.00 $442.92 9.80 $26.7305 $261.96 1/1/2016 0.00 $261.96 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 21453 0 20 Years 26.46 $28.0672 $742.66 1/1/2016 0.00 $742.66 22.68 $28.0672 $636.56 1/1/2016 0.00 $636.56 1/1/2016

2 SURGERY 21453 21 999 Years 26.46 $26.7305 $707.29 1/1/2016 0.00 $707.29 22.68 $26.7305 $606.25 1/1/2016 0.00 $606.25 1/1/2016

2 SURGERY 21454 0 20 Years 16.58 $28.0672 $465.35 1/1/2016 0.00 $465.35 16.58 $28.0672 $465.35 1/1/2016 0.00 $465.35 1/1/2016

2 SURGERY 21454 21 999 Years 16.58 $26.7305 $443.19 1/1/2016 0.00 $443.19 16.58 $26.7305 $443.19 1/1/2016 0.00 $443.19 1/1/2016

2 SURGERY 21461 0 20 Years 61.48 $28.0672 $1,725.57 1/1/2016 0.00 $1,725.57 10 27.14 $28.0672 $761.74 1/1/2016 0.00 $761.74 10 1/1/2016

2 SURGERY 21461 21 999 Years 61.48 $26.7305 $1,643.39 1/1/2016 0.00 $1,643.39 10 27.14 $26.7305 $725.47 1/1/2016 0.00 $725.47 10 1/1/2016

2 SURGERY 21462 0 20 Years 65.39 $28.0672 $1,835.31 1/1/2016 0.00 $1,835.31 10 30.24 $28.0672 $848.75 1/1/2016 0.00 $848.75 10 1/1/2016

2 SURGERY 21462 21 999 Years 65.39 $26.7305 $1,747.91 1/1/2016 0.00 $1,747.91 10 30.24 $26.7305 $808.33 1/1/2016 0.00 $808.33 10 1/1/2016

2 SURGERY 21465 0 20 Years 26.96 $28.0672 $756.69 1/1/2016 0.00 $756.69 10 26.96 $28.0672 $756.69 1/1/2016 0.00 $756.69 10 1/1/2016

2 SURGERY 21465 21 999 Years 26.96 $26.7305 $720.65 1/1/2016 0.00 $720.65 10 26.96 $26.7305 $720.65 1/1/2016 0.00 $720.65 10 1/1/2016

2 SURGERY 21470 0 20 Years 34.90 $28.0672 $979.55 1/1/2016 0.00 $979.55 10 34.90 $28.0672 $979.55 1/1/2016 0.00 $979.55 10 1/1/2016

2 SURGERY 21470 21 999 Years 34.90 $26.7305 $932.89 1/1/2016 0.00 $932.89 10 34.90 $26.7305 $932.89 1/1/2016 0.00 $932.89 10 1/1/2016

2 SURGERY 21480 0 20 Years 2.82 $28.0672 $79.15 1/1/2016 0.00 $79.15 0.92 $28.0672 $25.82 4/1/2014 0.00 $25.82 1/1/2016

2 SURGERY 21480 21 999 Years 2.82 $26.7305 $75.38 1/1/2016 0.00 $75.38 0.92 $26.7305 $24.59 4/1/2014 0.00 $24.59 1/1/2016

2 SURGERY 21485 0 20 Years 20.36 $28.0672 $571.45 1/1/2016 0.00 $571.45 17.02 $28.0672 $477.70 1/1/2016 0.00 $477.70 1/1/2016

2 SURGERY 21485 21 999 Years 20.36 $26.7305 $544.23 1/1/2016 0.00 $544.23 17.02 $26.7305 $454.95 1/1/2016 0.00 $454.95 1/1/2016

2 SURGERY 21490 0 20 Years 26.61 $28.0672 $746.87 1/1/2016 0.00 $746.87 10 26.61 $28.0672 $746.87 1/1/2016 0.00 $746.87 10 1/1/2016

2 SURGERY 21490 21 999 Years 26.61 $26.7305 $711.30 1/1/2016 0.00 $711.30 10 26.61 $26.7305 $711.30 1/1/2016 0.00 $711.30 10 1/1/2016

2 SURGERY 21495 0 20 Years 18.37 $28.0672 $515.59 1/1/2016 0.00 $515.59 18.37 $28.0672 $515.59 1/1/2016 0.00 $515.59 1/1/2016

2 SURGERY 21495 21 999 Years 18.37 $26.7305 $491.04 1/1/2016 0.00 $491.04 18.37 $26.7305 $491.04 1/1/2016 0.00 $491.04 1/1/2016

2 SURGERY 21497 0 20 Years 21.27 $28.0672 $596.99 1/1/2016 0.00 $596.99 17.66 $28.0672 $495.67 1/1/2016 0.00 $495.67 1/1/2016

2 SURGERY 21497 21 999 Years 21.27 $26.7305 $568.56 1/1/2016 0.00 $568.56 17.66 $26.7305 $472.06 1/1/2016 0.00 $472.06 1/1/2016

2 SURGERY 21499 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 10 5 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 10 5 1/1/2016

2 SURGERY 21501 0 20 Years 12.95 $28.0672 $363.47 1/1/2016 0.00 $363.47 9.21 $28.0672 $258.50 1/1/2016 0.00 $258.50 1/1/2016

2 SURGERY 21501 21 999 Years 12.95 $26.7305 $346.16 1/1/2016 0.00 $346.16 9.21 $26.7305 $246.19 1/1/2016 0.00 $246.19 1/1/2016

2 SURGERY 21550 0 20 Years 7.49 $28.0672 $210.22 1/1/2016 0.00 $210.22 4.54 $28.0672 $127.43 1/1/2016 0.00 $127.43 1/1/2016

2 SURGERY 21550 21 999 Years 7.49 $26.7305 $200.21 1/1/2016 0.00 $200.21 4.54 $26.7305 $121.36 1/1/2016 0.00 $121.36 1/1/2016

2 SURGERY 21552 0 20 Years 12.85 $28.0672 $360.66 1/1/2016 0.00 $360.66 10 12.85 $28.0672 $360.66 1/1/2016 0.00 $360.66 10 1/1/2016

2 SURGERY 21552 21 999 Years 12.85 $26.7305 $343.49 1/1/2016 0.00 $343.49 10 12.85 $26.7305 $343.49 1/1/2016 0.00 $343.49 10 1/1/2016

2 SURGERY 21554 0 20 Years 21.08 $28.0672 $591.66 1/1/2016 0.00 $591.66 10 21.08 $28.0672 $591.66 1/1/2016 0.00 $591.66 10 1/1/2016

2 SURGERY 21554 21 999 Years 21.08 $26.7305 $563.48 1/1/2016 0.00 $563.48 10 21.08 $26.7305 $563.48 1/1/2016 0.00 $563.48 10 1/1/2016

2 SURGERY 21555 0 20 Years 11.88 $28.0672 $333.44 1/1/2016 0.00 $333.44 8.79 $28.0672 $246.71 1/1/2016 0.00 $246.71 1/1/2016

2 SURGERY 21555 21 999 Years 11.88 $26.7305 $317.56 1/1/2016 0.00 $317.56 8.79 $26.7305 $234.96 1/1/2016 0.00 $234.96 1/1/2016

2 SURGERY 21556 0 20 Years 15.25 $28.0672 $428.02 1/1/2016 0.00 $428.02 15.25 $28.0672 $428.02 1/1/2016 0.00 $428.02 1/1/2016

2 SURGERY 21556 21 999 Years 15.25 $26.7305 $407.64 1/1/2016 0.00 $407.64 15.25 $26.7305 $407.64 1/1/2016 0.00 $407.64 1/1/2016

2 SURGERY 21558 0 20 Years 38.77 $28.0672 $1,088.17 1/1/2016 0.00 $1,088.17 1/1/2016

2 SURGERY 21558 21 999 Years 38.77 $26.7305 $1,036.34 1/1/2016 0.00 $1,036.34 1/1/2016

2 SURGERY 21685 0 20 Years 28.65 $28.0672 $804.13 1/1/2016 0.00 $804.13 28.65 $28.0672 $804.13 1/1/2016 0.00 $804.13 1/1/2016

2 SURGERY 21685 21 999 Years 28.65 $26.7305 $765.83 1/1/2016 0.00 $765.83 28.65 $26.7305 $765.83 1/1/2016 0.00 $765.83 1/1/2016

2 SURGERY 29800 0 20 Years 14.92 $28.0672 $418.76 1/1/2016 0.00 $418.76 14.92 $28.0672 $418.76 1/1/2016 0.00 $418.76 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 29800 21 999 Years 14.92 $26.7305 $398.82 1/1/2016 0.00 $398.82 14.92 $26.7305 $398.82 1/1/2016 0.00 $398.82 1/1/2016

2 SURGERY 29804 0 20 Years 18.49 $28.0672 $518.96 1/1/2016 0.00 $518.96 10 18.49 $28.0672 $518.96 1/1/2016 0.00 $518.96 10 1/1/2016

2 SURGERY 29804 21 999 Years 18.49 $26.7305 $494.25 1/1/2016 0.00 $494.25 10 18.49 $26.7305 $494.25 1/1/2016 0.00 $494.25 10 1/1/2016

2 SURGERY 29999 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 5 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 5 1/1/2016

2 SURGERY 30000 0 20 Years 6.56 $28.0672 $184.12 1/1/2016 0.00 $184.12 3.39 $28.0672 $95.15 1/1/2016 0.00 $95.15 1/1/2016

2 SURGERY 30000 21 999 Years 6.56 $26.7305 $175.35 1/1/2016 0.00 $175.35 3.39 $26.7305 $90.62 1/1/2016 0.00 $90.62 1/1/2016

2 SURGERY 30020 0 20 Years 6.64 $28.0672 $186.37 1/1/2016 0.00 $186.37 3.42 $28.0672 $95.99 1/1/2016 0.00 $95.99 1/1/2016

2 SURGERY 30020 21 999 Years 6.64 $26.7305 $177.49 1/1/2016 0.00 $177.49 3.42 $26.7305 $91.42 1/1/2016 0.00 $91.42 1/1/2016

2 SURGERY 30120 0 20 Years 14.79 $28.0672 $415.11 1/1/2016 0.00 $415.11 12.47 $28.0672 $350.00 1/1/2016 0.00 $350.00 1/1/2016

2 SURGERY 30120 21 999 Years 14.79 $26.7305 $395.34 1/1/2016 0.00 $395.34 12.47 $26.7305 $333.33 1/1/2016 0.00 $333.33 1/1/2016

2 SURGERY 30124 0 20 Years 8.13 $28.0672 $228.19 1/1/2016 0.00 $228.19 8.13 $28.0672 $228.19 1/1/2016 0.00 $228.19 1/1/2016

2 SURGERY 30124 21 999 Years 8.13 $26.7305 $217.32 1/1/2016 0.00 $217.32 8.13 $26.7305 $217.32 1/1/2016 0.00 $217.32 1/1/2016

2 SURGERY 30125 0 20 Years 17.34 $28.0672 $486.69 1/1/2016 0.00 $486.69 17.34 $28.0672 $486.69 1/1/2016 0.00 $486.69 1/1/2016

2 SURGERY 30125 21 999 Years 17.34 $26.7305 $463.51 1/1/2016 0.00 $463.51 17.34 $26.7305 $463.51 1/1/2016 0.00 $463.51 1/1/2016

2 SURGERY 30150 0 20 Years 21.94 $28.0672 $615.79 1/1/2016 0.00 $615.79 21.94 $28.0672 $615.79 1/1/2016 0.00 $615.79 1/1/2016

2 SURGERY 30150 21 999 Years 21.94 $26.7305 $586.47 1/1/2016 0.00 $586.47 21.94 $26.7305 $586.47 1/1/2016 0.00 $586.47 1/1/2016

2 SURGERY 30160 0 20 Years 22.07 $28.0672 $619.44 1/1/2016 0.00 $619.44 22.07 $28.0672 $619.44 1/1/2016 0.00 $619.44 1/1/2016

2 SURGERY 30160 21 999 Years 22.07 $26.7305 $589.94 1/1/2016 0.00 $589.94 22.07 $26.7305 $589.94 1/1/2016 0.00 $589.94 1/1/2016

2 SURGERY 30200 0 20 Years 3.24 $28.0672 $90.94 1/1/2016 0.00 $90.94 1.71 $28.0672 $47.99 1/1/2016 0.00 $47.99 1/1/2016

2 SURGERY 30200 21 999 Years 3.24 $26.7305 $86.61 1/1/2016 0.00 $86.61 1.71 $26.7305 $45.71 1/1/2016 0.00 $45.71 1/1/2016

2 SURGERY 30300 0 20 Years 6.57 $28.0672 $184.40 1/1/2016 0.00 $184.40 3.61 $28.0672 $101.32 1/1/2016 0.00 $101.32 1/1/2016

2 SURGERY 30300 21 999 Years 6.57 $26.7305 $175.62 1/1/2016 0.00 $175.62 3.61 $26.7305 $96.50 1/1/2016 0.00 $96.50 1/1/2016

2 SURGERY 30310 0 20 Years 5.85 $28.0672 $164.19 1/1/2016 0.00 $164.19 5.85 $28.0672 $164.19 1/1/2016 0.00 $164.19 1/1/2016

2 SURGERY 30310 21 999 Years 5.85 $26.7305 $156.37 1/1/2016 0.00 $156.37 5.85 $26.7305 $156.37 1/1/2016 0.00 $156.37 1/1/2016

2 SURGERY 30400 0 20 Years 28.68 $28.0672 $804.97 1/1/2016 0.00 $804.97 28.68 $28.0672 $804.97 1/1/2016 0.00 $804.97 1/1/2016

2 SURGERY 30400 21 999 Years 28.68 $26.7305 $766.63 1/1/2016 0.00 $766.63 28.68 $26.7305 $766.63 1/1/2016 0.00 $766.63 1/1/2016

2 SURGERY 30410 0 20 Years 33.67 $28.0672 $945.02 1/1/2016 0.00 $945.02 10 33.67 $28.0672 $945.02 1/1/2016 0.00 $945.02 10 1/1/2016

2 SURGERY 30410 21 999 Years 33.67 $26.7305 $900.02 1/1/2016 0.00 $900.02 10 33.67 $26.7305 $900.02 1/1/2016 0.00 $900.02 10 1/1/2016

2 SURGERY 30420 0 20 Years 39.18 $28.0672 $1,099.67 1/1/2016 0.00 $1,099.67 39.18 $28.0672 $1,099.67 1/1/2016 0.00 $1,099.67 1/1/2016

2 SURGERY 30420 21 999 Years 39.18 $26.7305 $1,047.30 1/1/2016 0.00 $1,047.30 39.18 $26.7305 $1,047.30 1/1/2016 0.00 $1,047.30 1/1/2016

2 SURGERY 30430 0 20 Years 24.68 $28.0672 $692.70 1/1/2016 0.00 $692.70 10 24.68 $28.0672 $692.70 1/1/2016 0.00 $692.70 10 1/1/2016

2 SURGERY 30430 21 999 Years 24.68 $26.7305 $659.71 1/1/2016 0.00 $659.71 10 24.68 $26.7305 $659.71 1/1/2016 0.00 $659.71 10 1/1/2016

2 SURGERY 30435 0 20 Years 35.56 $28.0672 $998.07 1/1/2016 0.00 $998.07 35.56 $28.0672 $998.07 1/1/2016 0.00 $998.07 1/1/2016

2 SURGERY 30435 21 999 Years 35.56 $26.7305 $950.54 1/1/2016 0.00 $950.54 35.56 $26.7305 $950.54 1/1/2016 0.00 $950.54 1/1/2016

2 SURGERY 30450 0 20 Years 42.67 $28.0672 $1,197.63 1/1/2016 0.00 $1,197.63 10 42.67 $28.0672 $1,197.63 1/1/2016 0.00 $1,197.63 10 1/1/2016

2 SURGERY 30450 21 999 Years 42.67 $26.7305 $1,140.59 1/1/2016 0.00 $1,140.59 10 42.67 $26.7305 $1,140.59 1/1/2016 0.00 $1,140.59 10 1/1/2016

2 SURGERY 30460 0 20 Years 23.22 $28.0672 $651.72 1/1/2016 0.00 $651.72 10 23.22 $28.0672 $651.72 1/1/2016 0.00 $651.72 10 1/1/2016

2 SURGERY 30460 21 999 Years 23.22 $26.7305 $620.68 1/1/2016 0.00 $620.68 10 23.22 $26.7305 $620.68 1/1/2016 0.00 $620.68 10 1/1/2016

2 SURGERY 30462 0 20 Years 40.40 $28.0672 $1,133.91 1/1/2016 0.00 $1,133.91 10 40.40 $28.0672 $1,133.91 1/1/2016 0.00 $1,133.91 10 1/1/2016

2 SURGERY 30462 21 999 Years 40.40 $26.7305 $1,079.91 1/1/2016 0.00 $1,079.91 10 40.40 $26.7305 $1,079.91 1/1/2016 0.00 $1,079.91 10 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 30465 0 20 Years 27.99 $28.0672 $785.60 1/1/2016 0.00 $785.60 1/1/2016

2 SURGERY 30465 21 999 Years 27.99 $26.7305 $748.19 1/1/2016 0.00 $748.19 1/1/2016

2 SURGERY 30520 0 20 Years 17.78 $28.0672 $499.03 1/1/2016 0.00 $499.03 17.78 $28.0672 $499.03 1/1/2016 0.00 $499.03 1/1/2016

2 SURGERY 30520 21 999 Years 17.78 $26.7305 $475.27 1/1/2016 0.00 $475.27 17.78 $26.7305 $475.27 1/1/2016 0.00 $475.27 1/1/2016

2 SURGERY 30580 0 20 Years 18.71 $28.0672 $525.14 1/1/2016 0.00 $525.14 14.68 $28.0672 $412.03 1/1/2016 0.00 $412.03 1/1/2016

2 SURGERY 30580 21 999 Years 18.71 $26.7305 $500.13 1/1/2016 0.00 $500.13 14.68 $26.7305 $392.40 1/1/2016 0.00 $392.40 1/1/2016

2 SURGERY 30600 0 20 Years 16.29 $28.0672 $457.21 1/1/2016 0.00 $457.21 12.23 $28.0672 $343.26 1/1/2016 0.00 $343.26 1/1/2016

2 SURGERY 30600 21 999 Years 16.29 $26.7305 $435.44 1/1/2016 0.00 $435.44 12.23 $26.7305 $326.91 1/1/2016 0.00 $326.91 1/1/2016

2 SURGERY 30620 0 20 Years 17.80 $28.0672 $499.60 1/1/2016 0.00 $499.60 17.80 $28.0672 $499.60 1/1/2016 0.00 $499.60 1/1/2016

2 SURGERY 30620 21 999 Years 17.80 $26.7305 $475.80 1/1/2016 0.00 $475.80 17.80 $26.7305 $475.80 1/1/2016 0.00 $475.80 1/1/2016

2 SURGERY 30630 0 20 Years 17.86 $28.0672 $501.28 1/1/2016 0.00 $501.28 17.86 $28.0672 $501.28 1/1/2016 0.00 $501.28 1/1/2016

2 SURGERY 30630 21 999 Years 17.86 $26.7305 $477.41 1/1/2016 0.00 $477.41 17.86 $26.7305 $477.41 1/1/2016 0.00 $477.41 1/1/2016

2 SURGERY 30801 0 20 Years 6.52 $28.0672 $183.00 1/1/2016 0.00 $183.00 3.91 $28.0672 $109.74 1/1/2016 0.00 $109.74 1/1/2016

2 SURGERY 30801 21 999 Years 6.52 $26.7305 $174.28 1/1/2016 0.00 $174.28 3.91 $26.7305 $104.52 1/1/2016 0.00 $104.52 1/1/2016

2 SURGERY 30802 0 20 Years 8.29 $28.0672 $232.68 1/1/2016 0.00 $232.68 5.45 $28.0672 $152.97 1/1/2016 0.00 $152.97 1/1/2016

2 SURGERY 30802 21 999 Years 8.29 $26.7305 $221.60 1/1/2016 0.00 $221.60 5.45 $26.7305 $145.68 1/1/2016 0.00 $145.68 1/1/2016

2 SURGERY 30901 0 20 Years 2.72 $28.0672 $76.34 1/1/2016 0.00 $76.34 1.63 $28.0672 $45.75 1/1/2016 0.00 $45.75 1/1/2016

2 SURGERY 30901 21 999 Years 2.72 $26.7305 $72.71 1/1/2016 0.00 $72.71 1.63 $26.7305 $43.57 1/1/2016 0.00 $43.57 1/1/2016

2 SURGERY 30903 0 20 Years 5.87 $28.0672 $164.75 1/1/2016 0.00 $164.75 2.28 $28.0672 $63.99 1/1/2016 0.00 $63.99 1/1/2016

2 SURGERY 30903 21 999 Years 5.87 $26.7305 $156.91 1/1/2016 0.00 $156.91 2.28 $26.7305 $60.95 1/1/2016 0.00 $60.95 1/1/2016

2 SURGERY 30905 0 20 Years 7.34 $28.0672 $206.01 1/1/2016 0.00 $206.01 2.88 $28.0672 $80.83 1/1/2016 0.00 $80.83 1/1/2016

2 SURGERY 30905 21 999 Years 7.34 $26.7305 $196.20 1/1/2016 0.00 $196.20 2.88 $26.7305 $76.98 1/1/2016 0.00 $76.98 1/1/2016

2 SURGERY 30906 0 20 Years 8.00 $28.0672 $224.54 1/1/2016 0.00 $224.54 3.77 $28.0672 $105.81 1/1/2016 0.00 $105.81 1/1/2016

2 SURGERY 30906 21 999 Years 8.00 $26.7305 $213.84 1/1/2016 0.00 $213.84 3.77 $26.7305 $100.77 1/1/2016 0.00 $100.77 1/1/2016

2 SURGERY 30930 0 20 Years 3.52 $28.0672 $98.80 1/1/2016 0.00 $98.80 3.52 $28.0672 $98.80 1/1/2016 0.00 $98.80 1/1/2016

2 SURGERY 30930 21 999 Years 3.52 $26.7305 $94.09 1/1/2016 0.00 $94.09 3.52 $26.7305 $94.09 1/1/2016 0.00 $94.09 1/1/2016

2 SURGERY 30999 0 999 Years 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 5 0.00 $0.0000 $0.00 1/1/2010 -2.00 $0.00 5 1/1/2016

2 SURGERY 31020 0 20 Years 13.89 $28.0672 $389.85 1/1/2016 0.00 $389.85 10.30 $28.0672 $289.09 1/1/2016 0.00 $289.09 1/1/2016

2 SURGERY 31020 21 999 Years 13.89 $26.7305 $371.29 1/1/2016 0.00 $371.29 10.30 $26.7305 $275.32 1/1/2016 0.00 $275.32 1/1/2016

