initial reimbursement rates and reimbursement rate changes … initial... · 2013-04-08 ·...

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Initial Reimbursement Rates and Reimbursement Rate Changes for Texas Medicaid Effective April 1, 2013 Information posted April 2, 2013

This is an update to an article titled “Proposed Reimbursement Rates for Texas Medicaid to Be Effective January 1, 2013, and April 1, 2013,” which was published on this website on February 28, 2013. Initial reimbursement rates and reimbursement rate changes for some procedure codes that were presented at a public rate hearing on February 13, 2013, will be effective for dates of service on or after April 1, 2013.

The tables on the following pages include the affected procedure codes:

Clinical laboratory services

Clinical laboratory panels

E codes (durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS))

Nonclinical laboratory services

Physician-administered drugs (non-oncology)

Physician-administered drugs (oncology)

S codes (medical services, surgery, and assistant surgery)

HCPCS 3rd Quarter 2012 update for physician-administered drugs

Aerosol treatments

Evoked response tests

Telemedicine and telehealth services

Texas Health Steps therapeutic dental services

Vaccines and toxoids

http://www.tmhp.com/News_Items/2013/02-Feb/02-28-13%20Proposed%20Reimbursement%20Rates%20for%20Texas%20Medicaid%20to%20Be%20Effective%20January%201.pdf

http://www.tmhp.com/News_Items/2013/02-Feb/02-28-13%20Proposed%20Reimbursement%20Rates%20for%20Texas%20Medicaid%20to%20Be%20Effective%20January%201.pdf

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

5 78267 0-999 $9.36 $9.08 $9.67 $9.38 $11.14 $10.81

5 78268 0-999 $80.14 $77.78 $82.81 $80.37 $95.40 $92.59

5 80047 0-999 $10.06 $9.77 $10.40 $10.09 $11.98 $11.63

5 80048 0-999 $10.06 $9.77 $10.40 $10.09 $11.98 $11.63

5 80051 0-999 $8.35 $8.10 $8.63 $8.37 $9.94 $9.64

5 80053 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 80061 0-999 $15.93 $15.47 $16.46 $15.99 $18.97 $18.42

5 80069 0-999 $10.33 $10.03 $10.68 $10.36 $12.30 $11.94

5 80074 0-999 $56.67 $54.99 $58.56 $56.83 $67.47 $65.47

5 80076 0-999 $9.72 $9.43 $10.05 $9.75 $11.57 $11.23

5 80102 0-999 $15.76 $15.29 $16.29 $15.80 $18.76 $18.20

5 80150 0-999 $17.93 $17.40 $18.53 $17.98 $21.35 $20.72

5 80152 0-999 $21.29 $20.67 $22.01 $21.36 $25.35 $24.61

5 80154 0-999 $22.01 $21.36 $22.74 $22.07 $26.20 $25.43

5 80156 0-999 $17.32 $16.82 $17.90 $17.38 $20.62 $20.02

5 80157 0-999 $15.77 $15.30 $16.30 $15.81 $18.77 $18.22

5 80158 0-999 $21.48 $20.84 $22.19 $21.54 $25.57 $24.81

5 80160 0-999 $20.48 $19.87 $21.16 $20.54 $24.38 $23.66

5 80162 0-999 $15.79 $15.33 $16.32 $15.84 $18.80 $18.25

5 80164 0-999 $16.12 $15.65 $16.66 $16.17 $19.19 $18.63

5 80166 0-999 $18.45 $17.89 $19.06 $18.49 $21.96 $21.30

5 80168 0-999 $16.16 $15.68 $16.70 $16.21 $19.24 $18.67

5 80170 0-999 $19.50 $18.93 $20.14 $19.56 $23.21 $22.53

5 80172 0-999 $19.38 $18.81 $20.03 $19.43 $23.07 $22.39

5 80173 0-999 $17.32 $16.82 $17.90 $17.38 $20.62 $20.02

5 80174 0-999 $20.48 $19.87 $21.16 $20.54 $24.38 $23.66

5 80176 0-999 $17.47 $16.96 $18.05 $17.52 $20.80 $20.19

5 80178 0-999 $7.86 $7.64 $8.12 $7.89 $9.36 $9.09

5 80182 0-999 $16.12 $15.65 $16.66 $16.17 $19.19 $18.63

5 80184 0-999 $13.62 $13.22 $14.08 $13.66 $16.22 $15.74

5 80185 0-999 $15.77 $15.30 $16.30 $15.81 $18.77 $18.22

5 80186 0-999 $16.38 $15.89 $16.93 $16.42 $19.50 $18.92

5 80188 0-999 $19.75 $19.16 $20.40 $19.80 $23.51 $22.81

5 80190 0-999 $19.92 $19.35 $20.59 $19.99 $23.72 $23.03

5 80192 0-999 $19.92 $19.35 $20.59 $19.99 $23.72 $23.03

5 80194 0-999 $17.37 $16.86 $17.95 $17.42 $20.68 $20.07

5 80195 0-999 $16.34 $15.85 $16.88 $16.38 $19.45 $18.87

5 80196 0-999 $8.44 $8.19 $8.73 $8.46 $10.05 $9.75

5 80197 0-999 $16.34 $15.85 $16.88 $16.38 $19.45 $18.87

5 80198 0-999 $16.83 $16.34 $17.40 $16.88 $20.04 $19.45

5 80200 0-999 $19.18 $18.61 $19.82 $19.23 $22.83 $22.16

5 80201 0-999 $14.19 $13.77 $14.66 $14.23 $16.89 $16.39

5 80202 0-999 $16.12 $15.65 $16.66 $16.17 $19.19 $18.63

5 80299 0-999 $16.30 $15.82 $16.84 $16.34 $19.40 $18.83

5 80400 0-999 $38.81 $37.65 $40.10 $38.90 $46.20 $44.82

5 80402 0-999 $103.45 $100.40 $106.91 $103.74 $123.16 $119.52

5 80406 0-999 $92.42 $89.68 $95.50 $92.67 $110.02 $106.76

5 80408 0-999 $149.30 $144.92 $154.27 $149.75 $177.74 $172.52

5 80410 0-999 $95.58 $92.79 $98.77 $95.88 $113.79 $110.46

5 80412 0-999 $392.16 $380.57 $405.23 $393.26 $466.86 $453.06

Sole community Hospital (SCH) DSHS LabClinical Lab

Clinical Laboratory Services

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 80414 0-999 $61.44 $59.62 $63.49 $61.61 $73.14 $70.98