2 SURGERY 31030 0 20 Years 15.15 $28.0672 $425.22 1/1/2016 0.00 $425.22 1/1/2016

2 SURGERY 31030 21 999 Years 15.15 $26.7305 $404.97 1/1/2016 0.00 $404.97 1/1/2016

2 SURGERY 31032 0 20 Years 16.40 $28.0672 $460.30 1/1/2016 0.00 $460.30 1/1/2016

2 SURGERY 31032 21 999 Years 16.40 $26.7305 $438.38 1/1/2016 0.00 $438.38 1/1/2016

2 SURGERY 31080 0 20 Years 29.38 $28.0672 $824.61 1/1/2016 0.00 $824.61 1/1/2016

2 SURGERY 31080 21 999 Years 29.38 $26.7305 $785.34 1/1/2016 0.00 $785.34 1/1/2016

2 SURGERY 31081 0 20 Years 43.63 $28.0672 $1,224.57 1/1/2016 0.00 $1,224.57 1/1/2016

2 SURGERY 31081 21 999 Years 43.63 $26.7305 $1,166.25 1/1/2016 0.00 $1,166.25 1/1/2016

2 SURGERY 31084 0 20 Years 32.87 $28.0672 $922.57 1/1/2016 0.00 $922.57 1/1/2016

2 SURGERY 31084 21 999 Years 32.87 $26.7305 $878.63 1/1/2016 0.00 $878.63 1/1/2016

2 SURGERY 31085 0 20 Years 41.98 $28.0672 $1,178.26 1/1/2016 0.00 $1,178.26 1/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 31085 21 999 Years 41.98 $26.7305 $1,122.15 1/1/2016 0.00 $1,122.15 1/1/2016

2 SURGERY 31086 0 20 Years 31.96 $28.0672 $897.03 1/1/2016 0.00 $897.03 1/1/2016

2 SURGERY 31086 21 999 Years 31.96 $26.7305 $854.31 1/1/2016 0.00 $854.31 1/1/2016

2 SURGERY 31087 0 20 Years 30.86 $28.0672 $866.15 1/1/2016 0.00 $866.15 1/1/2016

2 SURGERY 31087 21 999 Years 30.86 $26.7305 $824.90 1/1/2016 0.00 $824.90 1/1/2016

2 SURGERY 31225 0 20 Years 53.65 $28.0672 $1,505.81 1/1/2016 0.00 $1,505.81 53.65 $28.0672 $1,505.81 1/1/2016 0.00 $1,505.81 1/1/2016

2 SURGERY 31225 21 999 Years 53.65 $26.7305 $1,434.09 1/1/2016 0.00 $1,434.09 53.65 $26.7305 $1,434.09 1/1/2016 0.00 $1,434.09 1/1/2016

2 SURGERY 31230 0 20 Years 59.37 $28.0672 $1,666.35 1/1/2016 0.00 $1,666.35 1/1/2016

2 SURGERY 31230 21 999 Years 59.37 $26.7305 $1,586.99 1/1/2016 0.00 $1,586.99 1/1/2016

2 SURGERY 31600 0 20 Years 11.49 $28.0672 $322.49 1/1/2016 0.00 $322.49 11.49 $28.0672 $322.49 1/1/2016 0.00 $322.49 1/1/2016

2 SURGERY 31600 21 999 Years 11.49 $26.7305 $307.13 1/1/2016 0.00 $307.13 11.49 $26.7305 $307.13 1/1/2016 0.00 $307.13 1/1/2016

2 SURGERY 31603 0 20 Years 6.46 $28.0672 $181.31 1/1/2016 0.00 $181.31 6.46 $28.0672 $181.31 1/1/2016 0.00 $181.31 1/1/2016

2 SURGERY 31603 21 999 Years 6.46 $26.7305 $172.68 1/1/2016 0.00 $172.68 6.46 $26.7305 $172.68 1/1/2016 0.00 $172.68 1/1/2016

2 SURGERY 31605 0 20 Years 5.32 $28.0672 $149.32 1/1/2016 0.00 $149.32 5.32 $28.0672 $149.32 1/1/2016 0.00 $149.32 1/1/2016

2 SURGERY 31605 21 999 Years 5.32 $26.7305 $142.21 1/1/2016 0.00 $142.21 5.32 $26.7305 $142.21 1/1/2016 0.00 $142.21 1/1/2016

2 SURGERY 31830 0 20 Years 12.68 $28.0672 $355.89 1/1/2016 0.00 $355.89 9.84 $28.0672 $276.18 1/1/2016 0.00 $276.18 1/1/2016

2 SURGERY 31830 21 999 Years 12.68 $26.7305 $338.94 1/1/2016 0.00 $338.94 9.84 $26.7305 $263.03 1/1/2016 0.00 $263.03 1/1/2016

2 SURGERY 40490 0 20 Years 3.68 $28.0672 $103.29 4/1/2016 0.00 $103.29 2.11 $28.0672 $59.22 4/1/2014 0.00 $59.22 4/1/2016

2 SURGERY 40490 21 999 Years 3.68 $26.7305 $98.37 4/1/2016 0.00 $98.37 2.11 $26.7305 $56.40 4/1/2014 0.00 $56.40 4/1/2016

2 SURGERY 40500 0 20 Years 14.56 $28.0672 $408.66 4/1/2016 0.00 $408.66 10.52 $28.0672 $295.27 4/1/2016 0.00 $295.27 4/1/2016

2 SURGERY 40500 21 999 Years 14.56 $26.7305 $389.20 4/1/2016 0.00 $389.20 10.52 $26.7305 $281.20 4/1/2016 0.00 $281.20 4/1/2016

2 SURGERY 40510 0 20 Years 13.97 $28.0672 $392.10 4/1/2016 0.00 $392.10 10.33 $28.0672 $289.93 4/1/2016 0.00 $289.93 4/1/2016

2 SURGERY 40510 21 999 Years 13.97 $26.7305 $373.43 4/1/2016 0.00 $373.43 10.33 $26.7305 $276.13 4/1/2016 0.00 $276.13 4/1/2016

2 SURGERY 40520 0 20 Years 14.12 $28.0672 $396.31 4/1/2016 0.00 $396.31 10.40 $28.0672 $291.90 4/1/2016 0.00 $291.90 4/1/2016

2 SURGERY 40520 21 999 Years 14.12 $26.7305 $377.43 4/1/2016 0.00 $377.43 10.40 $26.7305 $278.00 4/1/2016 0.00 $278.00 4/1/2016

2 SURGERY 40525 0 20 Years 15.93 $28.0672 $447.11 4/1/2016 0.00 $447.11 15.93 $28.0672 $447.11 4/1/2016 0.00 $447.11 4/1/2016

2 SURGERY 40525 21 999 Years 15.93 $26.7305 $425.82 4/1/2016 0.00 $425.82 15.93 $26.7305 $425.82 4/1/2016 0.00 $425.82 4/1/2016

2 SURGERY 40527 0 20 Years 17.87 $28.0672 $501.56 4/1/2016 0.00 $501.56 17.87 $28.0672 $501.56 4/1/2016 0.00 $501.56 4/1/2016

2 SURGERY 40527 21 999 Years 17.87 $26.7305 $477.67 4/1/2016 0.00 $477.67 17.87 $26.7305 $477.67 4/1/2016 0.00 $477.67 4/1/2016

2 SURGERY 40530 0 20 Years 15.55 $28.0672 $436.44 4/1/2016 0.00 $436.44 11.67 $28.0672 $327.54 4/1/2016 0.00 $327.54 4/1/2016

2 SURGERY 40530 21 999 Years 15.55 $26.7305 $415.66 4/1/2016 0.00 $415.66 11.67 $26.7305 $311.94 4/1/2016 0.00 $311.94 4/1/2016

2 SURGERY 40650 0 20 Years 12.59 $28.0672 $353.37 4/1/2016 0.00 $353.37 8.62 $28.0672 $241.94 4/1/2016 0.00 $241.94 4/1/2016

2 SURGERY 40650 21 999 Years 12.59 $26.7305 $336.54 4/1/2016 0.00 $336.54 8.62 $26.7305 $230.42 4/1/2016 0.00 $230.42 4/1/2016

2 SURGERY 40652 0 20 Years 14.18 $28.0672 $397.99 4/1/2016 0.00 $397.99 10.27 $28.0672 $288.25 4/1/2016 0.00 $288.25 4/1/2016

2 SURGERY 40652 21 999 Years 14.18 $26.7305 $379.04 4/1/2016 0.00 $379.04 10.27 $26.7305 $274.52 4/1/2016 0.00 $274.52 4/1/2016

2 SURGERY 40654 0 20 Years 16.37 $28.0672 $459.46 4/1/2016 0.00 $459.46 12.28 $28.0672 $344.67 4/1/2016 0.00 $344.67 4/1/2016

2 SURGERY 40654 21 999 Years 16.37 $26.7305 $437.58 4/1/2016 0.00 $437.58 12.28 $26.7305 $328.25 4/1/2016 0.00 $328.25 4/1/2016

2 SURGERY 40700 0 20 Years 29.07 $28.0672 $815.91 4/1/2016 0.00 $815.91 29.07 $28.0672 $815.91 4/1/2016 0.00 $815.91 4/1/2016

2 SURGERY 40700 21 999 Years 29.07 $26.7305 $777.06 4/1/2016 0.00 $777.06 29.07 $26.7305 $777.06 4/1/2016 0.00 $777.06 4/1/2016

2 SURGERY 40701 0 20 Years 28.23 $28.0672 $792.34 4/1/2016 0.00 $792.34 28.23 $28.0672 $792.34 4/1/2016 0.00 $792.34 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 40701 21 999 Years 28.23 $26.7305 $754.60 4/1/2016 0.00 $754.60 28.23 $26.7305 $754.60 4/1/2016 0.00 $754.60 4/1/2016

2 SURGERY 40702 0 20 Years 27.15 $28.0672 $762.02 4/1/2016 0.00 $762.02 27.15 $28.0672 $762.02 4/1/2016 0.00 $762.02 4/1/2016

2 SURGERY 40702 21 999 Years 27.15 $26.7305 $725.73 4/1/2016 0.00 $725.73 27.15 $26.7305 $725.73 4/1/2016 0.00 $725.73 4/1/2016

2 SURGERY 40720 0 20 Years 29.71 $28.0672 $833.88 4/1/2016 0.00 $833.88 29.71 $28.0672 $833.88 4/1/2016 0.00 $833.88 4/1/2016

2 SURGERY 40720 21 999 Years 29.71 $26.7305 $794.16 4/1/2016 0.00 $794.16 29.71 $26.7305 $794.16 4/1/2016 0.00 $794.16 4/1/2016

2 SURGERY 40761 0 20 Years 28.22 $28.0672 $792.06 4/1/2016 0.00 $792.06 28.22 $28.0672 $792.06 4/1/2016 0.00 $792.06 4/1/2016

2 SURGERY 40761 21 999 Years 28.22 $26.7305 $754.33 4/1/2016 0.00 $754.33 28.22 $26.7305 $754.33 4/1/2016 0.00 $754.33 4/1/2016

2 SURGERY 40799 0 999 Years 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 4/1/2016

2 SURGERY 40800 0 20 Years 6.17 $28.0672 $173.17 4/1/2016 0.00 $173.17 3.87 $28.0672 $108.62 4/1/2016 0.00 $108.62 4/1/2016

2 SURGERY 40800 21 999 Years 6.17 $26.7305 $164.93 4/1/2016 0.00 $164.93 3.87 $26.7305 $103.45 4/1/2016 0.00 $103.45 4/1/2016

2 SURGERY 40801 0 20 Years 9.24 $28.0672 $259.34 4/1/2016 0.00 $259.34 6.54 $28.0672 $183.56 4/1/2016 0.00 $183.56 4/1/2016

2 SURGERY 40801 21 999 Years 9.24 $26.7305 $246.99 4/1/2016 0.00 $246.99 6.54 $26.7305 $174.82 4/1/2016 0.00 $174.82 4/1/2016

2 SURGERY 40804 0 20 Years 6.17 $28.0672 $173.17 4/1/2016 0.00 $173.17 3.84 $28.0672 $107.78 4/1/2016 0.00 $107.78 4/1/2016

2 SURGERY 40804 21 999 Years 6.17 $26.7305 $164.93 4/1/2016 0.00 $164.93 3.84 $26.7305 $102.65 4/1/2016 0.00 $102.65 4/1/2016

2 SURGERY 40805 0 20 Years 9.43 $28.0672 $264.67 4/1/2016 0.00 $264.67 6.86 $28.0672 $192.54 4/1/2016 0.00 $192.54 4/1/2016

2 SURGERY 40805 21 999 Years 9.43 $26.7305 $252.07 4/1/2016 0.00 $252.07 6.86 $26.7305 $183.37 4/1/2016 0.00 $183.37 4/1/2016

2 SURGERY 40806 0 20 Years 3.13 $28.0672 $87.85 4/1/2016 0.00 $87.85 0.97 $28.0672 $27.23 4/1/2016 0.00 $27.23 4/1/2016

2 SURGERY 40806 21 999 Years 3.13 $26.7305 $83.67 4/1/2016 0.00 $83.67 0.97 $26.7305 $25.93 4/1/2016 0.00 $25.93 4/1/2016

2 SURGERY 40808 0 20 Years 5.44 $28.0672 $152.69 4/1/2016 0.00 $152.69 3.19 $28.0672 $89.53 4/1/2016 0.00 $89.53 4/1/2016

2 SURGERY 40808 21 999 Years 5.44 $26.7305 $145.41 4/1/2016 0.00 $145.41 3.19 $26.7305 $85.27 4/1/2016 0.00 $85.27 4/1/2016

2 SURGERY 40810 0 20 Years 6.01 $28.0672 $168.68 4/1/2016 0.00 $168.68 3.76 $28.0672 $105.53 4/1/2016 0.00 $105.53 4/1/2016

2 SURGERY 40810 21 999 Years 6.01 $26.7305 $160.65 4/1/2016 0.00 $160.65 3.76 $26.7305 $100.51 4/1/2016 0.00 $100.51 4/1/2016

2 SURGERY 40812 0 20 Years 8.42 $28.0672 $236.33 4/1/2016 0.00 $236.33 5.81 $28.0672 $163.07 4/1/2016 0.00 $163.07 4/1/2016

2 SURGERY 40812 21 999 Years 8.42 $26.7305 $225.07 4/1/2016 0.00 $225.07 5.81 $26.7305 $155.30 4/1/2016 0.00 $155.30 4/1/2016

2 SURGERY 40814 0 20 Years 11.27 $28.0672 $316.32 4/1/2016 0.00 $316.32 8.96 $28.0672 $251.48 4/1/2016 0.00 $251.48 4/1/2016

2 SURGERY 40814 21 999 Years 11.27 $26.7305 $301.25 4/1/2016 0.00 $301.25 8.96 $26.7305 $239.51 4/1/2016 0.00 $239.51 4/1/2016

2 SURGERY 40816 0 20 Years 11.74 $28.0672 $329.51 4/1/2016 0.00 $329.51 9.29 $28.0672 $260.74 4/1/2016 0.00 $260.74 4/1/2016

2 SURGERY 40816 21 999 Years 11.74 $26.7305 $313.82 4/1/2016 0.00 $313.82 9.29 $26.7305 $248.33 4/1/2016 0.00 $248.33 4/1/2016

2 SURGERY 40818 0 20 Years 10.48 $28.0672 $294.14 4/1/2016 0.00 $294.14 7.99 $28.0672 $224.26 4/1/2016 0.00 $224.26 4/1/2016

2 SURGERY 40818 21 999 Years 10.48 $26.7305 $280.14 4/1/2016 0.00 $280.14 7.99 $26.7305 $213.58 4/1/2016 0.00 $213.58 4/1/2016

2 SURGERY 40819 0 20 Years 9.17 $28.0672 $257.38 4/1/2016 0.00 $257.38 7.00 $28.0672 $196.47 4/1/2016 0.00 $196.47 4/1/2016

2 SURGERY 40819 21 999 Years 9.17 $26.7305 $245.12 4/1/2016 0.00 $245.12 7.00 $26.7305 $187.11 4/1/2016 0.00 $187.11 4/1/2016

2 SURGERY 40820 0 20 Years 7.74 $28.0672 $217.24 4/1/2016 0.00 $217.24 5.04 $28.0672 $141.46 4/1/2016 0.00 $141.46 4/1/2016

2 SURGERY 40820 21 999 Years 7.74 $26.7305 $206.89 4/1/2016 0.00 $206.89 5.04 $26.7305 $134.72 4/1/2016 0.00 $134.72 4/1/2016

2 SURGERY 40830 0 20 Years 7.74 $28.0672 $217.24 4/1/2016 0.00 $217.24 4.87 $28.0672 $136.69 4/1/2016 0.00 $136.69 4/1/2016

2 SURGERY 40830 21 999 Years 7.74 $26.7305 $206.89 4/1/2016 0.00 $206.89 4.87 $26.7305 $130.18 4/1/2016 0.00 $130.18 4/1/2016

2 SURGERY 40831 0 20 Years 9.81 $28.0672 $275.34 4/1/2016 0.00 $275.34 6.56 $28.0672 $184.12 4/1/2016 0.00 $184.12 4/1/2016

2 SURGERY 40831 21 999 Years 9.81 $26.7305 $262.23 4/1/2016 0.00 $262.23 6.56 $26.7305 $175.35 4/1/2016 0.00 $175.35 4/1/2016

2 SURGERY 40840 0 20 Years 23.60 $28.0672 $662.39 4/1/2016 0.00 $662.39 18.31 $28.0672 $513.91 4/1/2016 0.00 $513.91 4/1/2016

2 SURGERY 40840 21 999 Years 23.60 $26.7305 $630.84 4/1/2016 0.00 $630.84 18.31 $26.7305 $489.44 4/1/2016 0.00 $489.44 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 40842 0 20 Years 23.82 $28.0672 $668.56 4/1/2016 0.00 $668.56 19.05 $28.0672 $534.68 4/1/2016 0.00 $534.68 4/1/2016

2 SURGERY 40842 21 999 Years 23.82 $26.7305 $636.72 4/1/2016 0.00 $636.72 19.05 $26.7305 $509.22 4/1/2016 0.00 $509.22 4/1/2016

2 SURGERY 40843 0 20 Years 31.63 $28.0672 $887.77 4/1/2016 0.00 $887.77 25.12 $28.0672 $705.05 4/1/2016 0.00 $705.05 4/1/2016

2 SURGERY 40843 21 999 Years 31.63 $26.7305 $845.49 4/1/2016 0.00 $845.49 25.12 $26.7305 $671.47 4/1/2016 0.00 $671.47 4/1/2016

2 SURGERY 40844 0 20 Years 37.49 $28.0672 $1,052.24 4/1/2016 0.00 $1,052.24 30.56 $28.0672 $857.73 4/1/2016 0.00 $857.73 4/1/2016

2 SURGERY 40844 21 999 Years 37.49 $26.7305 $1,002.13 4/1/2016 0.00 $1,002.13 30.56 $26.7305 $816.88 4/1/2016 0.00 $816.88 4/1/2016

2 SURGERY 40845 0 20 Years 42.53 $28.0672 $1,193.70 4/1/2016 0.00 $1,193.70 35.79 $28.0672 $1,004.53 4/1/2016 0.00 $1,004.53 4/1/2016

2 SURGERY 40845 21 999 Years 42.53 $26.7305 $1,136.85 4/1/2016 0.00 $1,136.85 35.79 $26.7305 $956.68 4/1/2016 0.00 $956.68 4/1/2016

2 SURGERY 40899 0 999 Years 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 4/1/2016

2 SURGERY 41000 0 20 Years 4.74 $28.0672 $133.04 4/1/2016 0.00 $133.04 3.30 $28.0672 $92.62 4/1/2016 0.00 $92.62 4/1/2016

2 SURGERY 41000 21 999 Years 4.74 $26.7305 $126.70 4/1/2016 0.00 $126.70 3.30 $26.7305 $88.21 4/1/2016 0.00 $88.21 4/1/2016

2 SURGERY 41005 0 20 Years 6.59 $28.0672 $184.96 4/1/2016 0.00 $184.96 3.66 $28.0672 $102.73 4/1/2016 0.00 $102.73 4/1/2016

2 SURGERY 41005 21 999 Years 6.59 $26.7305 $176.15 4/1/2016 0.00 $176.15 3.66 $26.7305 $97.83 4/1/2016 0.00 $97.83 4/1/2016

2 SURGERY 41006 0 20 Years 11.18 $28.0672 $313.79 4/1/2016 0.00 $313.79 7.84 $28.0672 $220.05 4/1/2016 0.00 $220.05 4/1/2016

2 SURGERY 41006 21 999 Years 11.18 $26.7305 $298.85 4/1/2016 0.00 $298.85 7.84 $26.7305 $209.57 4/1/2016 0.00 $209.57 4/1/2016

2 SURGERY 41007 0 20 Years 11.00 $28.0672 $308.74 4/1/2016 0.00 $308.74 7.61 $28.0672 $213.59 4/1/2016 0.00 $213.59 4/1/2016

2 SURGERY 41007 21 999 Years 11.00 $26.7305 $294.04 4/1/2016 0.00 $294.04 7.61 $26.7305 $203.42 4/1/2016 0.00 $203.42 4/1/2016

2 SURGERY 41008 0 20 Years 11.08 $28.0672 $310.98 4/1/2016 0.00 $310.98 7.91 $28.0672 $222.01 4/1/2016 0.00 $222.01 4/1/2016

2 SURGERY 41008 21 999 Years 11.08 $26.7305 $296.17 4/1/2016 0.00 $296.17 7.91 $26.7305 $211.44 4/1/2016 0.00 $211.44 4/1/2016

2 SURGERY 41009 0 20 Years 11.75 $28.0672 $329.79 4/1/2016 0.00 $329.79 8.59 $28.0672 $241.10 4/1/2016 0.00 $241.10 4/1/2016

2 SURGERY 41009 21 999 Years 11.75 $26.7305 $314.08 4/1/2016 0.00 $314.08 8.59 $26.7305 $229.61 4/1/2016 0.00 $229.61 4/1/2016

2 SURGERY 41010 0 20 Years 5.87 $28.0672 $164.75 4/1/2016 0.00 $164.75 3.16 $28.0672 $88.69 4/1/2014 0.00 $88.69 4/1/2016

2 SURGERY 41010 21 999 Years 5.87 $26.7305 $156.91 4/1/2016 0.00 $156.91 3.16 $26.7305 $84.47 4/1/2014 0.00 $84.47 4/1/2016

2 SURGERY 41015 0 20 Years 13.23 $28.0672 $371.33 4/1/2016 0.00 $371.33 10.29 $28.0672 $288.81 4/1/2016 0.00 $288.81 4/1/2016

2 SURGERY 41015 21 999 Years 13.23 $26.7305 $353.64 4/1/2016 0.00 $353.64 10.29 $26.7305 $275.06 4/1/2016 0.00 $275.06 4/1/2016

2 SURGERY 41016 0 20 Years 12.86 $28.0672 $360.94 4/1/2016 0.00 $360.94 10.32 $28.0672 $289.65 4/1/2016 0.00 $289.65 4/1/2016

2 SURGERY 41016 21 999 Years 12.86 $26.7305 $343.75 4/1/2016 0.00 $343.75 10.32 $26.7305 $275.86 4/1/2016 0.00 $275.86 4/1/2016

2 SURGERY 41017 0 20 Years 13.05 $28.0672 $366.28 4/1/2016 0.00 $366.28 10.40 $28.0672 $291.90 4/1/2016 0.00 $291.90 4/1/2016

2 SURGERY 41017 21 999 Years 13.05 $26.7305 $348.83 4/1/2016 0.00 $348.83 10.40 $26.7305 $278.00 4/1/2016 0.00 $278.00 4/1/2016

2 SURGERY 41018 0 20 Years 14.75 $28.0672 $413.99 4/1/2016 0.00 $413.99 12.09 $28.0672 $339.33 4/1/2016 0.00 $339.33 4/1/2016

2 SURGERY 41018 21 999 Years 14.75 $26.7305 $394.27 4/1/2016 0.00 $394.27 12.09 $26.7305 $323.17 4/1/2016 0.00 $323.17 4/1/2016

2 SURGERY 41100 0 20 Years 4.89 $28.0672 $137.25 4/1/2016 0.00 $137.25 3.16 $28.0672 $88.69 4/1/2016 0.00 $88.69 4/1/2016