5 80415 0-999 $66.49 $64.53 $68.71 $66.68 $79.16 $76.82

5 80416 0-999 $157.00 $152.41 $162.23 $157.49 $186.90 $181.44

5 80417 0-999 $52.33 $50.80 $54.08 $52.50 $62.30 $60.48

5 80418 0-999 $689.57 $669.24 $712.56 $691.55 $820.92 $796.72

5 80420 0-999 $85.71 $83.16 $88.57 $85.93 $102.04 $99.00

5 80422 0-999 $54.81 $53.17 $56.64 $54.94 $65.25 $63.30

5 80424 0-999 $60.08 $58.31 $62.08 $60.26 $71.52 $69.42

5 80426 0-999 $176.57 $171.36 $182.46 $177.07 $210.20 $204.00

5 80428 0-999 $79.36 $77.04 $82.01 $79.61 $94.48 $91.72

5 80430 0-999 $93.37 $90.63 $96.49 $93.65 $111.16 $107.89

5 80432 0-999 $160.73 $156.00 $166.08 $161.20 $191.34 $185.71

5 80434 0-999 $120.37 $116.76 $124.39 $120.65 $143.30 $139.00

5 80435 0-999 $122.56 $118.94 $126.64 $122.91 $145.90 $141.60

5 80436 0-999 $88.15 $85.53 $91.09 $88.38 $104.94 $101.82

5 80438 0-999 $59.98 $58.21 $61.98 $60.15 $71.40 $69.30

5 80439 0-999 $79.97 $77.62 $82.63 $80.20 $95.20 $92.40

5 80440 0-999 $69.17 $67.13 $71.48 $69.37 $82.35 $79.92

5 81000 0-999 $3.76 $3.65 $3.89 $3.78 $4.48 $4.35

5 81001 0-999 $3.76 $3.65 $3.89 $3.78 $4.48 $4.35

5 81002 0-999 $3.04 $2.96 $3.14 $3.06 $3.62 $3.52

5 81003 0-999 $2.67 $2.60 $2.76 $2.68 $3.18 $3.09

5 81005 0-999 $2.58 $2.50 $2.66 $2.59 $3.07 $2.98

5 81007 0-999 $3.05 $2.97 $3.15 $3.06 $3.63 $3.53

5 81015 0-999 $3.62 $3.51 $3.74 $3.63 $4.31 $4.18

5 81020 0-999 $4.38 $4.26 $4.53 $4.40 $5.22 $5.07

5 81025 0-999 $7.53 $7.31 $7.78 $7.55 $8.96 $8.70

D 81025 0-999 $7.53 $7.31 $7.78 $7.55 $8.96 $8.70

5 81050 0-999 $3.57 $3.46 $3.69 $3.58 $4.25 $4.12

5 82000 0-999 $14.74 $14.31 $15.23 $14.78 $17.55 $17.03

5 82003 0-999 $24.07 $23.37 $24.88 $24.15 $28.66 $27.82

5 82009 0-999 $5.18 $5.03 $5.36 $5.20 $6.17 $5.99

5 82010 0-999 $8.72 $8.46 $9.01 $8.74 $10.38 $10.07

5 82013 0-999 $8.40 $8.16 $8.68 $8.43 $10.00 $9.71

5 82016 0-999 $15.83 $15.36 $16.35 $15.87 $18.84 $18.28

5 82017 0-999 $11.86 $11.51 $12.26 $11.89 $14.12 $13.70

5 82024 0-999 $45.96 $44.60 $47.49 $46.09 $54.71 $53.10

5 82030 0-999 $24.14 $23.43 $24.95 $24.21 $28.74 $27.89

5 82040 0-999 $5.89 $5.71 $6.08 $5.90 $7.01 $6.80

5 82042 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 82043 0-999 $6.63 $6.43 $6.85 $6.65 $7.89 $7.66

5 82044 0-999 $5.44 $5.28 $5.63 $5.46 $6.48 $6.29

5 82045 0-999 $40.39 $39.19 $41.73 $40.50 $48.08 $46.66

5 82055 0-999 $12.85 $12.47 $13.28 $12.89 $15.30 $14.85

5 82075 0-999 $14.34 $13.92 $14.82 $14.38 $17.07 $16.57

5 82085 0-999 $11.55 $11.21 $11.94 $11.58 $13.75 $13.34

5 82088 0-999 $48.48 $47.06 $50.10 $48.63 $57.72 $56.02

5 82101 0-999 $35.71 $34.66 $36.90 $35.81 $42.51 $41.26

5 82103 0-999 $15.99 $15.51 $16.51 $16.03 $19.03 $18.47

5 82104 0-999 $17.20 $16.70 $17.77 $17.26 $20.48 $19.88

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 82105 0-999 $19.96 $19.37 $20.62 $20.02 $23.76 $23.06

5 82106 0-999 $19.96 $19.37 $20.62 $20.02 $23.76 $23.06

5 82107 0-999 $76.63 $74.37 $79.19 $76.85 $91.23 $88.54

5 82108 0-999 $30.31 $29.42 $31.32 $30.40 $36.08 $35.02

5 82120 0-999 $4.48 $4.34 $4.63 $4.49 $5.33 $5.17

5 82127 0-999 $15.83 $15.36 $16.35 $15.87 $18.84 $18.28

5 82128 0-999 $15.83 $15.36 $16.35 $15.87 $18.84 $18.28

5 82131 0-999 $20.07 $19.47 $20.74 $20.12 $23.89 $23.18

5 82135 0-999 $19.58 $19.00 $20.24 $19.63 $23.31 $22.62

5 82136 0-999 $11.86 $11.51 $12.26 $11.89 $14.12 $13.70

5 82139 0-999 $11.86 $11.51 $12.26 $11.89 $14.12 $13.70

5 82140 0-999 $17.34 $16.83 $17.92 $17.39 $20.64 $20.03

5 82143 0-999 $8.17 $7.93 $8.44 $8.19 $9.73 $9.44

5 82145 0-999 $18.50 $17.94 $19.11 $18.54 $22.02 $21.36

5 82150 0-999 $7.71 $7.48 $7.97 $7.73 $9.18 $8.91

5 82154 0-999 $34.31 $33.29 $35.45 $34.40 $40.84 $39.63

5 82157 0-999 $34.83 $33.80 $35.99 $34.93 $41.46 $40.24

5 82160 0-999 $29.75 $28.87 $30.74 $29.83 $35.42 $34.37

5 82163 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 82164 0-999 $17.37 $16.86 $17.95 $17.42 $20.68 $20.07