2 SURGERY 41100 21 999 Years 4.89 $26.7305 $130.71 4/1/2016 0.00 $130.71 3.16 $26.7305 $84.47 4/1/2016 0.00 $84.47 4/1/2016

2 SURGERY 41105 0 20 Years 4.97 $28.0672 $139.49 4/1/2016 0.00 $139.49 3.27 $28.0672 $91.78 4/1/2016 0.00 $91.78 4/1/2016

2 SURGERY 41105 21 999 Years 4.97 $26.7305 $132.85 4/1/2016 0.00 $132.85 3.27 $26.7305 $87.41 4/1/2016 0.00 $87.41 4/1/2016

2 SURGERY 41108 0 20 Years 4.31 $28.0672 $120.97 4/1/2016 0.00 $120.97 2.65 $28.0672 $74.38 4/1/2016 0.00 $74.38 4/1/2016

2 SURGERY 41108 21 999 Years 4.31 $26.7305 $115.21 4/1/2016 0.00 $115.21 2.65 $26.7305 $70.84 4/1/2016 0.00 $70.84 4/1/2016

2 SURGERY 41110 0 20 Years 6.16 $28.0672 $172.89 4/1/2016 0.00 $172.89 3.86 $28.0672 $108.34 4/1/2016 0.00 $108.34 4/1/2016

2 SURGERY 41110 21 999 Years 6.16 $26.7305 $164.66 4/1/2016 0.00 $164.66 3.86 $26.7305 $103.18 4/1/2016 0.00 $103.18 4/1/2016

2 SURGERY 41112 0 20 Years 9.77 $28.0672 $274.22 4/1/2016 0.00 $274.22 7.42 $28.0672 $208.26 4/1/2016 0.00 $208.26 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 41112 21 999 Years 9.77 $26.7305 $261.16 4/1/2016 0.00 $261.16 7.42 $26.7305 $198.34 4/1/2016 0.00 $198.34 4/1/2016

2 SURGERY 41113 0 20 Years 10.70 $28.0672 $300.32 4/1/2016 0.00 $300.32 8.22 $28.0672 $230.71 4/1/2016 0.00 $230.71 4/1/2016

2 SURGERY 41113 21 999 Years 10.70 $26.7305 $286.02 4/1/2016 0.00 $286.02 8.22 $26.7305 $219.72 4/1/2016 0.00 $219.72 4/1/2016

2 SURGERY 41114 0 20 Years 18.56 $28.0672 $520.93 4/1/2016 0.00 $520.93 18.56 $28.0672 $520.93 4/1/2016 0.00 $520.93 4/1/2016

2 SURGERY 41114 21 999 Years 18.56 $26.7305 $496.12 4/1/2016 0.00 $496.12 18.56 $26.7305 $496.12 4/1/2016 0.00 $496.12 4/1/2016

2 SURGERY 41115 0 20 Years 7.17 $28.0672 $201.24 4/1/2014 0.00 $201.24 4.26 $28.0672 $119.57 4/1/2016 0.00 $119.57 4/1/2016

2 SURGERY 41115 21 999 Years 7.17 $26.7305 $191.66 4/1/2014 0.00 $191.66 4.26 $26.7305 $113.87 4/1/2016 0.00 $113.87 4/1/2016

2 SURGERY 41116 0 20 Years 9.63 $28.0672 $270.29 4/1/2016 0.00 $270.29 6.43 $28.0672 $180.47 4/1/2016 0.00 $180.47 4/1/2016

2 SURGERY 41116 21 999 Years 9.63 $26.7305 $257.41 4/1/2016 0.00 $257.41 6.43 $26.7305 $171.88 4/1/2016 0.00 $171.88 4/1/2016

2 SURGERY 41120 0 20 Years 30.45 $28.0672 $854.65 4/1/2016 0.00 $854.65 10 4/1/2016

2 SURGERY 41120 21 999 Years 30.45 $26.7305 $813.94 4/1/2016 0.00 $813.94 10 4/1/2016

2 SURGERY 41130 0 20 Years 37.69 $28.0672 $1,057.85 4/1/2016 0.00 $1,057.85 10 4/1/2016

2 SURGERY 41130 21 999 Years 37.69 $26.7305 $1,007.47 4/1/2016 0.00 $1,007.47 10 4/1/2016

2 SURGERY 41135 0 20 Years 62.57 $28.0672 $1,756.16 4/1/2016 0.00 $1,756.16 4/1/2016

2 SURGERY 41135 21 999 Years 62.57 $26.7305 $1,672.53 4/1/2016 0.00 $1,672.53 4/1/2016

2 SURGERY 41140 0 20 Years 62.87 $28.0672 $1,764.58 4/1/2016 0.00 $1,764.58 10 4/1/2016

2 SURGERY 41140 21 999 Years 62.87 $26.7305 $1,680.55 4/1/2016 0.00 $1,680.55 10 4/1/2016

2 SURGERY 41145 0 20 Years 79.56 $28.0672 $2,233.03 4/1/2016 0.00 $2,233.03 4/1/2016

2 SURGERY 41145 21 999 Years 79.56 $26.7305 $2,126.68 4/1/2016 0.00 $2,126.68 4/1/2016

2 SURGERY 41150 0 20 Years 63.17 $28.0672 $1,773.01 4/1/2016 0.00 $1,773.01 4/1/2016

2 SURGERY 41150 21 999 Years 63.17 $26.7305 $1,688.57 4/1/2016 0.00 $1,688.57 4/1/2016

2 SURGERY 41153 0 20 Years 68.97 $28.0672 $1,935.79 4/1/2016 0.00 $1,935.79 4/1/2016

2 SURGERY 41153 21 999 Years 68.97 $26.7305 $1,843.60 4/1/2016 0.00 $1,843.60 4/1/2016

2 SURGERY 41155 0 20 Years 86.81 $28.0672 $2,436.51 4/1/2016 0.00 $2,436.51 4/1/2016

2 SURGERY 41155 21 999 Years 86.81 $26.7305 $2,320.47 4/1/2016 0.00 $2,320.47 4/1/2016

2 SURGERY 41250 0 20 Years 7.81 $28.0672 $219.20 4/1/2016 0.00 $219.20 4.50 $28.0672 $126.30 4/1/2014 0.00 $126.30 4/1/2016

2 SURGERY 41250 21 999 Years 7.81 $26.7305 $208.77 4/1/2016 0.00 $208.77 4.50 $26.7305 $120.29 4/1/2014 0.00 $120.29 4/1/2016

2 SURGERY 41251 0 20 Years 8.50 $28.0672 $238.57 4/1/2016 0.00 $238.57 5.37 $28.0672 $150.72 4/1/2016 0.00 $150.72 4/1/2016

2 SURGERY 41251 21 999 Years 8.50 $26.7305 $227.21 4/1/2016 0.00 $227.21 5.37 $26.7305 $143.54 4/1/2016 0.00 $143.54 4/1/2016

2 SURGERY 41252 0 20 Years 9.17 $28.0672 $257.38 4/1/2016 0.00 $257.38 6.13 $28.0672 $172.05 4/1/2016 0.00 $172.05 4/1/2016

2 SURGERY 41252 21 999 Years 9.17 $26.7305 $245.12 4/1/2016 0.00 $245.12 6.13 $26.7305 $163.86 4/1/2016 0.00 $163.86 4/1/2016

2 SURGERY 41500 0 20 Years 13.27 $28.0672 $372.45 4/1/2016 0.00 $372.45 13.27 $28.0672 $372.45 4/1/2016 0.00 $372.45 4/1/2016

2 SURGERY 41500 21 999 Years 13.27 $26.7305 $354.71 4/1/2016 0.00 $354.71 13.27 $26.7305 $354.71 4/1/2016 0.00 $354.71 4/1/2016

2 SURGERY 41510 0 20 Years 11.59 $28.0672 $325.30 4/1/2016 0.00 $325.30 11.59 $28.0672 $325.30 4/1/2016 0.00 $325.30 4/1/2016

2 SURGERY 41510 21 999 Years 11.59 $26.7305 $309.81 4/1/2016 0.00 $309.81 11.59 $26.7305 $309.81 4/1/2016 0.00 $309.81 4/1/2016

2 SURGERY 41520 0 20 Years 10.35 $28.0672 $290.50 4/1/2016 0.00 $290.50 7.59 $28.0672 $213.03 4/1/2016 0.00 $213.03 4/1/2016

2 SURGERY 41520 21 999 Years 10.35 $26.7305 $276.66 4/1/2016 0.00 $276.66 7.59 $26.7305 $202.88 4/1/2016 0.00 $202.88 4/1/2016

2 SURGERY 41599 0 999 Years 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 4/1/2016

2 SURGERY 41800 0 20 Years 7.81 $28.0672 $219.20 4/1/2016 0.00 $219.20 4.27 $28.0672 $119.85 4/1/2016 0.00 $119.85 4/1/2016

2 SURGERY 41800 21 999 Years 7.81 $26.7305 $208.77 4/1/2016 0.00 $208.77 4.27 $26.7305 $114.14 4/1/2016 0.00 $114.14 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 41805 0 20 Years 7.25 $28.0672 $203.49 4/1/2016 0.00 $203.49 5.03 $28.0672 $141.18 4/1/2016 0.00 $141.18 4/1/2016

2 SURGERY 41805 21 999 Years 7.25 $26.7305 $193.80 4/1/2016 0.00 $193.80 5.03 $26.7305 $134.45 4/1/2016 0.00 $134.45 4/1/2016

2 SURGERY 41806 0 20 Years 10.39 $28.0672 $291.62 4/1/2016 0.00 $291.62 7.66 $28.0672 $214.99 4/1/2016 0.00 $214.99 4/1/2016

2 SURGERY 41806 21 999 Years 10.39 $26.7305 $277.73 4/1/2016 0.00 $277.73 7.66 $26.7305 $204.76 4/1/2016 0.00 $204.76 4/1/2016

2 SURGERY 41820 0 20 Years 0.00 $0.0000 $173.17 4/1/2016 0.00 $173.17 0.00 $0.0000 $101.04 4/1/2016 0.00 $101.04 4/1/2016

2 SURGERY 41820 21 999 Years 0.00 $0.0000 $164.93 4/1/2016 0.00 $164.93 0.00 $0.0000 $96.23 4/1/2016 0.00 $96.23 4/1/2016

2 SURGERY 41821 0 20 Years 0.00 $0.0000 $106.66 4/1/2016 0.00 $106.66 0.00 $0.0000 $82.24 4/1/2016 0.00 $82.24 4/1/2016

2 SURGERY 41821 21 999 Years 0.00 $0.0000 $101.58 4/1/2016 0.00 $101.58 0.00 $0.0000 $78.32 4/1/2016 0.00 $78.32 4/1/2016

2 SURGERY 41822 0 20 Years 9.06 $28.0672 $254.29 4/1/2016 0.00 $254.29 5.40 $28.0672 $151.56 4/1/2016 0.00 $151.56 4/1/2016

2 SURGERY 41822 21 999 Years 9.06 $26.7305 $242.18 4/1/2016 0.00 $242.18 5.40 $26.7305 $144.34 4/1/2016 0.00 $144.34 4/1/2016

2 SURGERY 41823 0 20 Years 13.26 $28.0672 $372.17 4/1/2016 0.00 $372.17 9.72 $28.0672 $272.81 4/1/2016 0.00 $272.81 4/1/2016

2 SURGERY 41823 21 999 Years 13.26 $26.7305 $354.45 4/1/2016 0.00 $354.45 9.72 $26.7305 $259.82 4/1/2016 0.00 $259.82 4/1/2016

2 SURGERY 41825 0 20 Years 6.17 $28.0672 $173.17 4/1/2016 0.00 $173.17 3.60 $28.0672 $101.04 4/1/2016 0.00 $101.04 4/1/2016

2 SURGERY 41825 21 999 Years 6.17 $26.7305 $164.93 4/1/2016 0.00 $164.93 3.60 $26.7305 $96.23 4/1/2016 0.00 $96.23 4/1/2016

2 SURGERY 41826 0 20 Years 9.22 $28.0672 $258.78 4/1/2016 0.00 $258.78 6.26 $28.0672 $175.70 4/1/2016 0.00 $175.70 4/1/2016

2 SURGERY 41826 21 999 Years 9.22 $26.7305 $246.46 4/1/2016 0.00 $246.46 6.26 $26.7305 $167.33 4/1/2016 0.00 $167.33 4/1/2016

2 SURGERY 41827 0 20 Years 12.95 $28.0672 $363.47 4/1/2016 0.00 $363.47 9.07 $28.0672 $254.57 4/1/2016 0.00 $254.57 4/1/2016

2 SURGERY 41827 21 999 Years 12.95 $26.7305 $346.16 4/1/2016 0.00 $346.16 9.07 $26.7305 $242.45 4/1/2016 0.00 $242.45 4/1/2016

2 SURGERY 41828 0 20 Years 9.00 $28.0672 $252.60 4/1/2016 0.00 $252.60 6.33 $28.0672 $177.67 4/1/2016 0.00 $177.67 4/1/2016

2 SURGERY 41828 21 999 Years 9.00 $26.7305 $240.57 4/1/2016 0.00 $240.57 6.33 $26.7305 $169.20 4/1/2016 0.00 $169.20 4/1/2016

2 SURGERY 41830 0 20 Years 11.54 $28.0672 $323.90 4/1/2016 0.00 $323.90 8.39 $28.0672 $235.48 4/1/2016 0.00 $235.48 4/1/2016

2 SURGERY 41830 21 999 Years 11.54 $26.7305 $308.47 4/1/2016 0.00 $308.47 8.39 $26.7305 $224.27 4/1/2016 0.00 $224.27 4/1/2016

2 SURGERY 41850 0 20 Years 0.00 $0.0000 $111.43 4/1/2016 0.00 $111.43 0.00 $0.0000 $72.69 4/1/2016 0.00 $72.69 4/1/2016

2 SURGERY 41850 21 999 Years 0.00 $0.0000 $106.12 4/1/2016 0.00 $106.12 0.00 $0.0000 $69.23 4/1/2016 0.00 $69.23 4/1/2016

2 SURGERY 41870 0 20 Years 0.00 $0.0000 $146.23 4/1/2016 0.00 $146.23 0.00 $0.0000 $97.67 4/1/2016 0.00 $97.67 4/1/2016

2 SURGERY 41870 21 999 Years 0.00 $0.0000 $139.27 4/1/2016 0.00 $139.27 0.00 $0.0000 $93.02 4/1/2016 0.00 $93.02 4/1/2016

2 SURGERY 41872 0 20 Years 10.92 $28.0672 $306.49 4/1/2016 0.00 $306.49 7.68 $28.0672 $215.56 4/1/2016 0.00 $215.56 4/1/2016

2 SURGERY 41872 21 999 Years 10.92 $26.7305 $291.90 4/1/2016 0.00 $291.90 7.68 $26.7305 $205.29 4/1/2016 0.00 $205.29 4/1/2016

2 SURGERY 41874 0 20 Years 11.05 $28.0672 $310.14 4/1/2016 0.00 $310.14 7.53 $28.0672 $211.35 4/1/2016 0.00 $211.35 4/1/2016

2 SURGERY 41874 21 999 Years 11.05 $26.7305 $295.37 4/1/2016 0.00 $295.37 7.53 $26.7305 $201.28 4/1/2016 0.00 $201.28 4/1/2016

2 SURGERY 41899 0 999 Years 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 4/1/2016

2 SURGERY 42000 0 20 Years 4.58 $28.0672 $128.55 4/1/2016 0.00 $128.55 3.02 $28.0672 $84.76 4/1/2016 0.00 $84.76 4/1/2016

2 SURGERY 42000 21 999 Years 4.58 $26.7305 $122.43 4/1/2016 0.00 $122.43 3.02 $26.7305 $80.73 4/1/2016 0.00 $80.73 4/1/2016

2 SURGERY 42100 0 20 Years 4.38 $28.0672 $122.93 4/1/2016 0.00 $122.93 3.21 $28.0672 $90.10 4/1/2016 0.00 $90.10 4/1/2016

2 SURGERY 42100 21 999 Years 4.38 $26.7305 $117.08 4/1/2016 0.00 $117.08 3.21 $26.7305 $85.80 4/1/2016 0.00 $85.80 4/1/2016

2 SURGERY 42104 0 20 Years 6.27 $28.0672 $175.98 4/1/2016 0.00 $175.98 4.08 $28.0672 $114.51 4/1/2016 0.00 $114.51 4/1/2016

2 SURGERY 42104 21 999 Years 6.27 $26.7305 $167.60 4/1/2016 0.00 $167.60 4.08 $26.7305 $109.06 4/1/2016 0.00 $109.06 4/1/2016

2 SURGERY 42106 0 20 Years 7.98 $28.0672 $223.98 4/1/2016 0.00 $223.98 5.25 $28.0672 $147.35 4/1/2016 0.00 $147.35 4/1/2016

2 SURGERY 42106 21 999 Years 7.98 $26.7305 $213.31 4/1/2016 0.00 $213.31 5.25 $26.7305 $140.34 4/1/2016 0.00 $140.34 4/1/2016

2 SURGERY 42107 0 20 Years 13.40 $28.0672 $376.10 4/1/2016 0.00 $376.10 10.10 $28.0672 $283.48 4/1/2016 0.00 $283.48 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 42107 21 999 Years 13.40 $26.7305 $358.19 4/1/2016 0.00 $358.19 10.10 $26.7305 $269.98 4/1/2016 0.00 $269.98 4/1/2016

2 SURGERY 42120 0 20 Years 28.89 $28.0672 $810.86 4/1/2016 0.00 $810.86 10 28.89 $28.0672 $810.86 4/1/2016 0.00 $810.86 10 4/1/2016

2 SURGERY 42120 21 999 Years 28.89 $26.7305 $772.24 4/1/2016 0.00 $772.24 10 28.89 $26.7305 $772.24 4/1/2016 0.00 $772.24 10 4/1/2016

2 SURGERY 42140 0 20 Years 7.33 $28.0672 $205.73 4/1/2016 0.00 $205.73 4.53 $28.0672 $127.14 4/1/2016 0.00 $127.14 4/1/2016

2 SURGERY 42140 21 999 Years 7.33 $26.7305 $195.93 4/1/2016 0.00 $195.93 4.53 $26.7305 $121.09 4/1/2016 0.00 $121.09 4/1/2016

2 SURGERY 42145 0 20 Years 20.47 $28.0672 $574.54 4/1/2016 0.00 $574.54 20.47 $28.0672 $574.54 4/1/2016 0.00 $574.54 4/1/2016

2 SURGERY 42145 21 999 Years 20.47 $26.7305 $547.17 4/1/2016 0.00 $547.17 20.47 $26.7305 $547.17 4/1/2016 0.00 $547.17 4/1/2016

2 SURGERY 42160 0 20 Years 6.75 $28.0672 $189.45 4/1/2016 0.00 $189.45 4.31 $28.0672 $120.97 4/1/2016 0.00 $120.97 4/1/2016

2 SURGERY 42160 21 999 Years 6.75 $26.7305 $180.43 4/1/2016 0.00 $180.43 4.31 $26.7305 $115.21 4/1/2016 0.00 $115.21 4/1/2016

2 SURGERY 42180 0 20 Years 7.05 $28.0672 $197.87 4/1/2016 0.00 $197.87 5.35 $28.0672 $150.16 4/1/2014 0.00 $150.16 4/1/2016

2 SURGERY 42180 21 999 Years 7.05 $26.7305 $188.45 4/1/2016 0.00 $188.45 5.35 $26.7305 $143.01 4/1/2014 0.00 $143.01 4/1/2016

2 SURGERY 42182 0 20 Years 9.26 $28.0672 $259.90 4/1/2016 0.00 $259.90 7.44 $28.0672 $208.82 4/1/2016 0.00 $208.82 4/1/2016

2 SURGERY 42182 21 999 Years 9.26 $26.7305 $247.52 4/1/2016 0.00 $247.52 7.44 $26.7305 $198.87 4/1/2016 0.00 $198.87 4/1/2016

2 SURGERY 42200 0 20 Years 24.64 $28.0672 $691.58 4/1/2016 0.00 $691.58 4/1/2016

2 SURGERY 42200 21 999 Years 24.64 $26.7305 $658.64 4/1/2016 0.00 $658.64 4/1/2016

2 SURGERY 42205 0 20 Years 25.73 $28.0672 $722.17 4/1/2016 0.00 $722.17 4/1/2016

2 SURGERY 42205 21 999 Years 25.73 $26.7305 $687.78 4/1/2016 0.00 $687.78 4/1/2016

2 SURGERY 42210 0 20 Years 31.28 $28.0672 $877.94 4/1/2016 0.00 $877.94 10 4/1/2016

2 SURGERY 42210 21 999 Years 31.28 $26.7305 $836.13 4/1/2016 0.00 $836.13 10 4/1/2016

2 SURGERY 42215 0 20 Years 20.86 $28.0672 $585.48 4/1/2016 0.00 $585.48 4/1/2016

2 SURGERY 42215 21 999 Years 20.86 $26.7305 $557.60 4/1/2016 0.00 $557.60 4/1/2016

2 SURGERY 42220 0 20 Years 15.54 $28.0672 $436.16 4/1/2016 0.00 $436.16 4/1/2016

2 SURGERY 42220 21 999 Years 15.54 $26.7305 $415.39 4/1/2016 0.00 $415.39 4/1/2016

2 SURGERY 42225 0 20 Years 25.50 $28.0672 $715.71 4/1/2016 0.00 $715.71 4/1/2016

2 SURGERY 42225 21 999 Years 25.50 $26.7305 $681.63 4/1/2016 0.00 $681.63 4/1/2016

2 SURGERY 42226 0 20 Years 25.94 $28.0672 $728.06 4/1/2016 0.00 $728.06 4/1/2016

2 SURGERY 42226 21 999 Years 25.94 $26.7305 $693.39 4/1/2016 0.00 $693.39 4/1/2016

2 SURGERY 42227 0 20 Years 24.32 $28.0672 $682.59 4/1/2016 0.00 $682.59 4/1/2016

2 SURGERY 42227 21 999 Years 24.32 $26.7305 $650.09 4/1/2016 0.00 $650.09 4/1/2016

2 SURGERY 42235 0 20 Years 21.31 $28.0672 $598.11 4/1/2016 0.00 $598.11 4/1/2016

2 SURGERY 42235 21 999 Years 21.31 $26.7305 $569.63 4/1/2016 0.00 $569.63 4/1/2016

2 SURGERY 42260 0 20 Years 25.03 $28.0672 $702.52 4/1/2016 0.00 $702.52 20.97 $28.0672 $588.57 4/1/2016 0.00 $588.57 4/1/2016

2 SURGERY 42260 21 999 Years 25.03 $26.7305 $669.06 4/1/2016 0.00 $669.06 20.97 $26.7305 $560.54 4/1/2016 0.00 $560.54 4/1/2016

2 SURGERY 42280 0 20 Years 4.80 $28.0672 $134.72 4/1/2016 0.00 $134.72 3.26 $28.0672 $91.50 4/1/2016 0.00 $91.50 4/1/2016

2 SURGERY 42280 21 999 Years 4.80 $26.7305 $128.31 4/1/2016 0.00 $128.31 3.26 $26.7305 $87.14 4/1/2016 0.00 $87.14 4/1/2016

2 SURGERY 42281 0 20 Years 5.93 $28.0672 $166.44 4/1/2016 0.00 $166.44 4.40 $28.0672 $123.50 4/1/2014 0.00 $123.50 4/1/2016