5 82172 0-999 $18.44 $17.89 $19.05 $18.49 $21.95 $21.30

5 82175 0-999 $22.57 $21.91 $23.33 $22.64 $26.87 $26.08

5 82180 0-999 $11.76 $11.42 $12.15 $11.80 $14.00 $13.59

5 82190 0-999 $17.73 $17.21 $18.32 $17.79 $21.11 $20.49

5 82205 0-999 $13.62 $13.22 $14.08 $13.66 $16.22 $15.74

5 82232 0-999 $19.24 $18.68 $19.88 $19.30 $22.91 $22.24

5 82239 0-999 $20.38 $19.78 $21.06 $20.44 $24.26 $23.55

5 82240 0-999 $31.62 $30.69 $32.67 $31.71 $37.64 $36.53

5 82247 0-999 $5.96 $5.80 $6.17 $5.99 $7.10 $6.90

5 82248 0-999 $5.96 $5.80 $6.17 $5.99 $7.10 $6.90

5 82252 0-999 $5.42 $5.25 $5.59 $5.43 $6.45 $6.25

5 82261 0-999 $11.86 $11.51 $12.26 $11.89 $14.12 $13.70

5 82270 0-999 $3.87 $3.76 $4.00 $3.89 $4.61 $4.48

5 82271 0-999 $3.87 $3.76 $4.00 $3.89 $4.61 $4.48

5 82272 0-999 $3.87 $3.76 $4.00 $3.89 $4.61 $4.48

5 82274 0-999 $18.93 $18.36 $19.56 $18.97 $22.53 $21.86

5 82286 0-999 $8.20 $7.95 $8.48 $8.22 $9.76 $9.47

5 82300 0-999 $27.54 $26.72 $28.45 $27.61 $32.78 $31.81

5 82306 0-999 $32.33 $31.37 $33.41 $32.42 $38.49 $37.35

5 82308 0-999 $31.86 $30.93 $32.92 $31.96 $37.93 $36.82

5 82310 0-999 $6.13 $5.96 $6.33 $6.15 $7.30 $7.09

5 82330 0-999 $16.26 $15.78 $16.81 $16.31 $19.36 $18.79

5 82331 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 82340 0-999 $7.17 $6.96 $7.41 $7.20 $8.54 $8.29

5 82355 0-999 $13.77 $13.36 $14.23 $13.81 $16.39 $15.91

5 82360 0-999 $15.31 $14.86 $15.83 $15.35 $18.23 $17.69

5 82365 0-999 $15.34 $14.88 $15.85 $15.38 $18.26 $17.72

5 82370 0-999 $14.91 $14.46 $15.41 $14.95 $17.75 $17.22

5 82373 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82374 0-999 $5.82 $5.64 $6.01 $5.83 $6.93 $6.72

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 82375 0-999 $14.67 $14.23 $15.15 $14.70 $17.46 $16.94

5 82376 0-999 $7.13 $6.92 $7.37 $7.15 $8.49 $8.24

5 82378 0-999 $22.57 $21.91 $23.33 $22.64 $26.87 $26.08

5 82379 0-999 $11.86 $11.51 $12.26 $11.89 $14.12 $13.70

5 82380 0-999 $10.97 $10.65 $11.34 $11.01 $13.06 $12.68

5 82382 0-999 $20.45 $19.86 $21.13 $20.52 $24.35 $23.64

5 82383 0-999 $29.81 $28.94 $30.80 $29.90 $35.49 $34.45

5 82384 0-999 $30.04 $29.16 $31.04 $30.13 $35.76 $34.71

5 82387 0-999 $15.83 $15.36 $16.35 $15.87 $18.84 $18.28

5 82390 0-999 $12.78 $12.40 $13.20 $12.81 $15.21 $14.76

5 82397 0-999 $16.81 $16.31 $17.37 $16.86 $20.01 $19.42

5 82415 0-999 $15.08 $14.63 $15.58 $15.12 $17.95 $17.42

5 82435 0-999 $5.47 $5.31 $5.65 $5.49 $6.51 $6.32

5 82436 0-999 $5.98 $5.80 $6.18 $6.00 $7.12 $6.91

5 82438 0-999 $5.82 $5.64 $6.01 $5.83 $6.93 $6.72

5 82441 0-999 $7.14 $6.93 $7.38 $7.16 $8.50 $8.25

5 82465 0-999 $5.17 $5.02 $5.35 $5.19 $6.16 $5.98

5 82480 0-999 $9.37 $9.10 $9.69 $9.40 $11.16 $10.83

5 82482 0-999 $9.14 $8.87 $9.44 $9.17 $10.88 $10.56

5 82485 0-999 $24.57 $23.85 $25.39 $24.64 $29.25 $28.39

5 82486 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82487 0-999 $18.99 $18.44 $19.62 $19.05 $22.61 $21.95

5 82488 0-999 $25.43 $24.67 $26.28 $25.49 $30.27 $29.37

5 82489 0-999 $22.01 $21.36 $22.74 $22.07 $26.20 $25.43

5 82491 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82492 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82495 0-999 $24.13 $23.42 $24.94 $24.20 $28.73 $27.88

5 82507 0-999 $33.08 $32.10 $34.18 $33.17 $39.38 $38.22

5 82520 0-999 $18.03 $17.50 $18.64 $18.08 $21.47 $20.83

5 82523 0-999 $22.24 $21.58 $22.98 $22.30 $26.48 $25.69

5 82525 0-999 $14.77 $14.33 $15.26 $14.81 $17.58 $17.06

5 82528 0-999 $26.79 $26.00 $27.68 $26.86 $31.89 $30.95

5 82530 0-999 $19.88 $19.29 $20.55 $19.94 $23.67 $22.97

5 82533 0-999 $19.40 $18.82 $20.05 $19.45 $23.10 $22.41

5 82540 0-999 $5.51 $5.35 $5.70 $5.53 $6.56 $6.37

5 82541 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82542 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82543 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82544 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82550 0-999 $7.75 $7.52 $8.01 $7.77 $9.23 $8.95

5 82552 0-999 $15.94 $15.47 $16.47 $15.99 $18.98 $18.42

5 82553 0-999 $7.32 $7.11 $7.57 $7.34 $8.72 $8.46

5 82554 0-999 $7.32 $7.11 $7.57 $7.34 $8.72 $8.46

5 82565 0-999 $6.10 $5.91 $6.30 $6.11 $7.26 $7.04

5 82570 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 82575 0-999 $11.25 $10.91 $11.63 $11.28 $13.39 $12.99

5 82585 0-999 $10.21 $9.91 $10.54 $10.24 $12.15 $11.80

5 82595 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 82600 0-999 $23.08 $22.39 $23.86 $23.14 $27.48 $26.66

5 82607 0-999 $17.93 $17.40 $18.53 $17.98 $21.35 $20.72

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 82608 0-999 $17.04 $16.53 $17.61 $17.08 $20.28 $19.68