2 SURGERY 42281 21 999 Years 5.93 $26.7305 $158.51 4/1/2016 0.00 $158.51 4.40 $26.7305 $117.61 4/1/2014 0.00 $117.61 4/1/2016

2 SURGERY 42299 0 999 Years 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 4/1/2016

2 SURGERY 42300 0 20 Years 6.06 $28.0672 $170.09 4/1/2016 0.00 $170.09 4.45 $28.0672 $124.90 4/1/2016 0.00 $124.90 4/1/2016

2 SURGERY 42300 21 999 Years 6.06 $26.7305 $161.99 4/1/2016 0.00 $161.99 4.45 $26.7305 $118.95 4/1/2016 0.00 $118.95 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 42305 0 20 Years 12.50 $28.0672 $350.84 4/1/2016 0.00 $350.84 12.50 $28.0672 $350.84 4/1/2016 0.00 $350.84 4/1/2016

2 SURGERY 42305 21 999 Years 12.50 $26.7305 $334.13 4/1/2016 0.00 $334.13 12.50 $26.7305 $334.13 4/1/2016 0.00 $334.13 4/1/2016

2 SURGERY 42310 0 20 Years 4.68 $28.0672 $131.35 4/1/2016 0.00 $131.35 3.62 $28.0672 $101.60 4/1/2014 0.00 $101.60 4/1/2016

2 SURGERY 42310 21 999 Years 4.68 $26.7305 $125.10 4/1/2016 0.00 $125.10 3.62 $26.7305 $96.76 4/1/2014 0.00 $96.76 4/1/2016

2 SURGERY 42320 0 20 Years 7.22 $28.0672 $202.65 4/1/2016 0.00 $202.65 5.11 $28.0672 $143.42 4/1/2014 0.00 $143.42 4/1/2016

2 SURGERY 42320 21 999 Years 7.22 $26.7305 $192.99 4/1/2016 0.00 $192.99 5.11 $26.7305 $136.59 4/1/2014 0.00 $136.59 4/1/2016

2 SURGERY 42330 0 20 Years 6.73 $28.0672 $188.89 4/1/2016 0.00 $188.89 4.82 $28.0672 $135.28 4/1/2016 0.00 $135.28 4/1/2016

2 SURGERY 42330 21 999 Years 6.73 $26.7305 $179.90 4/1/2016 0.00 $179.90 4.82 $26.7305 $128.84 4/1/2016 0.00 $128.84 4/1/2016

2 SURGERY 42335 0 20 Years 10.86 $28.0672 $304.81 4/1/2016 0.00 $304.81 7.48 $28.0672 $209.94 4/1/2016 0.00 $209.94 4/1/2016

2 SURGERY 42335 21 999 Years 10.86 $26.7305 $290.29 4/1/2016 0.00 $290.29 7.48 $26.7305 $199.94 4/1/2016 0.00 $199.94 4/1/2016

2 SURGERY 42340 0 20 Years 13.53 $28.0672 $379.75 4/1/2016 0.00 $379.75 9.82 $28.0672 $275.62 4/1/2016 0.00 $275.62 4/1/2016

2 SURGERY 42340 21 999 Years 13.53 $26.7305 $361.66 4/1/2016 0.00 $361.66 9.82 $26.7305 $262.49 4/1/2016 0.00 $262.49 4/1/2016

2 SURGERY 42400 0 20 Years 3.07 $28.0672 $86.17 4/1/2016 0.00 $86.17 1.60 $28.0672 $44.91 4/1/2014 0.00 $44.91 4/1/2016

2 SURGERY 42400 21 999 Years 3.07 $26.7305 $82.06 4/1/2016 0.00 $82.06 1.60 $26.7305 $42.77 4/1/2014 0.00 $42.77 4/1/2016

2 SURGERY 42405 0 20 Years 8.63 $28.0672 $242.22 4/1/2014 0.00 $242.22 6.58 $28.0672 $184.68 4/1/2016 0.00 $184.68 4/1/2016

2 SURGERY 42405 21 999 Years 8.63 $26.7305 $230.68 4/1/2014 0.00 $230.68 6.58 $26.7305 $175.89 4/1/2016 0.00 $175.89 4/1/2016

2 SURGERY 42408 0 20 Years 13.10 $28.0672 $367.68 4/1/2016 0.00 $367.68 9.46 $28.0672 $265.52 4/1/2016 0.00 $265.52 4/1/2016

2 SURGERY 42408 21 999 Years 13.10 $26.7305 $350.17 4/1/2016 0.00 $350.17 9.46 $26.7305 $252.87 4/1/2016 0.00 $252.87 4/1/2016

2 SURGERY 42409 0 20 Years 9.65 $28.0672 $270.85 4/1/2016 0.00 $270.85 6.46 $28.0672 $181.31 4/1/2016 0.00 $181.31 4/1/2016

2 SURGERY 42409 21 999 Years 9.65 $26.7305 $257.95 4/1/2016 0.00 $257.95 6.46 $26.7305 $172.68 4/1/2016 0.00 $172.68 4/1/2016

2 SURGERY 42410 0 20 Years 18.00 $28.0672 $505.21 4/1/2016 0.00 $505.21 10 4/1/2016

2 SURGERY 42410 21 999 Years 18.00 $26.7305 $481.15 4/1/2016 0.00 $481.15 10 4/1/2016

2 SURGERY 42415 0 20 Years 30.60 $28.0672 $858.86 4/1/2016 0.00 $858.86 10 4/1/2016

2 SURGERY 42415 21 999 Years 30.60 $26.7305 $817.95 4/1/2016 0.00 $817.95 10 4/1/2016

2 SURGERY 42420 0 20 Years 34.38 $28.0672 $964.95 4/1/2016 0.00 $964.95 10 4/1/2016

2 SURGERY 42420 21 999 Years 34.38 $26.7305 $918.99 4/1/2016 0.00 $918.99 10 4/1/2016

2 SURGERY 42425 0 20 Years 24.21 $28.0672 $679.51 4/1/2016 0.00 $679.51 10 4/1/2016

2 SURGERY 42425 21 999 Years 24.21 $26.7305 $647.15 4/1/2016 0.00 $647.15 10 4/1/2016

2 SURGERY 42426 0 20 Years 39.15 $28.0672 $1,098.83 4/1/2016 0.00 $1,098.83 4/1/2016

2 SURGERY 42426 21 999 Years 39.15 $26.7305 $1,046.50 4/1/2016 0.00 $1,046.50 4/1/2016

2 SURGERY 42440 0 20 Years 11.95 $28.0672 $335.40 4/1/2016 0.00 $335.40 10 11.95 $28.0672 $335.40 4/1/2016 0.00 $335.40 10 4/1/2016

2 SURGERY 42440 21 999 Years 11.95 $26.7305 $319.43 4/1/2016 0.00 $319.43 10 11.95 $26.7305 $319.43 4/1/2016 0.00 $319.43 10 4/1/2016

2 SURGERY 42450 0 20 Years 13.14 $28.0672 $368.80 4/1/2016 0.00 $368.80 10.44 $28.0672 $293.02 4/1/2014 0.00 $293.02 4/1/2016

2 SURGERY 42450 21 999 Years 13.14 $26.7305 $351.24 4/1/2016 0.00 $351.24 10.44 $26.7305 $279.07 4/1/2014 0.00 $279.07 4/1/2016

2 SURGERY 42500 0 20 Years 12.58 $28.0672 $353.09 4/1/2016 0.00 $353.09 9.96 $28.0672 $279.55 4/1/2016 0.00 $279.55 4/1/2016

2 SURGERY 42500 21 999 Years 12.58 $26.7305 $336.27 4/1/2016 0.00 $336.27 9.96 $26.7305 $266.24 4/1/2016 0.00 $266.24 4/1/2016

2 SURGERY 42505 0 20 Years 16.11 $28.0672 $452.16 4/1/2016 0.00 $452.16 13.17 $28.0672 $369.65 4/1/2016 0.00 $369.65 4/1/2016

2 SURGERY 42505 21 999 Years 16.11 $26.7305 $430.63 4/1/2016 0.00 $430.63 13.17 $26.7305 $352.04 4/1/2016 0.00 $352.04 4/1/2016

2 SURGERY 42507 0 20 Years 14.87 $28.0672 $417.36 4/1/2016 0.00 $417.36 14.87 $28.0672 $417.36 4/1/2016 0.00 $417.36 4/1/2016

2 SURGERY 42507 21 999 Years 14.87 $26.7305 $397.48 4/1/2016 0.00 $397.48 14.87 $26.7305 $397.48 4/1/2016 0.00 $397.48 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 42509 0 20 Years 24.49 $28.0672 $687.37 4/1/2016 0.00 $687.37 24.49 $28.0672 $687.37 4/1/2016 0.00 $687.37 4/1/2016

2 SURGERY 42509 21 999 Years 24.49 $26.7305 $654.63 4/1/2016 0.00 $654.63 24.49 $26.7305 $654.63 4/1/2016 0.00 $654.63 4/1/2016

2 SURGERY 42510 0 20 Years 18.22 $28.0672 $511.38 4/1/2016 0.00 $511.38 18.22 $28.0672 $511.38 4/1/2016 0.00 $511.38 4/1/2016

2 SURGERY 42510 21 999 Years 18.22 $26.7305 $487.03 4/1/2016 0.00 $487.03 18.22 $26.7305 $487.03 4/1/2016 0.00 $487.03 4/1/2016

2 SURGERY 42550 0 20 Years 3.88 $28.0672 $108.90 4/1/2016 0.00 $108.90 1.84 $28.0672 $51.64 4/1/2016 0.00 $51.64 4/1/2016

2 SURGERY 42550 21 999 Years 3.88 $26.7305 $103.71 4/1/2016 0.00 $103.71 1.84 $26.7305 $49.18 4/1/2016 0.00 $49.18 4/1/2016

2 SURGERY 42600 0 20 Years 13.87 $28.0672 $389.29 4/1/2016 0.00 $389.29 10.09 $28.0672 $283.20 4/1/2016 0.00 $283.20 4/1/2016

2 SURGERY 42600 21 999 Years 13.87 $26.7305 $370.75 4/1/2016 0.00 $370.75 10.09 $26.7305 $269.71 4/1/2016 0.00 $269.71 4/1/2016

2 SURGERY 42650 0 20 Years 2.42 $28.0672 $67.92 4/1/2016 0.00 $67.92 1.71 $28.0672 $47.99 4/1/2016 0.00 $47.99 4/1/2016

2 SURGERY 42650 21 999 Years 2.42 $26.7305 $64.69 4/1/2016 0.00 $64.69 1.71 $26.7305 $45.71 4/1/2016 0.00 $45.71 4/1/2016

2 SURGERY 42660 0 20 Years 3.68 $28.0672 $103.29 4/1/2016 0.00 $103.29 2.60 $28.0672 $72.97 4/1/2016 0.00 $72.97 4/1/2016

2 SURGERY 42660 21 999 Years 3.68 $26.7305 $98.37 4/1/2016 0.00 $98.37 2.60 $26.7305 $69.50 4/1/2016 0.00 $69.50 4/1/2016

2 SURGERY 42665 0 20 Years 9.01 $28.0672 $252.89 4/1/2016 0.00 $252.89 5.98 $28.0672 $167.84 4/1/2016 0.00 $167.84 4/1/2016

2 SURGERY 42665 21 999 Years 9.01 $26.7305 $240.84 4/1/2016 0.00 $240.84 5.98 $26.7305 $159.85 4/1/2016 0.00 $159.85 4/1/2016

2 SURGERY 42699 0 999 Years 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 4/1/2016

2 SURGERY 42700 0 20 Years 5.50 $28.0672 $154.37 4/1/2016 0.00 $154.37 3.96 $28.0672 $111.15 4/1/2014 0.00 $111.15 4/1/2016

2 SURGERY 42700 21 999 Years 5.50 $26.7305 $147.02 4/1/2016 0.00 $147.02 3.96 $26.7305 $105.85 4/1/2014 0.00 $105.85 4/1/2016

2 SURGERY 42720 0 20 Years 13.14 $28.0672 $368.80 4/1/2014 0.00 $368.80 11.37 $28.0672 $319.12 4/1/2014 0.00 $319.12 4/1/2016

2 SURGERY 42720 21 999 Years 13.14 $26.7305 $351.24 4/1/2014 0.00 $351.24 11.37 $26.7305 $303.93 4/1/2014 0.00 $303.93 4/1/2016

2 SURGERY 42725 0 20 Years 23.74 $28.0672 $666.32 4/1/2016 0.00 $666.32 23.74 $28.0672 $666.32 4/1/2016 0.00 $666.32 4/1/2016

2 SURGERY 42725 21 999 Years 23.74 $26.7305 $634.58 4/1/2016 0.00 $634.58 23.74 $26.7305 $634.58 4/1/2016 0.00 $634.58 4/1/2016

2 SURGERY 42800 0 20 Years 4.60 $28.0672 $129.11 4/1/2016 0.00 $129.11 3.26 $28.0672 $91.50 4/1/2016 0.00 $91.50 4/1/2016

2 SURGERY 42800 21 999 Years 4.60 $26.7305 $122.96 4/1/2016 0.00 $122.96 3.26 $26.7305 $87.14 4/1/2016 0.00 $87.14 4/1/2016

2 SURGERY 42804 0 20 Years 5.64 $28.0672 $158.30 4/1/2016 0.00 $158.30 3.29 $28.0672 $92.34 4/1/2016 0.00 $92.34 4/1/2016

2 SURGERY 42804 21 999 Years 5.64 $26.7305 $150.76 4/1/2016 0.00 $150.76 3.29 $26.7305 $87.94 4/1/2016 0.00 $87.94 4/1/2016

2 SURGERY 42806 0 20 Years 6.33 $28.0672 $177.67 4/1/2016 0.00 $177.67 3.83 $28.0672 $107.50 4/1/2014 0.00 $107.50 4/1/2016

2 SURGERY 42806 21 999 Years 6.33 $26.7305 $169.20 4/1/2016 0.00 $169.20 3.83 $26.7305 $102.38 4/1/2014 0.00 $102.38 4/1/2016

2 SURGERY 42808 0 20 Years 6.55 $28.0672 $183.84 4/1/2016 0.00 $183.84 4.71 $28.0672 $132.20 4/1/2016 0.00 $132.20 4/1/2016

2 SURGERY 42808 21 999 Years 6.55 $26.7305 $175.08 4/1/2016 0.00 $175.08 4.71 $26.7305 $125.90 4/1/2016 0.00 $125.90 4/1/2016

2 SURGERY 42809 0 20 Years 5.02 $28.0672 $140.90 4/1/2016 0.00 $140.90 3.87 $28.0672 $108.62 4/1/2016 0.00 $108.62 4/1/2016

2 SURGERY 42809 21 999 Years 5.02 $26.7305 $134.19 4/1/2016 0.00 $134.19 3.87 $26.7305 $103.45 4/1/2016 0.00 $103.45 4/1/2016

2 SURGERY 42810 0 20 Years 11.24 $28.0672 $315.48 4/1/2016 0.00 $315.48 8.39 $28.0672 $235.48 4/1/2016 0.00 $235.48 4/1/2016

2 SURGERY 42810 21 999 Years 11.24 $26.7305 $300.45 4/1/2016 0.00 $300.45 8.39 $26.7305 $224.27 4/1/2016 0.00 $224.27 4/1/2016

2 SURGERY 42815 0 20 Years 16.25 $28.0672 $456.09 4/1/2016 0.00 $456.09 16.25 $28.0672 $456.09 4/1/2016 0.00 $456.09 4/1/2016

2 SURGERY 42815 21 999 Years 16.25 $26.7305 $434.37 4/1/2016 0.00 $434.37 16.25 $26.7305 $434.37 4/1/2016 0.00 $434.37 4/1/2016

2 SURGERY 42842 0 20 Years 28.86 $28.0672 $810.02 4/1/2016 0.00 $810.02 4/1/2016

2 SURGERY 42842 21 999 Years 28.86 $26.7305 $771.44 4/1/2016 0.00 $771.44 4/1/2016

2 SURGERY 42844 0 20 Years 39.69 $28.0672 $1,113.99 4/1/2016 0.00 $1,113.99 4/1/2016

2 SURGERY 42844 21 999 Years 39.69 $26.7305 $1,060.93 4/1/2016 0.00 $1,060.93 4/1/2016

2 SURGERY 42845 0 20 Years 64.19 $28.0672 $1,801.63 4/1/2016 0.00 $1,801.63 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 42845 21 999 Years 64.19 $26.7305 $1,715.83 4/1/2016 0.00 $1,715.83 4/1/2016

2 SURGERY 42890 0 20 Years 40.85 $28.0672 $1,146.55 4/1/2016 0.00 $1,146.55 40.85 $28.0672 $1,146.55 4/1/2016 0.00 $1,146.55 4/1/2016

2 SURGERY 42890 21 999 Years 40.85 $26.7305 $1,091.94 4/1/2016 0.00 $1,091.94 40.85 $26.7305 $1,091.94 4/1/2016 0.00 $1,091.94 4/1/2016

2 SURGERY 42892 0 20 Years 54.33 $28.0672 $1,524.89 4/1/2016 0.00 $1,524.89 4/1/2016

2 SURGERY 42892 21 999 Years 54.33 $26.7305 $1,452.27 4/1/2016 0.00 $1,452.27 4/1/2016

2 SURGERY 42894 0 20 Years 68.10 $28.0672 $1,911.38 4/1/2016 0.00 $1,911.38 4/1/2016

2 SURGERY 42894 21 999 Years 68.10 $26.7305 $1,820.35 4/1/2016 0.00 $1,820.35 4/1/2016

2 SURGERY 42900 0 20 Years 9.82 $28.0672 $275.62 4/1/2016 0.00 $275.62 9.82 $28.0672 $275.62 4/1/2016 0.00 $275.62 4/1/2016

2 SURGERY 42900 21 999 Years 9.82 $26.7305 $262.49 4/1/2016 0.00 $262.49 9.82 $26.7305 $262.49 4/1/2016 0.00 $262.49 4/1/2016

2 SURGERY 42950 0 20 Years 22.98 $28.0672 $644.98 4/1/2016 0.00 $644.98 22.98 $28.0672 $644.98 4/1/2016 0.00 $644.98 4/1/2016

2 SURGERY 42950 21 999 Years 22.98 $26.7305 $614.27 4/1/2016 0.00 $614.27 22.98 $26.7305 $614.27 4/1/2016 0.00 $614.27 4/1/2016

2 SURGERY 42960 0 20 Years 4.95 $28.0672 $138.93 4/1/2016 0.00 $138.93 4.95 $28.0672 $138.93 4/1/2016 0.00 $138.93 4/1/2016

2 SURGERY 42960 21 999 Years 4.95 $26.7305 $132.32 4/1/2016 0.00 $132.32 4.95 $26.7305 $132.32 4/1/2016 0.00 $132.32 4/1/2016

2 SURGERY 42961 0 20 Years 12.27 $28.0672 $344.38 4/1/2016 0.00 $344.38 4/1/2016

2 SURGERY 42961 21 999 Years 12.27 $26.7305 $327.98 4/1/2016 0.00 $327.98 4/1/2016

2 SURGERY 42962 0 20 Years 15.05 $28.0672 $422.41 4/1/2016 0.00 $422.41 15.05 $28.0672 $422.41 4/1/2016 0.00 $422.41 4/1/2016

2 SURGERY 42962 21 999 Years 15.05 $26.7305 $402.29 4/1/2016 0.00 $402.29 15.05 $26.7305 $402.29 4/1/2016 0.00 $402.29 4/1/2016

2 SURGERY 42970 0 20 Years 12.01 $28.0672 $337.09 4/1/2016 0.00 $337.09 12.01 $28.0672 $337.09 4/1/2016 0.00 $337.09 4/1/2016

2 SURGERY 42970 21 999 Years 12.01 $26.7305 $321.03 4/1/2016 0.00 $321.03 12.01 $26.7305 $321.03 4/1/2016 0.00 $321.03 4/1/2016

2 SURGERY 42972 0 20 Years 14.84 $28.0672 $416.52 4/1/2016 0.00 $416.52 4/1/2016

2 SURGERY 42972 21 999 Years 14.84 $26.7305 $396.68 4/1/2016 0.00 $396.68 4/1/2016

2 SURGERY 42999 0 999 Years 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 0.00 $0.0000 $0.00 12/19/1976 -2.00 $0.00 5 4/1/2016

2 SURGERY 61501 0 20 Years 33.67 $28.0672 $945.02 7/1/2016 0.00 $945.02 33.67 $28.0672 $945.02 7/1/2016 0.00 $945.02 7/1/2016

2 SURGERY 61501 21 999 Years 33.67 $26.7305 $900.02 7/1/2016 0.00 $900.02 33.67 $26.7305 $900.02 7/1/2016 0.00 $900.02 7/1/2016

2 SURGERY 61559 0 20 Years 61.33 $28.0672 $1,721.36 7/1/2016 0.00 $1,721.36 10 61.33 $28.0672 $1,721.36 7/1/2016 0.00 $1,721.36 10 7/1/2016

2 SURGERY 61559 21 999 Years 61.33 $26.7305 $1,639.38 7/1/2016 0.00 $1,639.38 10 61.33 $26.7305 $1,639.38 7/1/2016 0.00 $1,639.38 10 7/1/2016

2 SURGERY 61575 0 20 Years 62.30 $28.0672 $1,748.59 7/1/2016 0.00 $1,748.59 62.30 $28.0672 $1,748.59 7/1/2016 0.00 $1,748.59 7/1/2016

2 SURGERY 61575 21 999 Years 62.30 $26.7305 $1,665.31 7/1/2016 0.00 $1,665.31 62.30 $26.7305 $1,665.31 7/1/2016 0.00 $1,665.31 7/1/2016

2 SURGERY 61576 0 20 Years 105.36 $28.0672 $2,957.16 7/1/2016 0.00 $2,957.16 105.36 $28.0672 $2,957.16 7/1/2016 0.00 $2,957.16 7/1/2016

2 SURGERY 61576 21 999 Years 105.36 $26.7305 $2,816.33 7/1/2016 0.00 $2,816.33 105.36 $26.7305 $2,816.33 7/1/2016 0.00 $2,816.33 7/1/2016

2 SURGERY 61580 0 20 Years 72.87 $28.0672 $2,045.26 7/1/2016 0.00 $2,045.26 10 72.87 $28.0672 $2,045.26 7/1/2016 0.00 $2,045.26 10 7/1/2016

2 SURGERY 61580 21 999 Years 72.87 $26.7305 $1,947.85 7/1/2016 0.00 $1,947.85 10 72.87 $26.7305 $1,947.85 7/1/2016 0.00 $1,947.85 10 7/1/2016

2 SURGERY 61581 0 20 Years 77.07 $28.0672 $2,163.14 7/1/2016 0.00 $2,163.14 77.07 $28.0672 $2,163.14 7/1/2016 0.00 $2,163.14 7/1/2016

2 SURGERY 61581 21 999 Years 77.07 $26.7305 $2,060.12 7/1/2016 0.00 $2,060.12 77.07 $26.7305 $2,060.12 7/1/2016 0.00 $2,060.12 7/1/2016

2 SURGERY 61584 0 20 Years 83.66 $28.0672 $2,348.10 7/1/2016 0.00 $2,348.10 83.66 $28.0672 $2,348.10 7/1/2016 0.00 $2,348.10 7/1/2016

2 SURGERY 61584 21 999 Years 83.66 $26.7305 $2,236.27 7/1/2016 0.00 $2,236.27 83.66 $26.7305 $2,236.27 7/1/2016 0.00 $2,236.27 7/1/2016

2 SURGERY 61586 0 20 Years 70.45 $28.0672 $1,977.33 7/1/2016 0.00 $1,977.33 70.45 $28.0672 $1,977.33 7/1/2016 0.00 $1,977.33 7/1/2016

2 SURGERY 61586 21 999 Years 70.45 $26.7305 $1,883.16 7/1/2016 0.00 $1,883.16 70.45 $26.7305 $1,883.16 7/1/2016 0.00 $1,883.16 7/1/2016

2 SURGERY 61590 0 20 Years 88.47 $28.0672 $2,483.11 7/1/2016 0.00 $2,483.11 88.47 $28.0672 $2,483.11 7/1/2016 0.00 $2,483.11 7/1/2016

2 SURGERY 61590 21 999 Years 88.47 $26.7305 $2,364.85 7/1/2016 0.00 $2,364.85 88.47 $26.7305 $2,364.85 7/1/2016 0.00 $2,364.85 7/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 61592 0 20 Years 93.03 $28.0672 $2,611.09 7/1/2016 0.00 $2,611.09 7/1/2016

2 SURGERY 61592 21 999 Years 93.03 $26.7305 $2,486.74 7/1/2016 0.00 $2,486.74 7/1/2016

2 SURGERY 62147 0 20 Years 41.54 $28.0672 $1,165.91 7/1/2016 0.00 $1,165.91 10 41.54 $28.0672 $1,165.91 7/1/2016 0.00 $1,165.91 10 7/1/2016

2 SURGERY 62147 21 999 Years 41.54 $26.7305 $1,110.38 7/1/2016 0.00 $1,110.38 10 41.54 $26.7305 $1,110.38 7/1/2016 0.00 $1,110.38 10 7/1/2016

2 SURGERY 64400 0 20 Years 3.63 $28.0672 $101.88 7/1/2016 0.00 $101.88 2.04 $28.0672 $57.26 7/1/2016 0.00 $57.26 7/1/2016

2 SURGERY 64400 21 999 Years 3.63 $26.7305 $97.03 7/1/2016 0.00 $97.03 2.04 $26.7305 $54.53 7/1/2016 0.00 $54.53 7/1/2016

2 SURGERY 64402 0 20 Years 3.71 $28.0672 $104.13 7/1/2016 0.00 $104.13 2.26 $28.0672 $63.43 7/1/2016 0.00 $63.43 7/1/2016

2 SURGERY 64402 21 999 Years 3.71 $26.7305 $99.17 7/1/2016 0.00 $99.17 2.26 $26.7305 $60.41 7/1/2016 0.00 $60.41 7/1/2016

2 SURGERY 64600 0 20 Years 11.14 $28.0672 $312.67 7/1/2016 0.00 $312.67 6.32 $28.0672 $177.38 7/1/2016 0.00 $177.38 7/1/2016

2 SURGERY 64600 21 999 Years 11.14 $26.7305 $297.78 7/1/2016 0.00 $297.78 6.32 $26.7305 $168.94 7/1/2016 0.00 $168.94 7/1/2016

2 SURGERY 64612 0 20 Years 3.77 $28.0672 $105.81 7/1/2016 0.00 $105.81 3.37 $28.0672 $94.59 7/1/2016 0.00 $94.59 7/1/2016

2 SURGERY 64612 21 999 Years 3.77 $26.7305 $100.77 7/1/2016 0.00 $100.77 3.37 $26.7305 $90.08 7/1/2016 0.00 $90.08 7/1/2016

2 SURGERY 64722 0 20 Years 10.62 $28.0672 $298.07 7/1/2016 0.00 $298.07 10.62 $28.0672 $298.07 7/1/2016 0.00 $298.07 7/1/2016

2 SURGERY 64722 21 999 Years 10.62 $26.7305 $283.88 7/1/2016 0.00 $283.88 10.62 $26.7305 $283.88 7/1/2016 0.00 $283.88 7/1/2016

2 SURGERY 64736 0 20 Years 11.43 $28.0672 $320.81 7/1/2016 0.00 $320.81 11.43 $28.0672 $320.81 7/1/2016 0.00 $320.81 7/1/2016

2 SURGERY 64736 21 999 Years 11.43 $26.7305 $305.53 7/1/2016 0.00 $305.53 11.43 $26.7305 $305.53 7/1/2016 0.00 $305.53 7/1/2016

2 SURGERY 64738 0 20 Years 12.18 $28.0672 $341.86 7/1/2016 0.00 $341.86 12.18 $28.0672 $341.86 7/1/2016 0.00 $341.86 7/1/2016

2 SURGERY 64738 21 999 Years 12.18 $26.7305 $325.58 7/1/2016 0.00 $325.58 12.18 $26.7305 $325.58 7/1/2016 0.00 $325.58 7/1/2016

2 SURGERY 64740 0 20 Years 13.17 $28.0672 $369.65 7/1/2016 0.00 $369.65 13.17 $28.0672 $369.65 7/1/2016 0.00 $369.65 7/1/2016

2 SURGERY 64740 21 999 Years 13.17 $26.7305 $352.04 7/1/2016 0.00 $352.04 13.17 $26.7305 $352.04 7/1/2016 0.00 $352.04 7/1/2016

2 SURGERY 67900 0 20 Years 18.63 $28.0672 $522.89 7/1/2014 0.00 $522.89 15.03 $28.0672 $421.85 7/1/2014 0.00 $421.85 7/1/2016

2 SURGERY 67900 21 999 Years 18.63 $26.7305 $497.99 7/1/2014 0.00 $497.99 15.03 $26.7305 $401.76 7/1/2014 0.00 $401.76 7/1/2016

2 SURGERY 67914 0 20 Years 13.54 $28.0672 $380.03 7/1/2014 0.00 $380.03 9.62 $28.0672 $270.01 7/1/2014 0.00 $270.01 7/1/2016

2 SURGERY 67914 21 999 Years 13.54 $26.7305 $361.93 7/1/2014 0.00 $361.93 9.62 $26.7305 $257.15 7/1/2014 0.00 $257.15 7/1/2016

2 SURGERY 67915 0 20 Years 8.32 $28.0672 $233.52 7/1/2014 0.00 $233.52 5.71 $28.0672 $160.26 7/1/2014 0.00 $160.26 7/1/2016

2 SURGERY 67915 21 999 Years 8.32 $26.7305 $222.40 7/1/2014 0.00 $222.40 5.71 $26.7305 $152.63 7/1/2014 0.00 $152.63 7/1/2016

2 SURGERY 67916 0 20 Years 17.13 $28.0672 $480.79 7/1/2014 0.00 $480.79 12.69 $28.0672 $356.17 7/1/2014 0.00 $356.17 7/1/2016

2 SURGERY 67916 21 999 Years 17.13 $26.7305 $457.89 7/1/2014 0.00 $457.89 12.69 $26.7305 $339.21 7/1/2014 0.00 $339.21 7/1/2016

2 SURGERY 67917 0 20 Years 17.57 $28.0672 $493.14 7/1/2014 0.00 $493.14 13.59 $28.0672 $381.43 7/1/2014 0.00 $381.43 7/1/2016

2 SURGERY 67917 21 999 Years 17.57 $26.7305 $469.65 7/1/2014 0.00 $469.65 13.59 $26.7305 $363.27 7/1/2014 0.00 $363.27 7/1/2016

2 SURGERY 67921 0 20 Years 13.31 $28.0672 $373.57 7/1/2014 0.00 $373.57 9.18 $28.0672 $257.66 7/1/2014 0.00 $257.66 7/1/2016

2 SURGERY 67921 21 999 Years 13.31 $26.7305 $355.78 7/1/2014 0.00 $355.78 9.18 $26.7305 $245.39 7/1/2014 0.00 $245.39 7/1/2016

2 SURGERY 67922 0 20 Years 8.25 $28.0672 $231.55 7/1/2014 0.00 $231.55 5.70 $28.0672 $159.98 7/1/2014 0.00 $159.98 7/1/2016

2 SURGERY 67922 21 999 Years 8.25 $26.7305 $220.53 7/1/2014 0.00 $220.53 5.70 $26.7305 $152.36 7/1/2014 0.00 $152.36 7/1/2016

2 SURGERY 67923 0 20 Years 17.21 $28.0672 $483.04 7/1/2014 0.00 $483.04 12.77 $28.0672 $358.42 7/1/2014 0.00 $358.42 7/1/2016

2 SURGERY 67923 21 999 Years 17.21 $26.7305 $460.03 7/1/2014 0.00 $460.03 12.77 $26.7305 $341.35 7/1/2014 0.00 $341.35 7/1/2016

2 SURGERY 67924 0 20 Years 18.37 $28.0672 $515.59 7/1/2014 0.00 $515.59 0.00 $0.0000 $414.55 7/1/2014 0.00 $414.55 7/1/2016

2 SURGERY 67924 21 999 Years 18.37 $26.7305 $491.04 7/1/2014 0.00 $491.04 13.61 $26.7305 $363.80 7/1/2014 0.00 $363.80 7/1/2016

2 SURGERY 67930 0 20 Years 10.60 $28.0672 $297.51 7/1/2014 0.00 $297.51 7.18 $28.0672 $201.52 7/1/2014 0.00 $201.52 7/1/2016

2 SURGERY 67930 21 999 Years 10.60 $26.7305 $283.34 7/1/2014 0.00 $283.34 7.18 $26.7305 $191.92 7/1/2014 0.00 $191.92 7/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

2 SURGERY 67935 0 20 Years 17.39 $28.0672 $488.09 7/1/2014 0.00 $488.09 13.20 $28.0672 $370.49 7/1/2014 0.00 $370.49 7/1/2016

2 SURGERY 67935 21 999 Years 17.39 $26.7305 $464.84 7/1/2014 0.00 $464.84 13.20 $26.7305 $352.84 7/1/2014 0.00 $352.84 7/1/2016

2 SURGERY 67950 0 20 Years 16.68 $28.0672 $468.16 7/1/2014 0.00 $468.16 13.69 $28.0672 $384.24 7/1/2014 0.00 $384.24 7/1/2016

2 SURGERY 67950 21 999 Years 16.68 $26.7305 $445.86 7/1/2014 0.00 $445.86 13.69 $26.7305 $365.94 7/1/2014 0.00 $365.94 7/1/2016

2 SURGERY 67961 0 20 Years 16.79 $28.0672 $471.25 7/1/2014 0.00 $471.25 13.49 $28.0672 $378.63 7/1/2014 0.00 $378.63 7/1/2016

2 SURGERY 67961 21 999 Years 16.79 $26.7305 $448.81 7/1/2014 0.00 $448.81 13.49 $26.7305 $360.59 7/1/2014 0.00 $360.59 7/1/2016

4 RADIOLOGY 70100 0 20 Years 1.05 $28.0672 $29.47 1/1/2014 0.00 $29.47 9 1/1/2014

4 RADIOLOGY 70100 21 999 Years 1.05 $26.7305 $28.07 1/1/2014 0.00 $28.07 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70100 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70100 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014

T

TECHNICAL

COMPONENT 70100 0 20 Years 0.79 $28.0672 $22.17 1/1/2014 0.00 $22.17 9 1/1/2014

T

TECHNICAL

COMPONENT 70100 21 999 Years 0.79 $26.7305 $21.12 1/1/2014 0.00 $21.12 9 1/1/2014

4 RADIOLOGY 70110 0 20 Years 1.20 $28.0672 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014

4 RADIOLOGY 70110 21 999 Years 1.20 $26.7305 $32.08 1/1/2014 0.00 $32.08 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70110 0 20 Years 0.36 $28.0672 $10.10 1/1/2014 0.00 $10.10 9 0.36 $28.0672 $10.10 1/1/2014 0.00 $10.10 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70110 21 999 Years 0.36 $26.7305 $9.62 1/1/2014 0.00 $9.62 9 0.36 $26.7305 $9.62 1/1/2014 0.00 $9.62 9 1/1/2014

T

TECHNICAL

COMPONENT 70110 0 20 Years 0.84 $28.0672 $23.58 1/1/2014 0.00 $23.58 9 1/1/2014

T

TECHNICAL

COMPONENT 70110 21 999 Years 0.84 $26.7305 $22.45 1/1/2014 0.00 $22.45 9 1/1/2014

4 RADIOLOGY 70120 0 20 Years 1.09 $28.0672 $30.59 1/1/2014 0.00 $30.59 9 1/1/2014

4 RADIOLOGY 70120 21 999 Years 1.09 $26.7305 $29.14 1/1/2014 0.00 $29.14 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70120 0 20 Years 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 0.26 $28.0672 $7.30 1/1/2014 0.00 $7.30 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70120 21 999 Years 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 0.26 $26.7305 $6.95 1/1/2014 0.00 $6.95 9 1/1/2014

T

TECHNICAL

COMPONENT 70120 0 20 Years 0.83 $28.0672 $23.30 1/1/2014 0.00 $23.30 9 1/1/2014

T

TECHNICAL

COMPONENT 70120 21 999 Years 0.83 $26.7305 $22.19 1/1/2014 0.00 $22.19 9 1/1/2014

4 RADIOLOGY 70130 0 20 Years 1.78 $28.0672 $49.96 1/1/2014 0.00 $49.96 9 1.78 $28.0672 $49.96 1/1/2014 0.00 $49.96 9 1/1/2014

4 RADIOLOGY 70130 0 20 Years 1.78 $28.0672 $49.96 1/1/2014 0.00 $49.96 9 1/1/2014

4 RADIOLOGY 70130 21 999 Years 1.78 $26.7305 $47.58 1/1/2014 0.00 $47.58 9 1.78 $26.7305 $47.58 1/1/2014 0.00 $47.58 9 1/1/2014

4 RADIOLOGY 70130 21 999 Years 1.78 $26.7305 $47.58 1/1/2014 0.00 $47.58 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70130 0 20 Years 0.49 $28.0672 $13.75 1/1/2014 0.00 $13.75 9 0.49 $28.0672 $13.75 1/1/2014 0.00 $13.75 9 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

I

PROFESSIONAL

COMPONENT 70130 21 999 Years 0.49 $26.7305 $13.10 1/1/2014 0.00 $13.10 9 0.49 $26.7305 $13.10 1/1/2014 0.00 $13.10 9 1/1/2014

T

TECHNICAL

COMPONENT 70130 0 20 Years 1.29 $28.0672 $36.21 1/1/2014 0.00 $36.21 9 1/1/2014

T

TECHNICAL

COMPONENT 70130 21 999 Years 1.29 $26.7305 $34.48 1/1/2014 0.00 $34.48 9 1/1/2014

4 RADIOLOGY 70140 0 20 Years 0.91 $28.0672 $25.54 1/1/2014 0.00 $25.54 9 1/1/2014

4 RADIOLOGY 70140 21 999 Years 0.91 $26.7305 $24.32 1/1/2014 0.00 $24.32 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70140 0 20 Years 0.29 $28.0672 $8.14 1/1/2014 0.00 $8.14 9 0.29 $28.0672 $8.14 1/1/2014 0.00 $8.14 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70140 21 999 Years 0.29 $26.7305 $7.75 1/1/2014 0.00 $7.75 9 0.29 $26.7305 $7.75 1/1/2014 0.00 $7.75 9 1/1/2014

T

TECHNICAL

COMPONENT 70140 0 20 Years 0.62 $28.0672 $17.40 1/1/2014 0.00 $17.40 9 1/1/2014

T

TECHNICAL

COMPONENT 70140 21 999 Years 0.62 $26.7305 $16.57 1/1/2014 0.00 $16.57 9 1/1/2014

4 RADIOLOGY 70150 0 20 Years 1.29 $28.0672 $36.21 1/1/2014 0.00 $36.21 9 1/1/2014

4 RADIOLOGY 70150 21 999 Years 1.29 $26.7305 $34.48 1/1/2014 0.00 $34.48 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70150 0 20 Years 0.37 $28.0672 $10.38 1/1/2014 0.00 $10.38 9 0.37 $28.0672 $10.38 1/1/2014 0.00 $10.38 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70150 21 999 Years 0.37 $26.7305 $9.89 1/1/2014 0.00 $9.89 9 0.37 $26.7305 $9.89 1/1/2014 0.00 $9.89 9 1/1/2014

T

TECHNICAL

COMPONENT 70150 0 20 Years 0.92 $28.0672 $25.82 1/1/2014 0.00 $25.82 9 1/1/2014

T

TECHNICAL

COMPONENT 70150 21 999 Years 0.92 $26.7305 $24.59 1/1/2014 0.00 $24.59 9 1/1/2014

4 RADIOLOGY 70160 0 20 Years 1.02 $28.0672 $28.63 1/1/2014 0.00 $28.63 9 1/1/2014

4 RADIOLOGY 70160 21 999 Years 1.02 $26.7305 $27.27 1/1/2014 0.00 $27.27 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70160 0 20 Years 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 0.25 $28.0672 $7.02 1/1/2014 0.00 $7.02 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70160 21 999 Years 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 0.25 $26.7305 $6.68 1/1/2014 0.00 $6.68 9 1/1/2014

T

TECHNICAL

COMPONENT 70160 0 20 Years 0.77 $28.0672 $21.61 1/1/2014 0.00 $21.61 9 1/1/2014

T

TECHNICAL

COMPONENT 70160 21 999 Years 0.77 $26.7305 $20.58 1/1/2014 0.00 $20.58 9 1/1/2014

4 RADIOLOGY 70170 0 20 Years 0.00 $0.0000 $46.15 1/1/2014 0.00 $46.15 9 1/1/2014

4 RADIOLOGY 70170 21 999 Years 0.00 $0.0000 $43.95 1/1/2014 0.00 $43.95 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70170 0 20 Years 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 0.44 $28.0672 $12.35 1/1/2014 0.00 $12.35 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70170 21 999 Years 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 0.44 $26.7305 $11.76 1/1/2014 0.00 $11.76 9 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

4 RADIOLOGY 70190 0 20 Years 1.10 $28.0672 $30.87 1/1/2014 0.00 $30.87 9 1/1/2014

4 RADIOLOGY 70190 21 999 Years 1.10 $26.7305 $29.40 1/1/2014 0.00 $29.40 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70190 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70190 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014

T

TECHNICAL

COMPONENT 70190 0 20 Years 0.79 $28.0672 $22.17 1/1/2014 0.00 $22.17 9 1/1/2014

T

TECHNICAL

COMPONENT 70190 21 999 Years 0.79 $26.7305 $21.12 1/1/2014 0.00 $21.12 9 1/1/2014

4 RADIOLOGY 70200 0 20 Years 1.32 $28.0672 $37.05 1/1/2014 0.00 $37.05 9 1/1/2014

4 RADIOLOGY 70200 21 999 Years 1.32 $26.7305 $35.28 1/1/2014 0.00 $35.28 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70200 0 20 Years 0.40 $28.0672 $11.23 1/1/2014 0.00 $11.23 9 0.40 $28.0672 $11.23 1/1/2014 0.00 $11.23 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70200 21 999 Years 0.40 $26.7305 $10.69 1/1/2014 0.00 $10.69 9 0.40 $26.7305 $10.69 1/1/2014 0.00 $10.69 9 1/1/2014

T

TECHNICAL

COMPONENT 70200 0 20 Years 0.92 $28.0672 $25.82 1/1/2014 0.00 $25.82 9 1/1/2014

T

TECHNICAL

COMPONENT 70200 21 999 Years 0.92 $26.7305 $24.59 1/1/2014 0.00 $24.59 9 1/1/2014

4 RADIOLOGY 70250 0 20 Years 1.13 $28.0672 $31.72 1/1/2014 0.00 $31.72 9 1/1/2014

4 RADIOLOGY 70250 21 999 Years 1.13 $26.7305 $30.21 1/1/2014 0.00 $30.21 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70250 0 20 Years 0.36 $28.0672 $10.10 1/1/2014 0.00 $10.10 9 0.36 $28.0672 $10.10 1/1/2014 0.00 $10.10 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70250 21 999 Years 0.36 $26.7305 $9.62 1/1/2014 0.00 $9.62 9 0.36 $26.7305 $9.62 1/1/2014 0.00 $9.62 9 1/1/2014

T

TECHNICAL

COMPONENT 70250 0 20 Years 0.77 $28.0672 $21.61 1/1/2014 0.00 $21.61 9 1/1/2014

T

TECHNICAL

COMPONENT 70250 21 999 Years 0.77 $26.7305 $20.58 1/1/2014 0.00 $20.58 9 1/1/2014

4 RADIOLOGY 70260 0 20 Years 1.42 $28.0672 $39.86 1/1/2014 0.00 $39.86 9 1/1/2014

4 RADIOLOGY 70260 21 999 Years 1.42 $26.7305 $37.96 1/1/2014 0.00 $37.96 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70260 0 20 Years 0.49 $28.0672 $13.75 1/1/2014 0.00 $13.75 9 0.49 $28.0672 $13.75 1/1/2014 0.00 $13.75 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70260 21 999 Years 0.49 $26.7305 $13.10 1/1/2014 0.00 $13.10 9 0.49 $26.7305 $13.10 1/1/2014 0.00 $13.10 9 1/1/2014

T

TECHNICAL

COMPONENT 70260 0 20 Years 0.93 $28.0672 $26.10 1/1/2014 0.00 $26.10 9 1/1/2014

T

TECHNICAL

COMPONENT 70260 21 999 Years 0.93 $26.7305 $24.86 1/1/2014 0.00 $24.86 9 1/1/2014

4 RADIOLOGY 70300 0 20 Years 0.45 $28.0672 $12.63 1/1/2014 0.00 $12.63 9 1/1/2014

4 RADIOLOGY 70300 21 999 Years 0.45 $26.7305 $12.03 1/1/2014 0.00 $12.03 9 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

I

PROFESSIONAL

COMPONENT 70300 0 20 Years 0.17 $28.0672 $4.77 1/1/2014 0.00 $4.77 9 0.17 $28.0672 $4.77 1/1/2014 0.00 $4.77 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70300 21 999 Years 0.17 $26.7305 $4.54 1/1/2014 0.00 $4.54 9 0.17 $26.7305 $4.54 1/1/2014 0.00 $4.54 9 1/1/2014

T

TECHNICAL

COMPONENT 70300 0 20 Years 0.28 $28.0672 $7.86 1/1/2014 0.00 $7.86 9 1/1/2014

T

TECHNICAL

COMPONENT 70300 21 999 Years 0.28 $26.7305 $7.48 1/1/2014 0.00 $7.48 9 1/1/2014

4 RADIOLOGY 70310 0 20 Years 1.17 $28.0672 $32.84 1/1/2014 0.00 $32.84 9 1/1/2014

4 RADIOLOGY 70310 21 999 Years 1.17 $26.7305 $31.27 1/1/2014 0.00 $31.27 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70310 0 20 Years 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 0.23 $28.0672 $6.46 1/1/2014 0.00 $6.46 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70310 21 999 Years 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 0.23 $26.7305 $6.15 1/1/2014 0.00 $6.15 9 1/1/2014

T

TECHNICAL

COMPONENT 70310 0 20 Years 0.94 $28.0672 $26.38 1/1/2014 0.00 $26.38 9 1/1/2014

T

TECHNICAL

COMPONENT 70310 21 999 Years 0.94 $26.7305 $25.13 1/1/2014 0.00 $25.13 9 1/1/2014

4 RADIOLOGY 70320 0 20 Years 1.64 $28.0672 $46.03 1/1/2014 0.00 $46.03 9 1/1/2014

4 RADIOLOGY 70320 21 999 Years 1.64 $26.7305 $43.84 1/1/2014 0.00 $43.84 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70320 0 20 Years 0.34 $28.0672 $9.54 1/1/2014 0.00 $9.54 9 0.34 $28.0672 $9.54 1/1/2014 0.00 $9.54 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70320 21 999 Years 0.34 $26.7305 $9.09 1/1/2014 0.00 $9.09 9 0.34 $26.7305 $9.09 1/1/2014 0.00 $9.09 9 1/1/2014