5 82610 0-999 $16.17 $15.70 $16.71 $16.22 $19.25 $18.69

5 82615 0-999 $9.71 $9.42 $10.04 $9.74 $11.56 $11.22

5 82626 0-999 $30.06 $29.18 $31.06 $30.15 $35.79 $34.74

5 82627 0-999 $26.45 $25.67 $27.33 $26.53 $31.49 $30.56

5 82633 0-999 $24.67 $23.94 $25.49 $24.74 $29.37 $28.50

5 82634 0-999 $24.67 $23.94 $25.49 $24.74 $29.37 $28.50

5 82638 0-999 $14.57 $14.15 $15.06 $14.62 $17.35 $16.84

5 82646 0-999 $24.57 $23.85 $25.39 $24.64 $29.25 $28.39

5 82649 0-999 $30.58 $29.69 $31.60 $30.68 $36.41 $35.34

5 82651 0-999 $30.71 $29.80 $31.74 $30.80 $36.56 $35.48

5 82652 0-999 $45.81 $44.45 $47.33 $45.93 $54.53 $52.92

5 82654 0-999 $16.47 $15.99 $17.02 $16.52 $19.61 $19.03

5 82656 0-999 $13.73 $13.32 $14.18 $13.77 $16.34 $15.86

5 82657 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82658 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82664 0-999 $31.11 $30.19 $32.14 $31.20 $37.03 $35.94

5 82666 0-999 $23.47 $22.78 $24.25 $23.54 $27.94 $27.12

5 82668 0-999 $22.37 $21.71 $23.12 $22.43 $26.63 $25.84

5 82670 0-999 $33.25 $32.26 $34.36 $33.34 $39.58 $38.41

5 82671 0-999 $38.43 $37.30 $39.72 $38.54 $45.75 $44.40

5 82672 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 82677 0-999 $28.77 $27.93 $29.73 $28.86 $34.25 $33.25

5 82679 0-999 $29.69 $28.82 $30.69 $29.78 $35.35 $34.31

5 82690 0-999 $20.56 $19.95 $21.25 $20.62 $24.48 $23.75

5 82693 0-999 $17.72 $17.20 $18.31 $17.78 $21.10 $20.48

5 82696 0-999 $28.06 $27.23 $28.99 $28.14 $33.40 $32.42

5 82705 0-999 $6.06 $5.87 $6.26 $6.07 $7.21 $6.99

5 82710 0-999 $19.99 $19.40 $20.66 $20.05 $23.80 $23.10

5 82715 0-999 $20.26 $19.66 $20.93 $20.32 $24.12 $23.41

5 82725 0-999 $15.84 $15.37 $16.37 $15.88 $18.86 $18.30

5 82726 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 82728 0-999 $16.21 $15.73 $16.75 $16.26 $19.30 $18.73

5 82731 0-999 $76.63 $74.37 $79.19 $76.85 $91.23 $88.54

5 82735 0-999 $22.06 $21.41 $22.80 $22.13 $26.26 $25.49

5 82742 0-999 $23.55 $22.86 $24.33 $23.62 $28.04 $27.21

5 82746 0-999 $17.49 $16.98 $18.07 $17.54 $20.82 $20.21

5 82747 0-999 $20.57 $19.97 $21.26 $20.63 $24.49 $23.77

5 82757 0-999 $20.63 $20.03 $21.32 $20.69 $24.56 $23.84

5 82759 0-999 $10.74 $10.42 $11.10 $10.76 $12.78 $12.40

5 82760 0-999 $13.32 $12.93 $13.77 $13.36 $15.86 $15.39

5 82775 0-999 $25.07 $24.33 $25.90 $25.14 $29.84 $28.96

5 82776 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 82784 0-999 $11.06 $10.74 $11.43 $11.09 $13.17 $12.78

5 82785 0-999 $19.59 $19.02 $20.24 $19.65 $23.32 $22.64

5 82787 0-999 $4.98 $4.84 $5.15 $5.00 $5.93 $5.76

5 82800 0-999 $10.07 $9.77 $10.41 $10.09 $11.99 $11.63

5 82803 0-999 $23.02 $22.34 $23.78 $23.09 $27.40 $26.60

5 82805 0-999 $33.77 $32.77 $34.89 $33.86 $40.20 $39.01

5 82810 0-999 $10.38 $10.08 $10.73 $10.42 $12.36 $12.00

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 82820 0-999 $11.89 $11.53 $12.29 $11.92 $14.16 $13.73

5 82930 0-999 $6.49 $6.30 $6.71 $6.51 $7.73 $7.50

5 82938 0-999 $21.05 $20.43 $21.76 $21.11 $25.06 $24.32

5 82941 0-999 $20.98 $20.36 $21.68 $21.04 $24.98 $24.24

5 82943 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 82945 0-999 $4.67 $4.53 $4.83 $4.68 $5.56 $5.39

5 82946 0-999 $16.16 $15.68 $16.70 $16.21 $19.24 $18.67

5 82947 0-999 $4.67 $4.53 $4.83 $4.68 $5.56 $5.39

5 82948 0-999 $3.76 $3.65 $3.89 $3.78 $4.48 $4.35

5 82950 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

5 82951 0-999 $15.31 $14.86 $15.83 $15.35 $18.23 $17.69

5 82952 0-999 $4.66 $4.53 $4.82 $4.68 $5.55 $5.39

5 82953 0-999 $18.03 $17.49 $18.63 $18.07 $21.46 $20.82

5 82955 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 82960 0-999 $7.20 $6.99 $7.44 $7.22 $8.57 $8.32

5 82963 0-999 $25.56 $24.81 $26.41 $25.63 $30.43 $29.53

5 82965 0-999 $9.20 $8.93 $9.50 $9.23 $10.95 $10.63

5 82975 0-999 $18.85 $18.30 $19.48 $18.91 $22.44 $21.78

5 82977 0-999 $8.57 $8.32 $8.85 $8.59 $10.20 $9.90

5 82978 0-999 $16.96 $16.46 $17.52 $17.01 $20.19 $19.60

5 82979 0-999 $8.08 $7.85 $8.35 $8.11 $9.62 $9.34

5 82980 0-999 $21.80 $21.16 $22.53 $21.86 $25.95 $25.19

5 82985 0-999 $17.93 $17.40 $18.53 $17.98 $21.35 $20.72

5 83001 0-999 $22.11 $21.45 $22.85 $22.17 $26.32 $25.54

5 83002 0-999 $22.03 $21.39 $22.76 $22.10 $26.23 $25.46

5 83003 0-999 $19.84 $19.26 $20.50 $19.90 $23.62 $22.93

5 83008 0-999 $19.98 $19.38 $20.64 $20.02 $23.78 $23.07

5 83009 0-999 $80.14 $77.78 $82.81 $80.37 $95.40 $92.59

5 83010 0-999 $14.97 $14.52 $15.46 $15.01 $17.82 $17.29

5 83012 0-999 $20.45 $19.86 $21.13 $20.52 $24.35 $23.64

5 83013 0-999 $80.14 $77.78 $82.81 $80.37 $95.40 $92.59

5 83014 0-999 $9.36 $9.08 $9.67 $9.38 $11.14 $10.81

5 83015 0-999 $22.40 $21.75 $23.15 $22.47 $26.67 $25.89

5 83018 0-999 $26.13 $25.36 $27.01 $26.20 $31.11 $30.19

5 83020 0-999 $15.31 $14.86 $15.83 $15.35 $18.23 $17.69

5 83021 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 83026 0-999 $2.81 $2.73 $2.90 $2.82 $3.34 $3.25