T

TECHNICAL

COMPONENT 70320 0 20 Years 1.30 $28.0672 $36.49 1/1/2014 0.00 $36.49 9 1/1/2014

T

TECHNICAL

COMPONENT 70320 21 999 Years 1.30 $26.7305 $34.75 1/1/2014 0.00 $34.75 9 1/1/2014

4 RADIOLOGY 70328 0 20 Years 0.97 $28.0672 $27.23 1/1/2014 0.00 $27.23 9 1/1/2014

4 RADIOLOGY 70328 21 999 Years 0.97 $26.7305 $25.93 1/1/2014 0.00 $25.93 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70328 0 20 Years 0.27 $28.0672 $7.58 1/1/2014 0.00 $7.58 9 0.27 $28.0672 $7.58 1/1/2014 0.00 $7.58 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70328 21 999 Years 0.27 $26.7305 $7.22 1/1/2014 0.00 $7.22 9 0.27 $26.7305 $7.22 1/1/2014 0.00 $7.22 9 1/1/2014

T

TECHNICAL

COMPONENT 70328 0 20 Years 0.70 $28.0672 $19.65 1/1/2014 0.00 $19.65 9 1/1/2014

T

TECHNICAL

COMPONENT 70328 21 999 Years 0.70 $26.7305 $18.71 1/1/2014 0.00 $18.71 9 1/1/2014

4 RADIOLOGY 70332 0 20 Years 2.14 $28.0672 $60.06 1/1/2014 0.00 $60.06 9 1/1/2014

4 RADIOLOGY 70332 21 999 Years 2.14 $26.7305 $57.20 1/1/2014 0.00 $57.20 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70332 0 20 Years 0.77 $28.0672 $21.61 1/1/2014 0.00 $21.61 9 0.77 $28.0672 $21.61 1/1/2014 0.00 $21.61 9 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

I

PROFESSIONAL

COMPONENT 70332 21 999 Years 0.77 $26.7305 $20.58 1/1/2014 0.00 $20.58 9 0.77 $26.7305 $20.58 1/1/2014 0.00 $20.58 9 1/1/2014

T

TECHNICAL

COMPONENT 70332 0 20 Years 1.37 $28.0672 $38.45 1/1/2014 0.00 $38.45 9 1/1/2014

T

TECHNICAL

COMPONENT 70332 21 999 Years 1.37 $26.7305 $36.62 1/1/2014 0.00 $36.62 9 1/1/2014

4 RADIOLOGY 70336 0 20 Years 10.77 $28.0672 $302.28 1/1/2014 0.00 $302.28 1/1/2014

4 RADIOLOGY 70336 21 999 Years 10.77 $26.7305 $287.89 1/1/2014 0.00 $287.89 1/1/2014

I

PROFESSIONAL

COMPONENT 70336 0 20 Years 2.08 $28.0672 $58.38 1/1/2014 0.00 $58.38 9 2.08 $28.0672 $58.38 1/1/2014 0.00 $58.38 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70336 21 999 Years 2.08 $26.7305 $55.60 1/1/2014 0.00 $55.60 9 2.08 $26.7305 $55.60 1/1/2014 0.00 $55.60 9 1/1/2014

T

TECHNICAL

COMPONENT 70336 0 20 Years 8.69 $28.0672 $243.90 1/1/2014 0.00 $243.90 9 1/1/2014

T

TECHNICAL

COMPONENT 70336 21 999 Years 8.69 $26.7305 $232.29 1/1/2014 0.00 $232.29 9 1/1/2014

4 RADIOLOGY 70350 0 20 Years 0.65 $28.0672 $18.24 1/1/2014 0.00 $18.24 9 1/1/2014

4 RADIOLOGY 70350 21 999 Years 0.65 $26.7305 $17.37 1/1/2014 0.00 $17.37 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70350 0 20 Years 0.29 $28.0672 $8.14 1/1/2014 0.00 $8.14 9 0.29 $28.0672 $8.14 1/1/2014 0.00 $8.14 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70350 21 999 Years 0.29 $26.7305 $7.75 1/1/2014 0.00 $7.75 9 0.29 $26.7305 $7.75 1/1/2014 0.00 $7.75 9 1/1/2014

T

TECHNICAL

COMPONENT 70350 0 20 Years 0.36 $28.0672 $10.10 1/1/2014 0.00 $10.10 9 1/1/2014

T

TECHNICAL

COMPONENT 70350 21 999 Years 0.36 $26.7305 $9.62 1/1/2014 0.00 $9.62 9 1/1/2014

4 RADIOLOGY 70355 0 20 Years 0.63 $28.0672 $17.68 1/1/2014 0.00 $17.68 9 1/1/2014

4 RADIOLOGY 70355 21 999 Years 0.63 $26.7305 $16.84 1/1/2014 0.00 $16.84 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70355 0 20 Years 0.32 $28.0672 $8.98 1/1/2014 0.00 $8.98 9 0.32 $28.0672 $8.98 1/1/2014 0.00 $8.98 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70355 21 999 Years 0.32 $26.7305 $8.55 1/1/2014 0.00 $8.55 9 0.32 $26.7305 $8.55 1/1/2014 0.00 $8.55 9 1/1/2014

T

TECHNICAL

COMPONENT 70355 0 20 Years 0.31 $28.0672 $8.70 1/1/2014 0.00 $8.70 9 1/1/2014

T

TECHNICAL

COMPONENT 70355 21 999 Years 0.31 $26.7305 $8.29 1/1/2014 0.00 $8.29 9 1/1/2014

4 RADIOLOGY 70370 0 20 Years 2.46 $28.0672 $69.05 1/1/2014 0.00 $69.05 9 1/1/2014

4 RADIOLOGY 70370 21 999 Years 2.46 $26.7305 $65.76 1/1/2014 0.00 $65.76 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70370 0 20 Years 0.45 $28.0672 $12.63 1/1/2014 0.00 $12.63 9 0.45 $28.0672 $12.63 1/1/2014 0.00 $12.63 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70370 21 999 Years 0.45 $26.7305 $12.03 1/1/2014 0.00 $12.03 9 0.45 $26.7305 $12.03 1/1/2014 0.00 $12.03 9 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

T

TECHNICAL

COMPONENT 70370 0 20 Years 2.01 $28.0672 $56.42 1/1/2014 0.00 $56.42 9 1/1/2014

T

TECHNICAL

COMPONENT 70370 21 999 Years 2.01 $26.7305 $53.73 1/1/2014 0.00 $53.73 9 1/1/2014

4 RADIOLOGY 70371 0 20 Years 2.75 $28.0672 $77.18 1/1/2014 0.00 $77.18 9 1/1/2014

4 RADIOLOGY 70371 21 999 Years 2.75 $26.7305 $73.51 1/1/2014 0.00 $73.51 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70371 0 20 Years 1.20 $28.0672 $33.68 1/1/2014 0.00 $33.68 9 1.20 $28.0672 $33.68 1/1/2014 0.00 $33.68 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70371 21 999 Years 1.20 $26.7305 $32.08 1/1/2014 0.00 $32.08 9 1.20 $26.7305 $32.08 1/1/2014 0.00 $32.08 9 1/1/2014

4 RADIOLOGY 70380 0 20 Years 1.19 $28.0672 $33.40 1/1/2014 0.00 $33.40 9 1/1/2014

4 RADIOLOGY 70380 21 999 Years 1.19 $26.7305 $31.81 1/1/2014 0.00 $31.81 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70380 0 20 Years 0.27 $28.0672 $7.58 1/1/2014 0.00 $7.58 9 0.27 $28.0672 $7.58 1/1/2014 0.00 $7.58 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70380 21 999 Years 0.27 $26.7305 $7.22 1/1/2014 0.00 $7.22 9 0.27 $26.7305 $7.22 1/1/2014 0.00 $7.22 9 1/1/2014

T

TECHNICAL

COMPONENT 70380 0 20 Years 0.92 $28.0672 $25.82 1/1/2014 0.00 $25.82 9 1/1/2014

T

TECHNICAL

COMPONENT 70380 21 999 Years 0.92 $26.7305 $24.59 1/1/2014 0.00 $24.59 9 1/1/2014

4 RADIOLOGY 70390 0 20 Years 3.07 $28.0672 $86.17 1/1/2014 0.00 $86.17 9 1/1/2014

4 RADIOLOGY 70390 21 999 Years 3.07 $26.7305 $82.06 1/1/2014 0.00 $82.06 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70390 0 20 Years 0.55 $28.0672 $15.44 1/1/2014 0.00 $15.44 9 0.55 $28.0672 $15.44 1/1/2014 0.00 $15.44 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70390 21 999 Years 0.55 $26.7305 $14.70 1/1/2014 0.00 $14.70 9 0.55 $26.7305 $14.70 1/1/2014 0.00 $14.70 9 1/1/2014

T

TECHNICAL

COMPONENT 70390 0 20 Years 2.52 $28.0672 $70.73 1/1/2014 0.00 $70.73 9 1/1/2014

T

TECHNICAL

COMPONENT 70390 21 999 Years 2.52 $26.7305 $67.36 1/1/2014 0.00 $67.36 9 1/1/2014

I

PROFESSIONAL

COMPONENT 70450 0 20 Years 1.20 $28.0672 $33.68 1/1/2014 0.00 $33.68 1/1/2014

I

PROFESSIONAL

COMPONENT 70450 21 999 Years 1.20 $26.7305 $32.08 1/1/2014 0.00 $32.08 1/1/2014

I

PROFESSIONAL

COMPONENT 70460 0 20 Years 1.59 $28.0672 $44.63 1/1/2014 0.00 $44.63 1/1/2014

I

PROFESSIONAL

COMPONENT 70460 21 999 Years 1.59 $26.7305 $42.50 1/1/2014 0.00 $42.50 1/1/2014

I

PROFESSIONAL

COMPONENT 70470 0 20 Years 1.80 $28.0672 $50.52 1/1/2014 0.00 $50.52 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

I

PROFESSIONAL

COMPONENT 70470 21 999 Years 1.80 $26.7305 $48.11 1/1/2014 0.00 $48.11 1/1/2014

I

PROFESSIONAL

COMPONENT 70480 0 20 Years 1.82 $28.0672 $51.08 1/1/2014 0.00 $51.08 1/1/2014

I

PROFESSIONAL

COMPONENT 70480 21 999 Years 1.82 $26.7305 $48.65 1/1/2014 0.00 $48.65 1/1/2014

4 RADIOLOGY 70481 0 20 Years 9.58 $28.0672 $268.88 1/1/2014 0.00 $268.88 1/1/2014

4 RADIOLOGY 70481 21 999 Years 9.58 $26.7305 $256.08 1/1/2014 0.00 $256.08 1/1/2014

I

PROFESSIONAL

COMPONENT 70481 0 20 Years 1.96 $28.0672 $55.01 1/1/2014 0.00 $55.01 1.96 $28.0672 $55.01 1/1/2014 0.00 $55.01 1/1/2014

I

PROFESSIONAL

COMPONENT 70481 21 999 Years 1.96 $26.7305 $52.39 1/1/2014 0.00 $52.39 1.96 $26.7305 $52.39 1/1/2014 0.00 $52.39 1/1/2014

T

TECHNICAL

COMPONENT 70481 0 20 Years 7.62 $28.0672 $213.87 1/1/2014 0.00 $213.87 1/1/2014

T

TECHNICAL

COMPONENT 70481 21 999 Years 7.62 $26.7305 $203.69 1/1/2014 0.00 $203.69 1/1/2014

4 RADIOLOGY 70482 0 20 Years 10.61 $28.0672 $297.79 1/1/2014 0.00 $297.79 1/1/2014

4 RADIOLOGY 70482 21 999 Years 10.61 $26.7305 $283.61 1/1/2014 0.00 $283.61 1/1/2014

I

PROFESSIONAL

COMPONENT 70482 0 20 Years 2.05 $28.0672 $57.54 1/1/2014 0.00 $57.54 2.05 $28.0672 $57.54 1/1/2014 0.00 $57.54 1/1/2014

I

PROFESSIONAL

COMPONENT 70482 21 999 Years 2.05 $26.7305 $54.80 1/1/2014 0.00 $54.80 2.05 $26.7305 $54.80 1/1/2014 0.00 $54.80 1/1/2014

T

TECHNICAL

COMPONENT 70482 0 20 Years 8.56 $28.0672 $240.26 1/1/2014 0.00 $240.26 1/1/2014

T

TECHNICAL

COMPONENT 70482 21 999 Years 8.56 $26.7305 $228.81 1/1/2014 0.00 $228.81 1/1/2014

4 RADIOLOGY 70486 0 20 Years 6.80 $28.0672 $190.86 1/1/2014 0.00 $190.86 1/1/2014

4 RADIOLOGY 70486 21 999 Years 6.80 $26.7305 $181.77 1/1/2014 0.00 $181.77 1/1/2014

I

PROFESSIONAL

COMPONENT 70486 0 20 Years 1.62 $28.0672 $45.47 1/1/2014 0.00 $45.47 1.62 $28.0672 $45.47 1/1/2014 0.00 $45.47 1/1/2014

I

PROFESSIONAL

COMPONENT 70486 21 999 Years 1.62 $26.7305 $43.30 1/1/2014 0.00 $43.30 1.62 $26.7305 $43.30 1/1/2014 0.00 $43.30 1/1/2014

T

TECHNICAL

COMPONENT 70486 0 20 Years 5.18 $28.0672 $145.39 1/1/2014 0.00 $145.39 1/1/2014

T

TECHNICAL

COMPONENT 70486 21 999 Years 5.18 $26.7305 $138.46 1/1/2014 0.00 $138.46 1/1/2014

4 RADIOLOGY 70487 0 20 Years 8.19 $28.0672 $229.87 1/1/2014 0.00 $229.87 1/1/2014

4 RADIOLOGY 70487 21 999 Years 8.19 $26.7305 $218.92 1/1/2014 0.00 $218.92 1/1/2014

I

PROFESSIONAL

COMPONENT 70487 0 20 Years 1.84 $28.0672 $51.64 1/1/2014 0.00 $51.64 1.84 $28.0672 $51.64 1/1/2014 0.00 $51.64 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

I

PROFESSIONAL

COMPONENT 70487 21 999 Years 1.84 $26.7305 $49.18 1/1/2014 0.00 $49.18 1.84 $26.7305 $49.18 1/1/2014 0.00 $49.18 1/1/2014

T

TECHNICAL

COMPONENT 70487 0 20 Years 6.35 $28.0672 $178.23 1/1/2014 0.00 $178.23 1/1/2014

T

TECHNICAL

COMPONENT 70487 21 999 Years 6.35 $26.7305 $169.74 1/1/2014 0.00 $169.74 1/1/2014

4 RADIOLOGY 70488 0 20 Years 9.86 $28.0672 $276.74 1/1/2014 0.00 $276.74 1/1/2014

4 RADIOLOGY 70488 21 999 Years 9.86 $26.7305 $263.56 1/1/2014 0.00 $263.56 1/1/2014

I

PROFESSIONAL

COMPONENT 70488 0 20 Years 2.01 $28.0672 $56.42 1/1/2014 0.00 $56.42 2.01 $28.0672 $56.42 1/1/2014 0.00 $56.42 1/1/2014

I

PROFESSIONAL

COMPONENT 70488 21 999 Years 2.01 $26.7305 $53.73 1/1/2014 0.00 $53.73 2.01 $26.7305 $53.73 1/1/2014 0.00 $53.73 1/1/2014

T

TECHNICAL

COMPONENT 70488 0 20 Years 7.85 $28.0672 $220.33 1/1/2014 0.00 $220.33 1/1/2014

T

TECHNICAL

COMPONENT 70488 21 999 Years 7.85 $26.7305 $209.83 1/1/2014 0.00 $209.83 1/1/2014

4 RADIOLOGY 70490 0 20 Years 6.63 $28.0672 $186.09 1/1/2014 0.00 $186.09 1/1/2014

4 RADIOLOGY 70490 21 999 Years 6.63 $26.7305 $177.22 1/1/2014 0.00 $177.22 1/1/2014

I

PROFESSIONAL

COMPONENT 70490 0 20 Years 1.82 $28.0672 $51.08 1/1/2014 0.00 $51.08 1.82 $28.0672 $51.08 1/1/2014 0.00 $51.08 1/1/2014

I

PROFESSIONAL

COMPONENT 70490 21 999 Years 1.82 $26.7305 $48.65 1/1/2014 0.00 $48.65 1.82 $26.7305 $48.65 1/1/2014 0.00 $48.65 1/1/2014

T

TECHNICAL

COMPONENT 70490 0 20 Years 4.81 $28.0672 $135.00 1/1/2014 0.00 $135.00 1/1/2014

T

TECHNICAL

COMPONENT 70490 21 999 Years 4.81 $26.7305 $128.57 1/1/2014 0.00 $128.57 1/1/2014

4 RADIOLOGY 70491 0 20 Years 7.99 $28.0672 $224.26 1/1/2014 0.00 $224.26 1/1/2014

4 RADIOLOGY 70491 21 999 Years 7.99 $26.7305 $213.58 1/1/2014 0.00 $213.58 1/1/2014

I

PROFESSIONAL

COMPONENT 70491 0 20 Years 1.96 $28.0672 $55.01 1/1/2014 0.00 $55.01 1.96 $28.0672 $55.01 1/1/2014 0.00 $55.01 1/1/2014

I

PROFESSIONAL

COMPONENT 70491 21 999 Years 1.96 $26.7305 $52.39 1/1/2014 0.00 $52.39 1.96 $26.7305 $52.39 1/1/2014 0.00 $52.39 1/1/2014

T

TECHNICAL

COMPONENT 70491 0 20 Years 6.03 $28.0672 $169.25 1/1/2014 0.00 $169.25 1/1/2014

T

TECHNICAL

COMPONENT 70491 21 999 Years 6.03 $26.7305 $161.18 1/1/2014 0.00 $161.18 1/1/2014

4 RADIOLOGY 70492 0 20 Years 9.54 $28.0672 $267.76 1/1/2014 0.00 $267.76 1/1/2014

4 RADIOLOGY 70492 21 999 Years 9.54 $26.7305 $255.01 1/1/2014 0.00 $255.01 1/1/2014

I

PROFESSIONAL

COMPONENT 70492 0 20 Years 2.05 $28.0672 $57.54 1/1/2014 0.00 $57.54 2.05 $28.0672 $57.54 1/1/2014 0.00 $57.54 1/1/2014

I

PROFESSIONAL

COMPONENT 70492 21 999 Years 2.05 $26.7305 $54.80 1/1/2014 0.00 $54.80 2.05 $26.7305 $54.80 1/1/2014 0.00 $54.80 1/1/2014




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

T

TECHNICAL

COMPONENT 70492 0 20 Years 7.49 $28.0672 $210.22 1/1/2014 0.00 $210.22 1/1/2014

T

TECHNICAL

COMPONENT 70492 21 999 Years 7.49 $26.7305 $200.21 1/1/2014 0.00 $200.21 1/1/2014

4 RADIOLOGY 73100 0 20 Years 0.98 $28.0672 $27.51 1/1/2014 0.00 $27.51 9 1/1/2014

4 RADIOLOGY 73100 21 999 Years 0.98 $26.7305 $26.20 1/1/2014 0.00 $26.20 9 1/1/2014

I

PROFESSIONAL

COMPONENT 73100 0 20 Years 0.27 $28.0672 $7.58 1/1/2014 0.00 $7.58 9 0.27 $28.0672 $7.58 1/1/2014 0.00 $7.58 9 1/1/2014

I

PROFESSIONAL

COMPONENT 73100 21 999 Years 0.27 $26.7305 $7.22 1/1/2014 0.00 $7.22 9 0.27 $26.7305 $7.22 1/1/2014 0.00 $7.22 9 1/1/2014

T

TECHNICAL

COMPONENT 73100 0 20 Years 0.71 $28.0672 $19.93 1/1/2014 0.00 $19.93 9 1/1/2014

T

TECHNICAL

COMPONENT 73100 21 999 Years 0.71 $26.7305 $18.98 1/1/2014 0.00 $18.98 9 1/1/2014

5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015

5 LABORATORY 88305 0 20 Years 2.04 $28.0672 $57.26 4/1/2015 0.00 $57.26 4/1/2015

5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015

5 LABORATORY 88305 21 999 Years 2.04 $26.7305 $54.53 4/1/2015 0.00 $54.53 4/1/2015

5 LABORATORY 88331 0 20 Years 2.88 $28.0672 $80.83 4/1/2015 0.00 $80.83 9 2.88 $28.0672 $80.83 4/1/2015 0.00 $80.83 9 4/1/2015

5 LABORATORY 88331 0 20 Years 2.88 $28.0672 $80.83 4/1/2015 0.00 $80.83 9 4/1/2015







1

MEDICAL

SERVICES 90284 0 999 Years 0.00 $0.0000 $18.04 4/1/2016 0.00 $18.04 9 10/1/2016

2 SURGERY 92511 0 20 Years 3.85 $28.0672 $108.06 11/1/2015 0.00 $108.06 1.38 $28.0672 $38.73 11/1/2015 0.00 $38.73 11/1/2015

2 SURGERY 92511 21 999 Years 3.85 $26.7305 $102.91 11/1/2015 0.00 $102.91 1.38 $26.7305 $36.89 11/1/2015 0.00 $36.89 11/1/2015

1

MEDICAL

SERVICES 96372 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 9 1/1/2016

1

MEDICAL

SERVICES 96372 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 9 1/1/2016

1

MEDICAL

SERVICES 96374 0 20 Years 1.60 $28.0672 $44.91 7/1/2015 0.00 $44.91 7/1/2015

1

MEDICAL

SERVICES 96374 21 999 Years 1.60 $26.7305 $42.77 7/1/2015 0.00 $42.77 7/1/2015




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES 96375 0 20 Years 0.63 $28.0672 $17.68 7/1/2015 0.00 $17.68 7/1/2015

1

MEDICAL

SERVICES 96375 21 999 Years 0.63 $26.7305 $16.84 7/1/2015 0.00 $16.84 7/1/2015

1

MEDICAL

SERVICES 97597 0 20 Years 2.15 $28.0672 $60.34 7/1/2015 0.00 $60.34 0.68 $28.0672 $19.09 7/1/2015 0.00 $19.09 7/1/2015

1

MEDICAL

SERVICES 97597 21 999 Years 2.15 $26.7305 $57.47 7/1/2015 0.00 $57.47 0.68 $26.7305 $18.18 7/1/2015 0.00 $18.18 7/1/2015

1

MEDICAL

SERVICES 97598 0 20 Years 0.71 $28.0672 $19.93 7/1/2015 0.00 $19.93 0.33 $28.0672 $9.26 7/1/2013 0.00 $9.26 7/1/2015

1

MEDICAL

SERVICES 97598 21 999 Years 0.71 $26.7305 $18.98 7/1/2015 0.00 $18.98 0.33 $26.7305 $8.82 7/1/2013 0.00 $8.82 7/1/2015

1

MEDICAL

SERVICES 99050 0 20 Years 0.00 $0.0000 $14.70 7/1/2013 0.00 $14.70 7/1/2015

1

MEDICAL

SERVICES 99050 21 999 Years 0.00 $0.0000 $14.70 7/1/2013 0.00 $14.70 7/1/2015

1

MEDICAL

SERVICES 99056 0 20 Years 0.00 $0.0000 $14.70 7/1/2013 0.00 $14.70 7/1/2015

1

MEDICAL

SERVICES 99056 21 999 Years 0.00 $0.0000 $14.70 7/1/2013 0.00 $14.70 7/1/2015

1

MEDICAL

SERVICES 99060 0 999 Years 0.00 $0.0000 $24.50 7/1/2013 0.00 $24.50 7/1/2015

1

MEDICAL

SERVICES 99100 0 20 Years 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 7/1/2015