5 83030 0-999 $9.84 $9.55 $10.16 $9.87 $11.71 $11.37

5 83033 0-999 $7.09 $6.88 $7.32 $7.11 $8.44 $8.19

5 83036 0-999 $11.55 $11.21 $11.94 $11.58 $13.75 $13.34

5 83037 0-999 $11.55 $11.21 $11.94 $11.58 $13.75 $13.34

5 83045 0-999 $3.43 $3.33 $3.54 $3.44 $4.08 $3.96

5 83050 0-999 $3.50 $3.40 $3.62 $3.52 $4.17 $4.05

5 83051 0-999 $8.69 $8.44 $8.99 $8.72 $10.35 $10.05

5 83055 0-999 $5.85 $5.68 $6.05 $5.87 $6.97 $6.76

5 83060 0-999 $6.86 $6.66 $7.09 $6.88 $8.17 $7.93

5 83065 0-999 $8.20 $7.95 $8.48 $8.22 $9.76 $9.47

5 83068 0-999 $8.08 $7.85 $8.35 $8.11 $9.62 $9.34

5 83069 0-999 $4.70 $4.56 $4.86 $4.71 $5.59 $5.43

5 83070 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 83071 0-999 $8.17 $7.93 $8.44 $8.19 $9.73 $9.44

5 83080 0-999 $11.86 $11.51 $12.26 $11.89 $14.12 $13.70

5 83088 0-999 $35.14 $34.10 $36.30 $35.24 $41.83 $40.60

5 83090 0-999 $20.07 $19.48 $20.74 $20.13 $23.89 $23.19

5 83150 0-999 $12.41 $12.04 $12.82 $12.44 $14.77 $14.33

5 83491 0-999 $20.84 $20.23 $21.54 $20.90 $24.81 $24.08

5 83497 0-999 $5.53 $5.37 $5.71 $5.55 $6.58 $6.39

5 83498 0-999 $32.32 $31.37 $33.40 $32.42 $38.48 $37.35

5 83499 0-999 $30.00 $29.11 $31.00 $30.08 $35.71 $34.65

5 83500 0-999 $26.95 $26.15 $27.85 $27.02 $32.08 $31.13

5 83505 0-999 $28.92 $28.07 $29.89 $29.01 $34.43 $33.42

5 83516 0-999 $13.73 $13.32 $14.18 $13.77 $16.34 $15.86

5 83518 0-999 $10.08 $9.79 $10.42 $10.11 $12.00 $11.65

5 83519 0-999 $16.08 $15.60 $16.62 $16.12 $19.14 $18.57

5 83520 0-999 $15.41 $14.95 $15.92 $15.45 $18.34 $17.80

5 83525 0-999 $13.60 $13.20 $14.05 $13.64 $16.19 $15.71

5 83527 0-999 $15.41 $14.95 $15.92 $15.45 $18.34 $17.80

5 83528 0-999 $18.93 $18.36 $19.56 $18.97 $22.53 $21.86

5 83540 0-999 $7.71 $7.48 $7.97 $7.73 $9.18 $8.90

5 83550 0-999 $10.40 $10.10 $10.74 $10.43 $12.38 $12.02

5 83570 0-999 $10.53 $10.21 $10.88 $10.55 $12.53 $12.16

5 83582 0-999 $16.87 $16.36 $17.43 $16.91 $20.08 $19.48

5 83586 0-999 $15.24 $14.78 $15.74 $15.28 $18.14 $17.60

5 83593 0-999 $26.09 $25.32 $26.96 $26.16 $31.06 $30.14

5 83605 0-999 $12.71 $12.33 $13.13 $12.74 $15.13 $14.68

5 83615 0-999 $7.18 $6.97 $7.43 $7.20 $8.55 $8.30

5 83625 0-999 $15.23 $14.78 $15.73 $15.28 $18.13 $17.60

5 83630 0-999 $23.35 $22.66 $24.13 $23.42 $27.80 $26.98

5 83631 0-999 $23.35 $22.66 $24.13 $23.42 $27.80 $26.98

5 83632 0-999 $24.05 $23.34 $24.85 $24.12 $28.63 $27.79

5 83633 0-999 $5.53 $5.37 $5.71 $5.55 $6.58 $6.39

5 83634 0-999 $3.43 $3.33 $3.54 $3.44 $4.08 $3.96

5 83655 0-999 $14.41 $13.98 $14.88 $14.44 $17.15 $16.64

S 83655 0-999 $14.41 $13.98 $14.88 $14.44 $17.15 $16.64

5 83661 0-999 $26.16 $25.38 $27.03 $26.23 $31.14 $30.22

5 83662 0-999 $22.51 $21.84 $23.26 $22.57 $26.80 $26.00

5 83663 0-999 $22.51 $21.84 $23.26 $22.57 $26.80 $26.00

5 83664 0-999 $22.51 $21.84 $23.26 $22.57 $26.80 $26.00

5 83670 0-999 $10.90 $10.58 $11.26 $10.93 $12.98 $12.59

5 83690 0-999 $8.20 $7.95 $8.48 $8.22 $9.76 $9.47

5 83695 0-999 $15.41 $14.95 $15.92 $15.45 $18.34 $17.80

5 83700 0-999 $13.40 $12.99 $13.84 $13.43 $15.95 $15.47

5 83701 0-999 $29.53 $28.66 $30.52 $29.62 $35.16 $34.12

5 83704 0-999 $37.54 $36.42 $38.79 $37.64 $44.69 $43.36

5 83718 0-999 $9.74 $9.46 $10.07 $9.77 $11.60 $11.26

5 83719 0-999 $13.84 $13.43 $14.31 $13.88 $16.48 $15.99

5 83721 0-999 $11.35 $11.01 $11.73 $11.38 $13.51 $13.11

5 83727 0-999 $20.45 $19.86 $21.13 $20.52 $24.35 $23.64

5 83735 0-999 $7.97 $7.74 $8.24 $7.99 $9.49 $9.21

5 83775 0-999 $8.77 $8.51 $9.06 $8.79 $10.44 $10.13

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 83785 0-999 $29.26 $28.39 $30.23 $29.34 $34.83 $33.80

5 83788 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 83789 0-999 $21.48 $20.85 $22.19 $21.54 $25.57 $24.82

5 83805 0-999 $20.97 $20.35 $21.67 $21.03 $24.97 $24.23

5 83825 0-999 $15.43 $14.98 $15.94 $15.48 $18.37 $17.83

5 83835 0-999 $20.16 $19.56 $20.83 $20.22 $24.00 $23.29

5 83840 0-999 $19.43 $18.86 $20.08 $19.49 $23.13 $22.45

5 83857 0-999 $12.78 $12.40 $13.20 $12.81 $15.21 $14.76

5 83858 0-999 $8.08 $7.85 $8.35 $8.11 $9.62 $9.34

5 83861 0-999 $19.66 $19.08 $20.31 $19.71 $23.40 $22.71

5 83864 0-999 $23.69 $22.99 $24.48 $23.76 $28.20 $27.37

5 83866 0-999 $11.41 $11.07 $11.79 $11.44 $13.58 $13.18

5 83872 0-999 $6.97 $6.77 $7.21 $7.00 $8.30 $8.06

5 83873 0-999 $20.47 $19.87 $21.15 $20.53 $24.37 $23.65

5 83874 0-999 $15.36 $14.91 $15.88 $15.41 $18.29 $17.75

5 83880 0-999 $40.39 $39.19 $41.73 $40.50 $48.08 $46.66

5 83883 0-999 $16.17 $15.70 $16.71 $16.22 $19.25 $18.69

5 83885 0-999 $29.15 $28.29 $30.12 $29.23 $34.70 $33.68

5 83887 0-999 $28.17 $27.34 $29.11 $28.25 $33.54 $32.55

5 83915 0-999 $13.27 $12.88 $13.72 $13.31 $15.80 $15.33

5 83916 0-999 $23.92 $23.22 $24.72 $23.99 $28.48 $27.64

5 83918 0-999 $19.58 $19.00 $20.24 $19.63 $23.31 $22.62

5 83919 0-999 $19.58 $19.00 $20.24 $19.63 $23.31 $22.62

5 83921 0-999 $19.58 $19.00 $20.24 $19.63 $23.31 $22.62

5 83925 0-999 $23.15 $22.46 $23.92 $23.21 $27.56 $26.74

5 83930 0-999 $5.86 $5.69 $6.06 $5.88 $6.98 $6.77

5 83935 0-999 $5.86 $5.69 $6.06 $5.88 $6.98 $6.77

5 83937 0-999 $33.88 $32.88 $35.00 $33.97 $40.33 $39.14

5 83945 0-999 $15.31 $14.86 $15.83 $15.35 $18.23 $17.69

5 83950 0-999 $76.63 $74.37 $79.19 $76.85 $91.23 $88.54

5 83951 0-999 $76.63 $74.37 $79.19 $76.85 $91.23 $88.54

5 83970 0-999 $49.11 $47.66 $50.74 $49.25 $58.46 $56.74

5 83986 0-999 $4.26 $4.13 $4.40 $4.27 $5.07 $4.92

5 83992 0-999 $17.49 $16.97 $18.07 $17.53 $20.82 $20.20

5 83993 0-999 $23.35 $22.66 $24.13 $23.42 $27.80 $26.98

5 84022 0-999 $13.51 $13.11 $13.96 $13.55 $16.08 $15.61

5 84030 0-999 $6.54 $6.35 $6.76 $6.56 $7.79 $7.56

5 84035 0-999 $2.42 $2.35 $2.50 $2.43 $2.88 $2.80

5 84060 0-999 $8.79 $8.53 $9.08 $8.81 $10.46 $10.15

5 84066 0-999 $11.49 $11.16 $11.88 $11.53 $13.68 $13.28

5 84075 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 84078 0-999 $8.69 $8.43 $8.97 $8.71 $10.34 $10.03

5 84080 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 84081 0-999 $19.66 $19.08 $20.31 $19.71 $23.40 $22.71

5 84085 0-999 $8.02 $7.78 $8.29 $8.04 $9.55 $9.26

5 84087 0-999 $12.28 $11.92 $12.69 $12.32 $14.62 $14.19

5 84100 0-999 $5.64 $5.48 $5.83 $5.66 $6.72 $6.52

5 84105 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 84106 0-999 $5.09 $4.94 $5.26 $5.10 $6.06 $5.88

5 84110 0-999 $10.05 $9.74 $10.38 $10.07 $11.96 $11.60

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 84112 0-999 $76.63 $74.37 $79.19 $76.85 $91.23 $88.54

5 84119 0-999 $10.25 $9.95 $10.59 $10.28 $12.20 $11.84

5 84120 0-999 $17.50 $16.98 $18.08 $17.55 $20.83 $20.22

5 84126 0-999 $30.31 $29.41 $31.32 $30.39 $36.08 $35.01

5 84127 0-999 $13.86 $13.46 $14.32 $13.91 $16.50 $16.02

5 84132 0-999 $5.47 $5.31 $5.65 $5.49 $6.51 $6.32

5 84133 0-999 $5.12 $4.96 $5.28 $5.13 $6.09 $5.91

5 84134 0-999 $10.05 $9.75 $10.38 $10.08 $11.96 $11.61

5 84135 0-999 $22.76 $22.09 $23.52 $22.83 $27.10 $26.30

5 84138 0-999 $20.76 $20.15 $21.45 $20.82 $24.72 $23.99

5 84140 0-999 $24.60 $23.87 $25.43 $24.67 $29.29 $28.42

5 84143 0-999 $26.80 $26.01 $27.69 $26.88 $31.91 $30.97

5 84144 0-999 $24.82 $24.09 $25.65 $24.89 $29.55 $28.68

5 84145 0-999 $31.86 $30.93 $32.92 $31.96 $37.93 $36.82

5 84146 0-999 $23.06 $22.38 $23.83 $23.12 $27.45 $26.64

5 84150 0-999 $29.69 $28.82 $30.69 $29.78 $35.35 $34.31

5 84152 0-999 $21.89 $21.24 $22.62 $21.95 $26.06 $25.29

5 84153 0-999 $21.89 $21.24 $22.62 $21.95 $26.06 $25.29

5 84154 0-999 $21.89 $21.24 $22.62 $21.95 $26.06 $25.29

5 84155 0-999 $4.36 $4.23 $4.50 $4.37 $5.19 $5.04

5 84156 0-999 $4.36 $4.23 $4.50 $4.37 $5.19 $5.04

5 84157 0-999 $4.36 $4.23 $4.50 $4.37 $5.19 $5.04

5 84160 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 84163 0-999 $10.39 $10.09 $10.74 $10.42 $12.37 $12.01