1

MEDICAL

SERVICES 99100 21 999 Years 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 7/1/2015

1

MEDICAL

SERVICES 99116 0 20 Years 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 7/1/2015

1

MEDICAL

SERVICES 99116 21 999 Years 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 7/1/2015

1

MEDICAL

SERVICES 99135 0 20 Years 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 7/1/2015

1

MEDICAL

SERVICES 99135 21 999 Years 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 12 7/1/2015

1

MEDICAL

SERVICES 99140 0 999 Years 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 0.00 $0.0000 $73.50 7/1/2013 0.00 $73.50 7/1/2015

1

MEDICAL

SERVICES 99201 0 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1 1/1/2015

1

MEDICAL

SERVICES 99201 21 999 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1 1/1/2015

1

MEDICAL

SERVICES 99201 TH 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015

1

MEDICAL


2 SURGERY 99201 10 20 Years 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 0.00 $0.0000 $28.87 9/1/2007 -2.00 $28.29 1/1/2015

2 SURGERY 99201 21 55 Years 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 0.00 $0.0000 $26.04 9/1/2007 -2.00 $25.52 1/1/2015

1

MEDICAL

SERVICES 99202 0 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1 1/1/2015

1

MEDICAL

SERVICES 99202 21 999 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1 1/1/2015

1

MEDICAL





1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL


2 SURGERY 99202 10 20 Years 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 0.00 $0.0000 $45.56 9/1/2007 -2.00 $44.65 1/1/2015

2 SURGERY 99202 21 55 Years 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 0.00 $0.0000 $41.09 9/1/2007 -2.00 $40.27 1/1/2015

1

MEDICAL

SERVICES 99203 0 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1 1/1/2015

1

MEDICAL

SERVICES 99203 21 999 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1 1/1/2015

1

MEDICAL


1

MEDICAL


2 SURGERY 99203 10 20 Years 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 0.00 $0.0000 $61.56 9/1/2007 -2.00 $60.33 1/1/2015

2 SURGERY 99203 21 55 Years 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 0.00 $0.0000 $55.52 9/1/2007 -2.00 $54.41 1/1/2015

1

MEDICAL

SERVICES 99204 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1 1/1/2015

1

MEDICAL

SERVICES 99204 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1 1/1/2015

1

MEDICAL


1

MEDICAL


2 SURGERY 99204 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015

2 SURGERY 99204 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015

1

MEDICAL

SERVICES 99205 0 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1 1/1/2015

1

MEDICAL

SERVICES 99205 21 999 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1 1/1/2015

1

MEDICAL


1

MEDICAL


2 SURGERY 99205 10 20 Years 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 0.00 $0.0000 $111.98 9/1/2007 -2.00 $109.74 1/1/2015

2 SURGERY 99205 21 55 Years 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 0.00 $0.0000 $101.00 9/1/2007 -2.00 $98.98 1/1/2015

1

MEDICAL

SERVICES 99211 0 20 Years 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 0.00 $0.0000 $14.96 9/1/2007 -2.00 $14.66 1 1/1/2015

1

MEDICAL

SERVICES 99211 21 999 Years 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 0.00 $0.0000 $13.49 9/1/2007 -2.00 $13.22 1 1/1/2015

1

MEDICAL

SERVICES 99212 0 20 Years 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 0.00 $0.0000 $25.04 9/1/2007 -2.00 $24.54 1 1/1/2015

1

MEDICAL

SERVICES 99212 21 999 Years 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 0.00 $0.0000 $22.59 9/1/2007 -2.00 $22.14 1 1/1/2015

1

MEDICAL

SERVICES 99213 0 20 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1 1/1/2015

1

MEDICAL

SERVICES 99213 21 999 Years 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 0.00 $0.0000 $33.95 9/1/2007 -2.00 $33.27 1 1/1/2015

1

MEDICAL

SERVICES 99214 0 20 Years 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 0.00 $0.0000 $52.86 9/1/2007 -2.00 $51.80 1 1/1/2015

1

MEDICAL

SERVICES 99214 21 999 Years 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 0.00 $0.0000 $47.68 9/1/2007 -2.00 $46.73 1 1/1/2015




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES 99215 0 20 Years 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 0.00 $0.0000 $81.38 9/1/2007 -2.00 $79.75 1 1/1/2015

1

MEDICAL

SERVICES 99215 21 999 Years 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 0.00 $0.0000 $73.40 9/1/2007 -2.00 $71.93 1 1/1/2015

1

MEDICAL

SERVICES 99217 0 999 Years 0.00 $0.0000 $58.08 9/1/2007 -2.00 $56.92 1/1/2015

1

MEDICAL

SERVICES 99217 21 999 Years 0.00 $0.0000 $52.38 9/1/2007 -2.00 $51.33 1/1/2015

1

MEDICAL

SERVICES 99218 0 999 Years 0.00 $0.0000 $58.24 9/1/2007 -2.00 $57.08 1/1/2015

1

MEDICAL

SERVICES 99218 21 999 Years 0.00 $0.0000 $52.53 9/1/2007 -2.00 $51.48 1/1/2015

1

MEDICAL

SERVICES 99219 0 999 Years 0.00 $0.0000 $90.59 9/1/2007 -2.00 $88.78 1/1/2015

1

MEDICAL

SERVICES 99219 21 999 Years 0.00 $0.0000 $81.71 9/1/2007 -2.00 $80.08 1/1/2015

1

MEDICAL

SERVICES 99220 0 999 Years 0.00 $0.0000 $122.95 9/1/2007 -2.00 $120.49 1/1/2015

1

MEDICAL

SERVICES 99220 21 999 Years 0.00 $0.0000 $110.89 9/1/2007 -2.00 $108.67 1/1/2015

1

MEDICAL

SERVICES 99221 0 999 Years 0.00 $0.0000 $66.43 9/1/2007 -2.00 $65.10 1/1/2015

1

MEDICAL

SERVICES 99221 21 999 Years 0.00 $0.0000 $59.92 9/1/2007 -2.00 $58.72 1/1/2015

1

MEDICAL

SERVICES 99222 0 999 Years 0.00 $0.0000 $105.38 9/1/2007 -2.00 $103.27 1/1/2015

1

MEDICAL

SERVICES 99222 21 999 Years 0.00 $0.0000 $95.05 9/1/2007 -2.00 $93.15 1/1/2015

1

MEDICAL

SERVICES 99223 0 999 Years 0.00 $0.0000 $133.20 9/1/2007 -2.00 $130.54 1/1/2015

1

MEDICAL

SERVICES 99223 21 999 Years 0.00 $0.0000 $120.14 9/1/2007 -2.00 $117.74 1/1/2015

1

MEDICAL

SERVICES 99224 0 20 Years 0.82 $28.6400 $23.48 1/1/2011 -2.00 $23.01 1/1/2015

1

MEDICAL

SERVICES 99224 21 999 Years 0.82 $27.2760 $22.37 1/1/2011 -2.00 $21.92 1/1/2015

1

MEDICAL

SERVICES 99225 0 20 Years 1.45 $28.6400 $41.53 1/1/2011 -2.00 $40.70 1/1/2015

1

MEDICAL

SERVICES 99225 21 999 Years 1.45 $27.2760 $39.55 1/1/2011 -2.00 $38.76 1/1/2015

1

MEDICAL

SERVICES 99226 0 20 Years 2.17 $28.6400 $62.15 1/1/2011 -2.00 $60.91 1/1/2015

1

MEDICAL

SERVICES 99226 21 999 Years 2.17 $27.2760 $59.19 1/1/2011 -2.00 $58.01 1/1/2015

1

MEDICAL

SERVICES 99231 0 999 Years 0.00 $0.0000 $35.13 9/1/2007 -2.00 $34.43 1/1/2015

1

MEDICAL

SERVICES 99231 21 999 Years 0.00 $0.0000 $31.68 9/1/2007 -2.00 $31.05 1/1/2015

1

MEDICAL

SERVICES 99232 0 999 Years 0.00 $0.0000 $50.43 9/1/2007 -2.00 $49.42 1/1/2015

1

MEDICAL

SERVICES 99232 21 999 Years 0.00 $0.0000 $45.48 9/1/2007 -2.00 $44.57 1/1/2015




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES 99233 0 999 Years 0.00 $0.0000 $67.82 9/1/2007 -2.00 $66.46 1/1/2015

1

MEDICAL

SERVICES 99233 21 999 Years 0.00 $0.0000 $61.17 9/1/2007 -2.00 $59.95 1/1/2015

1

MEDICAL

SERVICES 99234 0 999 Years 0.00 $0.0000 $114.76 9/1/2007 -2.00 $112.46 1/1/2015

1

MEDICAL

SERVICES 99234 21 999 Years 0.00 $0.0000 $103.51 9/1/2007 -2.00 $101.44 1/1/2015

1

MEDICAL

SERVICES 99235 0 999 Years 0.00 $0.0000 $158.58 9/1/2007 -2.00 $155.41 1/1/2015

1

MEDICAL

SERVICES 99235 21 999 Years 0.00 $0.0000 $143.04 9/1/2007 -2.00 $140.18 1/1/2015

1

MEDICAL

SERVICES 99236 0 999 Years 0.00 $0.0000 $191.28 9/1/2007 -2.00 $187.45 1/1/2015

1

MEDICAL

SERVICES 99236 21 999 Years 0.00 $0.0000 $172.52 9/1/2007 -2.00 $169.07 1/1/2015

1

MEDICAL

SERVICES 99238 0 999 Years 0.00 $0.0000 $60.51 9/1/2007 -2.00 $59.30 1/1/2015

1

MEDICAL

SERVICES 99238 21 999 Years 0.00 $0.0000 $54.58 9/1/2007 -2.00 $53.49 1/1/2015

1

MEDICAL

SERVICES 99239 0 999 Years 0.00 $0.0000 $79.99 9/1/2007 -2.00 $78.39 1/1/2015

1

MEDICAL

SERVICES 99239 21 999 Years 0.00 $0.0000 $72.15 9/1/2007 -2.00 $70.71 1/1/2015

3 CONSULTATION 99241 0 999 Years 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 0.00 $0.0000 $44.87 9/1/2007 -2.00 $43.97 1/1/2015










3 CONSULTATION 99251 0 999 Years 0.00 $0.0000 $48.34 9/1/2007 -2.00 $47.37 1/1/2015







1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date







1

MEDICAL

SERVICES 99281 0 20 Years 0.00 $0.0000 $21.47 9/1/2013 0.00 $21.47 1A 1/1/2015

1

MEDICAL

SERVICES 99281 21 999 Years 0.00 $0.0000 $23.13 9/1/2013 0.00 $23.13 1A 1/1/2015

1

MEDICAL

SERVICES 99282 0 20 Years 0.00 $0.0000 $42.57 9/1/2013 0.00 $42.57 1A 1/1/2015

1

MEDICAL

SERVICES 99282 21 999 Years 0.00 $0.0000 $41.09 9/1/2011 -2.00 $40.27 1A 1/1/2015

1

MEDICAL

SERVICES 99283 0 20 Years 0.00 $0.0000 $61.56 9/1/2011 -2.00 $60.33 1A 1/1/2015

1

MEDICAL

SERVICES 99283 21 999 Years 0.00 $0.0000 $55.52 9/1/2011 -2.00 $54.41 1A 1/1/2015

1

MEDICAL

SERVICES 99284 0 20 Years 0.00 $0.0000 $90.07 9/1/2011 -2.00 $88.27 1/1/2015

1

MEDICAL

SERVICES 99284 21 999 Years 0.00 $0.0000 $81.24 9/1/2011 -2.00 $79.62 1/1/2015

1

MEDICAL

SERVICES 99285 0 20 Years 0.00 $0.0000 $111.98 9/1/2011 -2.00 $109.74 1/1/2015

1

MEDICAL

SERVICES 99285 21 999 Years 0.00 $0.0000 $101.00 9/1/2011 -2.00 $98.98 1/1/2015

1

MEDICAL

SERVICES 99304 0 999 Years 0.00 $0.0000 $49.73 9/1/2007 -2.00 $48.74 1/1/2015

1

MEDICAL

SERVICES 99304 21 999 Years 0.00 $0.0000 $44.85 9/1/2007 -2.00 $43.95 1/1/2015

1

MEDICAL

SERVICES 99305 0 999 Years 0.00 $0.0000 $59.47 9/1/2007 -2.00 $58.28 1/1/2015

1

MEDICAL

SERVICES 99305 21 999 Years 0.00 $0.0000 $53.64 9/1/2007 -2.00 $52.57 1/1/2015

1

MEDICAL

SERVICES 99306 0 999 Years 0.00 $0.0000 $80.68 9/1/2007 -2.00 $79.07 1/1/2015

1

MEDICAL

SERVICES 99306 21 999 Years 0.00 $0.0000 $72.77 9/1/2007 -2.00 $71.31 1/1/2015

1

MEDICAL

SERVICES 99307 0 999 Years 0.00 $0.0000 $30.96 9/1/2007 -2.00 $30.34 1/1/2015

1

MEDICAL

SERVICES 99307 21 999 Years 0.00 $0.0000 $27.92 9/1/2007 -2.00 $27.36 1/1/2015

1

MEDICAL

SERVICES 99308 0 999 Years 0.00 $0.0000 $41.04 9/1/2007 -2.00 $40.22 1/1/2015

1

MEDICAL

SERVICES 99308 21 999 Years 0.00 $0.0000 $37.02 9/1/2007 -2.00 $36.28 1/1/2015




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES 99309 0 999 Years 0.00 $0.0000 $55.64 9/1/2007 -2.00 $54.53 1/1/2015

1

MEDICAL

SERVICES 99309 21 999 Years 0.00 $0.0000 $50.19 9/1/2007 -2.00 $49.19 1/1/2015

1

MEDICAL

SERVICES 99310 0 999 Years 0.00 $0.0000 $55.64 9/1/2007 -2.00 $54.53 1/1/2015

1

MEDICAL

SERVICES 99310 21 999 Years 0.00 $0.0000 $50.19 9/1/2007 -2.00 $49.19 1/1/2015

1

MEDICAL

SERVICES 99315 0 999 Years 1.68 $27.2760 $45.82 9/1/1999 -2.00 $44.90 1/1/2015

1

MEDICAL

SERVICES 99315 21 999 Years 0.00 $0.0000 $52.69 9/1/2007 -2.00 $51.64 1/1/2015

1

MEDICAL

SERVICES 99316 0 999 Years 0.00 $0.0000 $71.29 9/1/2007 -2.00 $69.86 1/1/2015

1

MEDICAL

SERVICES 99316 21 999 Years 0.00 $0.0000 $64.31 9/1/2007 -2.00 $63.02 1/1/2015

1

MEDICAL

SERVICES 99318 0 999 Years 0.00 $0.0000 $49.73 9/1/2007 -2.00 $48.74 1/1/2015

1

MEDICAL

SERVICES 99318 21 999 Years 0.00 $0.0000 $44.85 9/1/2007 -2.00 $43.95 1/1/2015

1

MEDICAL

SERVICES 99324 0 999 Years 1.16 $27.2760 $31.64 9/1/2007 -2.00 $31.01 1/1/2015

1

MEDICAL

SERVICES 99324 21 999 Years 0.00 $0.0000 $36.39 9/1/2007 -2.00 $35.66 1/1/2015

1

MEDICAL

SERVICES 99325 0 999 Years 0.00 $0.0000 $58.08 9/1/2007 -2.00 $56.92 1/1/2015

1

MEDICAL

SERVICES 99325 21 999 Years 0.00 $0.0000 $52.38 9/1/2007 -2.00 $51.33 1/1/2015

1

MEDICAL

SERVICES 99326 0 999 Years 0.00 $0.0000 $76.51 9/1/2007 -2.00 $74.98 1/1/2015

1

MEDICAL

SERVICES 99326 21 999 Years 0.00 $0.0000 $69.01 9/1/2007 -2.00 $67.63 1/1/2015

1

MEDICAL

SERVICES 99327 0 999 Years 2.20 $27.2760 $60.01 1/1/2006 -2.00 $58.81 1/1/2015

1

MEDICAL

SERVICES 99327 21 999 Years 0.00 $0.0000 $69.01 9/1/2007 -2.00 $67.63 1/1/2015

1

MEDICAL

SERVICES 99328 0 999 Years 2.20 $27.2760 $60.01 1/1/2006 -2.00 $58.81 1/1/2015

1

MEDICAL

SERVICES 99328 21 999 Years 0.00 $0.0000 $69.01 9/1/2007 -2.00 $67.63 1/1/2015

1

MEDICAL

SERVICES 99334 0 999 Years 0.00 $0.0000 $41.73 9/1/2007 -2.00 $40.90 1/1/2015

1

MEDICAL

SERVICES 99334 21 999 Years 0.00 $0.0000 $37.64 9/1/2007 -2.00 $36.89 1/1/2015

1

MEDICAL

SERVICES 99335 0 999 Years 0.00 $0.0000 $63.65 9/1/2007 -2.00 $62.38 1/1/2015

1

MEDICAL

SERVICES 99335 21 999 Years 0.00 $0.0000 $57.41 9/1/2007 -2.00 $56.26 1/1/2015

1

MEDICAL

SERVICES 99336 0 999 Years 0.00 $0.0000 $93.20 9/1/2007 -2.00 $91.34 1/1/2015

1

MEDICAL

SERVICES 99336 21 999 Years 0.00 $0.0000 $84.07 9/1/2007 -2.00 $82.39 1/1/2015




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES 99337 0 999 Years 2.68 $27.2760 $73.10 1/1/2006 -2.00 $71.64 1/1/2015

1

MEDICAL

SERVICES 99337 21 999 Years 0.00 $0.0000 $84.07 9/1/2007 -2.00 $82.39 1/1/2015

1

MEDICAL

SERVICES 99341 0 20 Years 0.00 $0.0000 $53.81 9/1/2013 0.00 $53.81 1/1/2015

1

MEDICAL

SERVICES 99341 21 999 Years 0.00 $0.0000 $49.57 9/1/2007 -2.00 $48.58 1/1/2015

1

MEDICAL

SERVICES 99341 TH 10 20 Years 0.00 $0.0000 $53.81 9/1/2013 0.00 $53.81 1/1/2015

1

MEDICAL

SERVICES 99341 TH 21 55 Years 0.00 $0.0000 $49.57 9/1/2007 -2.00 $48.58 1/1/2015

2 SURGERY 99341 10 20 Years 0.00 $0.0000 $53.81 9/1/2013 0.00 $53.81 1/1/2015

2 SURGERY 99341 21 55 Years 0.00 $0.0000 $49.57 9/1/2007 -2.00 $48.58 1/1/2015

1

MEDICAL

SERVICES 99342 0 20 Years 0.00 $0.0000 $69.55 9/1/2007 -2.00 $68.16 1/1/2015

1

MEDICAL

SERVICES 99342 21 999 Years 0.00 $0.0000 $62.73 9/1/2007 -2.00 $61.48 1/1/2015

1

MEDICAL


1

MEDICAL


2 SURGERY 99342 10 20 Years 0.00 $0.0000 $69.55 9/1/2007 -2.00 $68.16 1/1/2015

2 SURGERY 99342 21 55 Years 0.00 $0.0000 $62.73 9/1/2007 -2.00 $61.48 1/1/2015

1

MEDICAL

SERVICES 99343 0 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015

1

MEDICAL

SERVICES 99343 21 999 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015

1

MEDICAL


1

MEDICAL


2 SURGERY 99343 10 20 Years 0.00 $0.0000 $90.07 9/1/2007 -2.00 $88.27 1/1/2015

2 SURGERY 99343 21 55 Years 0.00 $0.0000 $81.24 9/1/2007 -2.00 $79.62 1/1/2015

1

MEDICAL

SERVICES 99344 0 20 Years 0.00 $0.0000 $138.07 9/1/2007 -2.00 $135.31 1/1/2015

1

MEDICAL

SERVICES 99344 21 999 Years 0.00 $0.0000 $124.53 9/1/2007 -2.00 $122.04 1/1/2015

1

MEDICAL


1

MEDICAL


2 SURGERY 99344 10 20 Years 0.00 $0.0000 $138.07 9/1/2007 -2.00 $135.31 1/1/2015

2 SURGERY 99344 21 55 Years 0.00 $0.0000 $124.53 9/1/2007 -2.00 $122.04 1/1/2015

1

MEDICAL

SERVICES 99345 0 20 Years 0.00 $0.0000 $164.50 9/1/2007 -2.00 $161.21 1/1/2015

1

MEDICAL

SERVICES 99345 21 999 Years 0.00 $0.0000 $148.37 9/1/2007 -2.00 $145.40 1/1/2015

1

MEDICAL





1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL


2 SURGERY 99345 10 20 Years 0.00 $0.0000 $164.50 9/1/2007 -2.00 $161.21 1/1/2015

2 SURGERY 99345 21 55 Years 0.00 $0.0000 $148.37 9/1/2007 -2.00 $145.40 1/1/2015

1

MEDICAL

SERVICES 99347 0 20 Years 0.00 $0.0000 $43.48 9/1/2007 -2.00 $42.61 1/1/2015

1

MEDICAL

SERVICES 99347 21 999 Years 0.00 $0.0000 $39.22 9/1/2007 -2.00 $38.44 1/1/2015

1

MEDICAL

SERVICES 99348 0 20 Years 0.00 $0.0000 $63.65 9/1/2007 -2.00 $62.38 1/1/2015

1

MEDICAL

SERVICES 99348 21 999 Years 0.00 $0.0000 $57.41 9/1/2007 -2.00 $56.26 1/1/2015

1

MEDICAL

SERVICES 99349 0 20 Years 0.00 $0.0000 $93.20 9/1/2007 -2.00 $91.34 1/1/2015

1

MEDICAL

SERVICES 99349 21 999 Years 0.00 $0.0000 $87.07 9/1/2007 -2.00 $85.33 1/1/2015

1

MEDICAL

SERVICES 99350 0 20 Years 0.00 $0.0000 $134.24 9/1/2007 -2.00 $131.56 1/1/2015

1

MEDICAL

SERVICES 99350 21 999 Years 0.00 $0.0000 $121.08 9/1/2007 -2.00 $118.66 1/1/2015

1

MEDICAL

SERVICES 99354 0 999 Years 0.00 $0.0000 $60.51 9/1/2007 -2.00 $59.30 0.00 $0.0000 $60.51 9/1/2007 -2.00 $59.30 1/1/2015

1

MEDICAL

SERVICES 99354 21 999 Years 0.00 $0.0000 $54.58 9/1/2007 -2.00 $53.49 0.00 $0.0000 $54.58 9/1/2007 -2.00 $53.49 1/1/2015

1

MEDICAL

SERVICES 99355 0 999 Years 0.00 $0.0000 $27.48 9/1/2007 -2.00 $26.93 0.00 $0.0000 $27.48 9/1/2007 -2.00 $26.93 1/1/2015

1

MEDICAL

SERVICES 99355 21 999 Years 0.00 $0.0000 $24.78 9/1/2007 -2.00 $24.28 0.00 $0.0000 $24.78 9/1/2007 -2.00 $24.28 1/1/2015