5 84165 0-999 $12.78 $12.40 $13.20 $12.81 $15.21 $14.76

5 84166 0-999 $21.22 $20.60 $21.92 $21.28 $25.26 $24.52

I 84166 0-999 $21.22 $20.60 $21.92 $21.28 $25.26 $24.52

5 84181 0-999 $20.26 $19.66 $20.93 $20.32 $24.12 $23.41

5 84182 0-999 $21.41 $20.78 $22.13 $21.47 $25.49 $24.74

5 84202 0-999 $10.51 $10.20 $10.86 $10.54 $12.51 $12.14

5 84203 0-999 $10.25 $9.94 $10.59 $10.27 $12.20 $11.83

5 84206 0-999 $21.19 $20.57 $21.90 $21.26 $25.23 $24.49

5 84207 0-999 $33.43 $32.44 $34.55 $33.52 $39.80 $38.62

5 84210 0-999 $12.91 $12.53 $13.34 $12.95 $15.37 $14.92

5 84220 0-999 $11.22 $10.89 $11.60 $11.26 $13.36 $12.97

5 84228 0-999 $13.84 $13.43 $14.31 $13.88 $16.48 $15.99

5 84233 0-999 $76.63 $74.37 $79.19 $76.85 $91.23 $88.54

5 84234 0-999 $77.19 $74.91 $79.76 $77.41 $91.89 $89.18

5 84235 0-999 $62.27 $60.43 $64.34 $62.44 $74.13 $71.94

5 84238 0-999 $43.50 $42.23 $44.96 $43.63 $51.79 $50.27

5 84244 0-999 $26.17 $25.40 $27.04 $26.25 $31.15 $30.24

5 84252 0-999 $24.07 $23.37 $24.88 $24.15 $28.66 $27.82

5 84255 0-999 $30.37 $29.48 $31.39 $30.47 $36.16 $35.10

5 84260 0-999 $20.70 $20.08 $21.39 $20.75 $24.64 $23.91

5 84270 0-999 $25.86 $25.09 $26.72 $25.93 $30.78 $29.87

5 84275 0-999 $11.73 $11.39 $12.13 $11.77 $13.97 $13.56

5 84285 0-999 $28.01 $27.19 $28.95 $28.10 $33.35 $32.37

5 84295 0-999 $5.73 $5.56 $5.92 $5.75 $6.82 $6.62

5 84300 0-999 $5.79 $5.62 $5.98 $5.81 $6.89 $6.69

5 84302 0-999 $5.79 $5.62 $5.98 $5.81 $6.89 $6.69

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 84305 0-999 $25.29 $24.54 $26.13 $25.36 $30.11 $29.22

5 84307 0-999 $21.76 $21.11 $22.48 $21.81 $25.90 $25.13

5 84311 0-999 $8.32 $8.07 $8.59 $8.34 $9.90 $9.61

5 84315 0-999 $2.98 $2.90 $3.08 $2.99 $3.55 $3.45

5 84375 0-999 $23.33 $22.64 $24.11 $23.39 $27.77 $26.95

5 84376 0-999 $5.53 $5.37 $5.71 $5.55 $6.58 $6.39

5 84377 0-999 $5.53 $5.37 $5.71 $5.55 $6.58 $6.39

5 84378 0-999 $3.43 $3.33 $3.54 $3.44 $4.08 $3.96

5 84379 0-999 $3.43 $3.33 $3.54 $3.44 $4.08 $3.96

5 84392 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

5 84402 0-999 $30.30 $29.40 $31.31 $30.38 $36.07 $35.00

5 84403 0-999 $30.72 $29.81 $31.74 $30.81 $36.57 $35.49

5 84425 0-999 $8.08 $7.85 $8.35 $8.11 $9.62 $9.34

5 84430 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 84431 0-999 $19.99 $19.40 $20.66 $20.05 $23.80 $23.10

5 84432 0-999 $19.12 $18.55 $19.76 $19.17 $22.76 $22.08

5 84436 0-999 $8.17 $7.93 $8.44 $8.19 $9.73 $9.44

5 84437 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 84439 0-999 $10.73 $10.42 $11.09 $10.76 $12.77 $12.40

5 84442 0-999 $17.60 $17.08 $18.19 $17.65 $20.95 $20.33

5 84443 0-999 $19.99 $19.40 $20.66 $20.05 $23.80 $23.10

5 84445 0-999 $60.50 $58.72 $62.51 $60.67 $72.02 $69.90

5 84446 0-999 $16.87 $16.37 $17.43 $16.92 $20.08 $19.49

5 84449 0-999 $21.41 $20.78 $22.13 $21.47 $25.49 $24.74

5 84450 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 84460 0-999 $6.30 $6.11 $6.51 $6.31 $7.50 $7.27

5 84466 0-999 $10.95 $10.63 $11.31 $10.98 $13.03 $12.65

5 84478 0-999 $6.85 $6.64 $7.07 $6.86 $8.15 $7.90

5 84479 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 84480 0-999 $16.87 $16.37 $17.43 $16.92 $20.08 $19.49

5 84481 0-999 $20.16 $19.56 $20.83 $20.22 $24.00 $23.29

5 84482 0-999 $9.16 $8.89 $9.46 $9.18 $10.90 $10.58

5 84484 0-999 $11.71 $11.37 $12.10 $11.74 $13.94 $13.53

5 84485 0-999 $8.93 $8.67 $9.22 $8.96 $10.63 $10.32

5 84488 0-999 $8.69 $8.43 $8.97 $8.71 $10.34 $10.03

5 84490 0-999 $9.05 $8.79 $9.35 $9.08 $10.77 $10.46

5 84510 0-999 $12.37 $12.01 $12.78 $12.41 $14.73 $14.30

5 84512 0-999 $8.79 $8.53 $9.08 $8.81 $10.46 $10.15

5 84520 0-999 $4.70 $4.56 $4.86 $4.71 $5.59 $5.43

5 84525 0-999 $4.48 $4.34 $4.63 $4.49 $5.33 $5.17

5 84540 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

5 84545 0-999 $7.85 $7.63 $8.11 $7.88 $9.35 $9.08

5 84550 0-999 $5.38 $5.22 $5.55 $5.39 $6.40 $6.21

5 84560 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

5 84577 0-999 $6.86 $6.66 $7.09 $6.88 $8.17 $7.93

5 84578 0-999 $3.86 $3.75 $3.99 $3.88 $4.60 $4.47

5 84580 0-999 $6.86 $6.66 $7.09 $6.88 $8.17 $7.93

5 84583 0-999 $5.98 $5.80 $6.18 $6.00 $7.12 $6.91

5 84585 0-999 $18.45 $17.89 $19.06 $18.49 $21.96 $21.30

5 84586 0-999 $16.60 $16.11 $17.15 $16.65 $19.76 $19.18

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 84588 0-999 $40.39 $39.19 $41.73 $40.50 $48.08 $46.66