1

MEDICAL

SERVICES 99356 0 999 Years 0.00 $0.0000 $60.51 9/1/2007 -2.00 $59.30 1/1/2015

1

MEDICAL

SERVICES 99356 21 999 Years 0.00 $0.0000 $54.58 9/1/2007 -2.00 $53.49 1/1/2015

1

MEDICAL

SERVICES 99357 0 999 Years 0.00 $0.0000 $27.48 9/1/2007 -2.00 $26.93 1/1/2015

1

MEDICAL

SERVICES 99357 21 999 Years 0.00 $0.0000 $24.78 9/1/2007 -2.00 $24.28 1/1/2015

1

MEDICAL

SERVICES 99499 0 999 Years 0.00 $0.0000 $0.00 4/1/1992 -2.00 $0.00 5 0.00 $0.0000 $0.00 4/1/1992 -2.00 $0.00 5 1/1/2015

9

OTHER

MEDICAL

ITEMS OR

SERVICES C9367 0 999 Years 0.00 $0.0000 $0.00 1/1/2011 $0.00 5 4/1/2016

1

MEDICAL

SERVICES J0120 0 999 Years 0.00 $0.0000 $1.25 4/1/2012 0.00 $1.25 9 4/1/2016

1

MEDICAL

SERVICES J0171 0 999 Years 0.00 $0.0000 $0.14 10/1/2016 0.00 $0.14 9 10/1/2016

1

MEDICAL

SERVICES J0280 0 999 Years 0.00 $0.0000 $7.25 11/1/2015 0.00 $7.25 9 4/1/2016

1

MEDICAL

SERVICES J0290 0 999 Years 0.00 $0.0000 $1.19 10/1/2016 0.00 $1.19 9 4/1/2016

1

MEDICAL

SERVICES J0295 0 999 Years 0.00 $0.0000 $2.02 10/1/2016 0.00 $2.02 9 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES J0330 0 999 Years 0.00 $0.0000 $0.95 11/1/2015 0.00 $0.95 9 4/1/2016

1

MEDICAL

SERVICES J0360 0 999 Years 0.00 $0.0000 $5.04 10/1/2016 0.00 $5.04 9 4/1/2016

1

MEDICAL

SERVICES J0475 0 999 Years 0.00 $0.0000 $146.85 11/1/2015 0.00 $146.85 9 4/1/2016

1

MEDICAL

SERVICES J0558 0 999 Years 0.00 $0.0000 $5.58 10/1/2016 0.00 $5.58 9 4/1/2016

1

MEDICAL

SERVICES J0561 0 999 Years 0.00 $0.0000 $7.14 10/1/2016 0.00 $7.14 9 4/1/2016

1

MEDICAL

SERVICES J0670 0 999 Years 0.00 $0.0000 $1.89 4/1/2014 0.00 $1.89 4/1/2016

1

MEDICAL

SERVICES J0690 0 999 Years 0.00 $0.0000 $0.72 10/1/2016 0.00 $0.72 9 4/1/2016

1

MEDICAL

SERVICES J0692 0 999 Years 0.00 $0.0000 $2.41 10/1/2016 0.00 $2.41 9 10/1/2016

1

MEDICAL

SERVICES J0694 0 999 Years 0.00 $0.0000 $4.34 10/1/2016 0.00 $4.34 9 4/1/2016

1

MEDICAL

SERVICES J0696 0 999 Years 0.00 $0.0000 $0.50 10/1/2016 0.00 $0.50 9 10/1/2016

1

MEDICAL

SERVICES J0697 0 999 Years 0.00 $0.0000 $2.93 10/1/2016 0.00 $2.93 9 4/1/2016

1

MEDICAL

SERVICES J0698 0 999 Years 0.00 $0.0000 $0.54 10/1/2016 0.00 $0.54 9 4/1/2016

1

MEDICAL

SERVICES J0702 0 999 Years 0.00 $0.0000 $5.42 4/1/2012 0.00 $5.42 9 4/1/2016

1

MEDICAL

SERVICES J0710 0 999 Years 0.00 $0.0000 $1.44 4/1/2012 0.00 $1.44 9 4/1/2016

1

MEDICAL

SERVICES J0713 0 999 Years 0.00 $0.0000 $2.48 10/1/2016 0.00 $2.48 9 10/1/2016

1

MEDICAL

SERVICES J0715 0 999 Years 0.00 $0.0000 $5.14 4/1/2012 0.00 $5.14 9 4/1/2016

1

MEDICAL

SERVICES J0720 0 999 Years 0.00 $0.0000 $30.95 10/1/2016 0.00 $30.95 9 4/1/2016

1

MEDICAL

SERVICES J0744 0 999 Years 0.00 $0.0000 $1.49 10/1/2016 0.00 $1.49 9 10/1/2016

1

MEDICAL

SERVICES J0780 0 999 Years 0.00 $0.0000 $12.59 10/1/2016 0.00 $12.59 9 10/1/2016

1

MEDICAL

SERVICES J0945 0 999 Years 0.00 $0.0000 $0.83 4/1/2012 0.00 $0.83 9 4/1/2016

1

MEDICAL

SERVICES J1020 0 999 Years 0.00 $0.0000 $3.56 10/1/2016 0.00 $3.56 9 4/1/2016

1

MEDICAL

SERVICES J1030 0 999 Years 0.00 $0.0000 $4.95 10/1/2016 0.00 $4.95 10/1/2016

1

MEDICAL

SERVICES J1040 0 999 Years 0.00 $0.0000 $9.48 10/1/2016 0.00 $9.48 9 10/1/2016

1

MEDICAL

SERVICES J1094 0 999 Years 0.00 $0.0000 $0.24 4/1/2012 0.00 $0.24 9 4/1/2016

1

MEDICAL

SERVICES J1100 0 999 Years 0.00 $0.0000 $0.12 10/1/2016 0.00 $0.12 9 10/1/2016

1

MEDICAL

SERVICES J1165 0 999 Years 0.00 $0.0000 $0.50 4/1/2016 0.00 $0.50 9 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES J1170 0 999 Years 0.00 $0.0000 $1.96 10/1/2016 0.00 $1.96 9 10/1/2016

1

MEDICAL

SERVICES J1200 0 999 Years 0.00 $0.0000 $0.52 10/1/2016 0.00 $0.52 9 10/1/2016

1

MEDICAL

SERVICES J1364 0 999 Years 0.00 $0.0000 $44.28 10/1/2016 0.00 $44.28 9 4/1/2016

1

MEDICAL

SERVICES J1459 0 999 Years 0.00 $0.0000 $38.23 10/1/2016 0.00 $38.23 9 10/1/2016

1

MEDICAL

SERVICES J1557 0 999 Years 0.00 $0.0000 $35.92 4/1/2015 0.00 $35.92 9 4/1/2016

1

MEDICAL

SERVICES J1559 0 999 Years 0.00 $0.0000 $7.38 10/1/2016 0.00 $7.38 9 4/1/2016

1

MEDICAL

SERVICES J1561 0 999 Years 0.00 $0.0000 $40.90 10/1/2016 0.00 $40.90 9 10/1/2016

1

MEDICAL

SERVICES J1566 0 999 Years 0.00 $0.0000 $34.03 10/1/2016 0.00 $34.03 9 12 10/1/2016

1

MEDICAL

SERVICES J1568 0 999 Years 0.00 $0.0000 $39.78 10/1/2016 0.00 $39.78 9 10/1/2016

1

MEDICAL

SERVICES J1569 0 999 Years 0.00 $0.0000 $40.00 10/1/2016 0.00 $40.00 9 10/1/2016

1

MEDICAL

SERVICES J1571 19 999 Years 0.00 $0.0000 $47.20 4/1/2013 0.00 $47.20 9 4/1/2016

1

MEDICAL

SERVICES J1572 0 999 Years 0.00 $0.0000 $37.89 10/1/2016 0.00 $37.89 9 10/1/2016

1

MEDICAL

SERVICES J1580 0 999 Years 0.00 $0.0000 $1.09 4/1/2015 0.00 $1.09 4/1/2016

1

MEDICAL

SERVICES J1599 0 999 Years 0.00 $0.0000 $0.00 10/1/2012 $0.00 5 4/1/2016

1

MEDICAL

SERVICES J1630 0 999 Years 0.00 $0.0000 $1.28 10/1/2016 0.00 $1.28 9 10/1/2016

1

MEDICAL

SERVICES J1631 0 999 Years 0.00 $0.0000 $15.22 4/1/2016 0.00 $15.22 9 4/1/2016

1

MEDICAL

SERVICES J1700 0 999 Years 0.00 $0.0000 $0.30 4/1/2012 0.00 $0.30 9 4/1/2016

1

MEDICAL

SERVICES J1710 0 999 Years 0.00 $0.0000 $4.90 4/1/2012 0.00 $4.90 9 4/1/2016

1

MEDICAL

SERVICES J1720 0 999 Years 0.00 $0.0000 $8.16 10/1/2016 0.00 $8.16 9 10/1/2016

1

MEDICAL

SERVICES J1730 0 999 Years 0.00 $0.0000 $109.61 4/1/2012 0.00 $109.61 9 4/1/2016

1

MEDICAL

SERVICES J1790 0 999 Years 0.00 $0.0000 $2.90 4/1/2016 0.00 $2.90 9 10/1/2016

1

MEDICAL

SERVICES J1800 0 999 Years 0.00 $0.0000 $3.33 10/1/2016 0.00 $3.33 9 4/1/2016

1

MEDICAL

SERVICES J1840 0 999 Years 0.00 $0.0000 $7.71 4/1/2016 0.00 $7.71 9 4/1/2016

1

MEDICAL

SERVICES J1850 0 999 Years 0.00 $0.0000 $1.16 4/1/2016 0.00 $1.16 9 4/1/2016

1

MEDICAL

SERVICES J1885 0 999 Years 0.00 $0.0000 $0.53 4/1/2016 0.00 $0.53 9 4/1/2016

1

MEDICAL

SERVICES J1890 0 999 Years 0.00 $0.0000 $9.51 4/1/2012 0.00 $9.51 9 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES J1940 0 999 Years 0.00 $0.0000 $2.95 10/1/2016 0.00 $2.95 9 10/1/2016

1

MEDICAL

SERVICES J1990 0 999 Years 0.00 $0.0000 $20.63 4/1/2012 0.00 $20.63 9 4/1/2016

1

MEDICAL

SERVICES J2010 0 999 Years 0.00 $0.0000 $8.68 10/1/2016 0.00 $8.68 9 4/1/2016

1

MEDICAL

SERVICES J2060 0 999 Years 0.00 $0.0000 $0.80 10/1/2016 0.00 $0.80 9 10/1/2016

1

MEDICAL

SERVICES J2175 0 999 Years 0.00 $0.0000 $5.12 10/1/2016 0.00 $5.12 9 10/1/2016

1

MEDICAL

SERVICES J2180 0 999 Years 0.00 $0.0000 $3.71 4/1/2012 0.00 $3.71 9 4/1/2016

1

MEDICAL

SERVICES J2360 0 999 Years 0.00 $0.0000 $4.48 10/1/2016 0.00 $4.48 4/1/2016

1

MEDICAL

SERVICES J2370 0 999 Years 0.00 $0.0000 $3.04 11/1/2015 0.00 $3.04 9 4/1/2016

1

MEDICAL

SERVICES J2400 0 999 Years 0.00 $0.0000 $17.84 10/1/2016 0.00 $17.84 9 4/1/2016

1

MEDICAL

SERVICES J2410 0 999 Years 0.00 $0.0000 $2.17 4/1/2012 0.00 $2.17 9 4/1/2016

1

MEDICAL

SERVICES J2460 0 999 Years 0.00 $0.0000 $0.92 4/1/2012 0.00 $0.92 9 4/1/2016

1

MEDICAL

SERVICES J2510 0 999 Years 0.00 $0.0000 $18.79 10/1/2016 0.00 $18.79 9 4/1/2016

1

MEDICAL

SERVICES J2515 0 999 Years 0.00 $0.0000 $33.98 10/1/2016 0.00 $33.98 9 4/1/2016

1

MEDICAL

SERVICES J2540 0 999 Years 0.00 $0.0000 $0.73 10/1/2016 0.00 $0.73 9 4/1/2016

1

MEDICAL

SERVICES J2550 0 999 Years 0.00 $0.0000 $1.63 10/1/2016 0.00 $1.63 9 10/1/2016

1

MEDICAL

SERVICES J2560 0 999 Years 0.00 $0.0000 $21.90 4/1/2016 0.00 $21.90 9 4/1/2016

1

MEDICAL

SERVICES J2650 0 999 Years 0.00 $0.0000 $0.18 4/1/2012 0.00 $0.18 9 4/1/2016

1

MEDICAL

SERVICES J2690 0 999 Years 0.00 $0.0000 $42.95 4/1/2015 0.00 $42.95 9 4/1/2016

1

MEDICAL

SERVICES J2700 0 999 Years 0.00 $0.0000 $1.65 10/1/2016 0.00 $1.65 9 4/1/2016

1

MEDICAL

SERVICES J2765 0 999 Years 0.00 $0.0000 $0.69 10/1/2016 0.00 $0.69 9 10/1/2016

1

MEDICAL

SERVICES J2770 0 999 Years 0.00 $0.0000 $284.90 10/1/2016 0.00 $284.90 9 4/1/2016

1

MEDICAL

SERVICES J2800 0 999 Years 0.00 $0.0000 $39.50 10/1/2016 0.00 $39.50 9 4/1/2016

1

MEDICAL

SERVICES J2810 0 999 Years 0.00 $0.0000 $0.23 10/1/2016 0.00 $0.23 9 4/1/2016

1

MEDICAL

SERVICES J2920 0 999 Years 0.00 $0.0000 $3.33 10/1/2016 0.00 $3.33 9 10/1/2016

1

MEDICAL

SERVICES J2930 0 999 Years 0.00 $0.0000 $4.96 10/1/2016 0.00 $4.96 9 10/1/2016

1

MEDICAL

SERVICES J3000 0 999 Years 0.00 $0.0000 $10.12 4/1/2014 0.00 $10.12 9 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES J3010 0 999 Years 0.00 $0.0000 $0.43 10/1/2016 0.00 $0.43 9 10/1/2016

1

MEDICAL

SERVICES J3260 0 999 Years 0.00 $0.0000 $2.09 10/1/2016 0.00 $2.09 9 4/1/2016

1

MEDICAL

SERVICES J3301 0 999 Years 0.00 $0.0000 $1.52 4/1/2012 0.00 $1.52 9 4/1/2016

1

MEDICAL

SERVICES J3302 0 999 Years 0.00 $0.0000 $0.27 4/1/2012 0.00 $0.27 9 4/1/2016

1

MEDICAL

SERVICES J3303 0 999 Years 0.00 $0.0000 $1.61 4/1/2015 0.00 $1.61 9 4/1/2016

1

MEDICAL

SERVICES J3310 0 999 Years 0.00 $0.0000 $6.05 4/1/2014 0.00 $6.05 9 4/1/2016

1

MEDICAL

SERVICES J3320 0 999 Years 0.00 $0.0000 $30.95 4/1/2012 0.00 $30.95 9 4/1/2016

1

MEDICAL

SERVICES J3360 0 999 Years 0.00 $0.0000 $9.29 10/1/2016 0.00 $9.29 9 10/1/2016

1

MEDICAL

SERVICES J3370 0 999 Years 0.00 $0.0000 $2.84 10/1/2016 0.00 $2.84 9 10/1/2016

1

MEDICAL

SERVICES J3410 0 999 Years 0.00 $0.0000 $1.64 4/1/2016 0.00 $1.64 9 4/1/2016

1

MEDICAL

SERVICES J3430 0 999 Years 0.00 $0.0000 $3.38 10/1/2016 0.00 $3.38 9 10/1/2016

1

MEDICAL

SERVICES J3480 0 999 Years 0.00 $0.0000 $0.14 4/1/2016 0.00 $0.14 9 10/1/2016

1

MEDICAL

SERVICES J3485 0 999 Years 0.00 $0.0000 $1.28 4/1/2012 0.00 $1.28 9 4/1/2016

1

MEDICAL

SERVICES J3490 0 999 Years 0.00 $0.0000 $5.01 12/31/1976 0.00 $5.01 5A 10/1/2016

1

MEDICAL

SERVICES J3520 0 999 Years 0.00 $0.0000 $1.27 4/1/2014 0.00 $1.27 9 4/1/2016

1

MEDICAL

SERVICES J9262 0 999 Years 0.00 $0.0000 $3.13 10/1/2016 0.00 $3.13 9 10/1/2016

5 LABORATORY Q3031 0 20 Years 0.00 $0.0000 $12.07 4/1/2013 0.00 $12.07 4/1/2015

5 LABORATORY Q3031 21 999 Years 0.00 $0.0000 $11.49 4/1/2013 0.00 $11.49 4/1/2015

1

MEDICAL

SERVICES Q4100 0 999 Years 0.00 $0.0000 $0.00 1/1/2009 $0.00 5 4/1/2016

1

MEDICAL

SERVICES Q4101 0 999 Years 0.00 $0.0000 $31.03 10/1/2016 0.00 $31.03 4/1/2016

1

MEDICAL

SERVICES Q4102 0 999 Years 0.00 $0.0000 $8.13 11/1/2015 0.00 $8.13 4/1/2016

1

MEDICAL

SERVICES Q4103 0 999 Years 0.00 $0.0000 $7.27 4/1/2014 0.00 $7.27 4/1/2016

1

MEDICAL

SERVICES Q4104 0 999 Years 0.00 $0.0000 $29.09 10/1/2016 0.00 $29.09 4/1/2016

1

MEDICAL

SERVICES Q4105 0 999 Years 0.00 $0.0000 $22.37 10/1/2016 0.00 $22.37 4/1/2016

1

MEDICAL

SERVICES Q4106 0 999 Years 0.00 $0.0000 $32.86 4/1/2016 0.00 $32.86 4/1/2016

1

MEDICAL

SERVICES Q4107 0 999 Years 0.00 $0.0000 $88.20 10/1/2016 0.00 $88.20 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES Q4108 0 999 Years 0.00 $0.0000 $27.41 10/1/2016 0.00 $27.41 4/1/2016

1

MEDICAL

SERVICES Q4110 0 999 Years 0.00 $0.0000 $36.08 10/1/2016 0.00 $36.08 4/1/2016

1

MEDICAL

SERVICES Q4111 0 999 Years 0.00 $0.0000 $6.78 4/1/2012 0.00 $6.78 4/1/2016

1

MEDICAL

SERVICES Q4112 0 999 Years 0.00 $0.0000 $223.73 4/1/2016 0.00 $223.73 4/1/2016

1

MEDICAL

SERVICES Q4113 0 999 Years 0.00 $0.0000 $223.73 4/1/2016 0.00 $223.73 4/1/2016

1

MEDICAL

SERVICES Q4114 0 999 Years 0.00 $0.0000 $1,333.53 10/1/2016 0.00 $1,333.53 4/1/2016

1

MEDICAL

SERVICES Q4122 0 999 Years 0.00 $0.0000 $94.99 10/1/2016 0.00 $94.99 4/1/2016

1

MEDICAL

SERVICES Q4123 0 999 Years 0.00 $0.0000 $18.71 10/1/2016 0.00 $18.71 4/1/2016

1

MEDICAL

SERVICES Q4124 0 999 Years 0.00 $0.0000 $12.48 4/1/2015 0.00 $12.48 4/1/2016

1

MEDICAL

SERVICES Q4126 0 999 Years 0.00 $0.0000 $106.91 4/1/2014 0.00 $106.91 4/1/2016

1

MEDICAL

SERVICES Q4127 0 999 Years 0.00 $0.0000 $36.83 11/1/2015 0.00 $36.83 4/1/2016

1

MEDICAL

SERVICES Q4128 0 999 Years 0.00 $0.0000 $27.84 10/1/2016 0.00 $27.84 4/1/2016

1

MEDICAL

SERVICES Q4129 0 999 Years 0.00 $0.0000 $37.72 1/1/2012 0.00 $37.72 4/1/2016

1

MEDICAL

SERVICES Q4130 0 999 Years 0.00 $0.0000 $36.44 10/1/2016 0.00 $36.44 4/1/2016

1

MEDICAL

SERVICES Q4131 0 999 Years 0.00 $0.0000 $178.31 10/1/2016 0.00 $178.31 4/1/2016

1

MEDICAL

SERVICES Q4134 0 999 Years 0.00 $0.0000 $30.60 4/1/2014 0.00 $30.60 4/1/2016

1

MEDICAL

SERVICES Q4135 0 999 Years 0.00 $0.0000 $2.06 4/1/2014 0.00 $2.06 4/1/2016

1

MEDICAL

SERVICES Q4136 0 999 Years 0.00 $0.0000 $2.03 4/1/2014 0.00 $2.03 4/1/2016

1

MEDICAL

SERVICES Q4137 0 999 Years 0.00 $0.0000 $119.53 4/1/2015 0.00 $119.53 4/1/2016

1

MEDICAL

SERVICES Q4138 0 999 Years 0.00 $0.0000 $166.79 10/1/2016 0.00 $166.79 4/1/2016

1

MEDICAL

SERVICES Q4140 0 999 Years 0.00 $0.0000 $140.78 4/1/2015 0.00 $140.78 4/1/2016

1

MEDICAL

SERVICES Q4142 0 999 Years 0.00 $0.0000 $36.04 10/1/2016 0.00 $36.04 4/1/2016

1

MEDICAL

SERVICES Q4143 0 999 Years 0.00 $0.0000 $21.91 1/1/2014 0.00 $21.91 4/1/2016

1

MEDICAL

SERVICES Q4146 0 999 Years 0.00 $0.0000 $118.24 11/1/2015 0.00 $118.24 4/1/2016

1

MEDICAL

SERVICES Q4147 0 999 Years 0.00 $0.0000 $58.91 1/1/2014 0.00 $58.91 4/1/2016

1

MEDICAL

SERVICES Q4148 0 999 Years 0.00 $0.0000 $220.72 4/1/2016 0.00 $220.72 4/1/2016




1 2 3 1 2 3

TOS TOS DescProc

Code

Last Pricing

Review Date

Mod

1

Mod

2

Client Age Facility

Note Codes

Non-facility

Note Codes

Frm Thru Units

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

Total

RVUs/

Base

Units

Conversion

Factor

Medicaid

Fee

Fee Effect

Date

Adjust

%

Adjusted

Fee for

Report

Date

1

MEDICAL

SERVICES Q4149 0 999 Years 0.00 $0.0000 $43.35 1/1/2014 0.00 $43.35 4/1/2016

1

MEDICAL

SERVICES S0021 0 999 Years 0.00 $0.0000 $16.05 4/1/2012 0.00 $16.05 9 4/1/2016


12/19/2016 57 of 58TEXAS MEDICAID FEE SCHEDULE -


Note Code(s): 1 - In an outpatient setting, this procedure is subject to a 60% payable if diagnosis is non-emergency.

10 - Assistant surgery is payable at a percentage of surgery.

12 - CRNA/AA providers are reimbursed at 92 percent of the fee applicable to a physician for the same service.

1A - Payment was reduced by 40% due to non-emergency services rendered in an outpatient hospital emergency room for professional providers. Non-Rural Hospital providers are limited to a flat rate.

3 - The calculated payable amount for anesthesia could be reduced or increased based on the modifier used.

5 - This procedure is manually reviewed to determine pricing.

5A - Procedure suspends for manual pricing if billed amount is greater than the max fee.

9 - The NP/CNS/PA/CNM Provider Fee Schedule reflects 100 percent of the fee applicable to a physician.


12/19/2016 58 of 58TEXAS MEDICAID FEE SCHEDULE -


1A - Payment was reduced by 40% due to non-emergency services rendered in an outpatient hospital emergency room for professional providers. Non-Rural Hospital providers are limited to a flat rate.


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