5 84590 0-999 $13.80 $13.40 $14.26 $13.84 $16.43 $15.95

5 84591 0-999 $13.80 $13.40 $14.26 $13.84 $16.43 $15.95

5 84597 0-999 $8.08 $7.85 $8.35 $8.11 $9.62 $9.34

5 84600 0-999 $19.13 $18.56 $19.77 $19.18 $22.77 $22.10

5 84620 0-999 $14.10 $13.68 $14.57 $14.14 $16.78 $16.29

5 84630 0-999 $13.54 $13.15 $13.99 $13.58 $16.12 $15.65

5 84681 0-999 $24.75 $24.03 $25.58 $24.83 $29.47 $28.61

5 84702 0-999 $10.39 $10.09 $10.74 $10.42 $12.37 $12.01

5 84703 0-999 $8.94 $8.68 $9.23 $8.97 $10.64 $10.33

5 84704 0-999 $10.39 $10.09 $10.74 $10.42 $12.37 $12.01

5 85002 0-999 $5.36 $5.20 $5.54 $5.37 $6.38 $6.19

5 85004 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 85007 0-999 $4.09 $3.97 $4.23 $4.11 $4.87 $4.73

5 85008 0-999 $4.09 $3.97 $4.23 $4.11 $4.87 $4.73

5 85009 0-999 $4.43 $4.29 $4.58 $4.44 $5.27 $5.11

5 85013 0-999 $2.81 $2.74 $2.91 $2.83 $3.35 $3.26

5 85014 0-999 $2.81 $2.74 $2.91 $2.83 $3.35 $3.26

5 85018 0-999 $2.81 $2.74 $2.91 $2.83 $3.35 $3.26

5 85025 0-999 $9.26 $8.98 $9.57 $9.28 $11.02 $10.69

5 85027 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 85032 0-999 $5.12 $4.96 $5.28 $5.13 $6.09 $5.91

5 85041 0-999 $3.59 $3.48 $3.70 $3.59 $4.27 $4.14

5 85044 0-999 $5.12 $4.96 $5.28 $5.13 $6.09 $5.91

5 85045 0-999 $4.76 $4.62 $4.92 $4.77 $5.67 $5.50

5 85046 0-999 $6.64 $6.44 $6.85 $6.66 $7.90 $7.67

5 85048 0-999 $3.02 $2.93 $3.12 $3.03 $3.60 $3.49

5 85049 0-999 $5.32 $5.17 $5.49 $5.34 $6.33 $6.15

5 85055 0-999 $31.85 $30.91 $32.91 $31.94 $37.92 $36.80

5 85130 0-999 $14.15 $13.73 $14.62 $14.19 $16.85 $16.35

5 85170 0-999 $4.30 $4.17 $4.44 $4.31 $5.12 $4.97

5 85175 0-999 $5.42 $5.25 $5.59 $5.43 $6.45 $6.25

5 85210 0-999 $15.45 $14.99 $15.96 $15.49 $18.39 $17.85

5 85220 0-999 $21.00 $20.38 $21.70 $21.06 $25.00 $24.26

5 85230 0-999 $21.30 $20.67 $22.02 $21.36 $25.36 $24.61

5 85240 0-999 $7.64 $7.41 $7.89 $7.66 $9.09 $8.82

5 85244 0-999 $24.28 $23.57 $25.09 $24.36 $28.91 $28.06

5 85245 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 85246 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 85247 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 85250 0-999 $22.65 $21.98 $23.41 $22.72 $26.97 $26.17

5 85260 0-999 $21.30 $20.67 $22.02 $21.36 $25.36 $24.61

5 85270 0-999 $21.30 $20.67 $22.02 $21.36 $25.36 $24.61

5 85280 0-999 $23.02 $22.34 $23.78 $23.09 $27.40 $26.60

5 85290 0-999 $19.45 $18.87 $20.09 $19.50 $23.15 $22.47

5 85291 0-999 $10.58 $10.26 $10.93 $10.61 $12.59 $12.22

5 85292 0-999 $22.54 $21.87 $23.28 $22.59 $26.83 $26.03

5 85293 0-999 $22.54 $21.87 $23.28 $22.59 $26.83 $26.03

5 85300 0-999 $14.10 $13.68 $14.57 $14.14 $16.79 $16.29

5 85301 0-999 $12.86 $12.48 $13.29 $12.90 $15.31 $14.86

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 85302 0-999 $14.31 $13.88 $14.78 $14.34 $17.03 $16.52

5 85303 0-999 $16.46 $15.97 $17.00 $16.50 $19.59 $19.01

5 85305 0-999 $13.80 $13.40 $14.26 $13.84 $16.43 $15.95

5 85306 0-999 $16.42 $15.93 $16.97 $16.47 $19.55 $18.97

5 85307 0-999 $16.42 $15.93 $16.97 $16.47 $19.55 $18.97

5 85335 0-999 $15.31 $14.86 $15.83 $15.35 $18.23 $17.69

5 85337 0-999 $12.41 $12.04 $12.82 $12.44 $14.77 $14.33

5 85345 0-999 $5.12 $4.96 $5.28 $5.13 $6.09 $5.91

5 85347 0-999 $5.07 $4.91 $5.23 $5.08 $6.03 $5.85

5 85348 0-999 $4.44 $4.30 $4.59 $4.44 $5.28 $5.12

5 85360 0-999 $10.00 $9.70 $10.33 $10.03 $11.90 $11.55

5 85362 0-999 $8.20 $7.95 $8.48 $8.22 $9.76 $9.47

5 85366 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 85370 0-999 $11.08 $10.75 $11.45 $11.11 $13.19 $12.80

5 85378 0-999 $8.48 $8.24 $8.77 $8.52 $10.10 $9.81

5 85379 0-999 $11.08 $10.75 $11.45 $11.11 $13.19 $12.80

5 85380 0-999 $11.08 $10.75 $11.45 $11.11 $13.19 $12.80

5 85384 0-999 $10.11 $9.81 $10.44 $10.14 $12.03 $11.68

5 85385 0-999 $10.11 $9.81 $10.44 $10.14 $12.03 $11.68

5 85390 0-999 $6.15 $5.96 $6.35 $6.16 $7.32 $7.10

5 85397 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 85400 0-999 $10.53 $10.21 $10.88 $10.55 $12.53 $12.16

5 85410 0-999 $9.18 $8.90 $9.48 $9.20 $10.93 $10.60

5 85415 0-999 $20.45 $19.86 $21.13 $20.52 $24.35 $23.64

5 85420 0-999 $7.78 $7.54 $8.04 $7.79 $9.26 $8.98

5 85421 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 85441 0-999 $5.01 $4.86 $5.17 $5.02 $5.96 $5.78

5 85445 0-999 $8.11 $7.87 $8.37 $8.13 $9.65 $9.37

5 85460 0-999 $9.21 $8.94 $9.53 $9.24 $10.97 $10.64

5 85461 0-999 $7.90 $7.66 $8.16 $7.92 $9.40 $9.12

5 85475 0-999 $10.56 $10.25 $10.91 $10.59 $12.57 $12.20

5 85520 0-999 $15.57 $15.12 $16.09 $15.62 $18.54 $18.00

5 85525 0-999 $14.10 $13.68 $14.57 $14.13 $16.78 $16.28

5 85530 0-999 $16.16 $15.68 $16.70 $16.21 $19.24 $18.67

5 85536 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 85540 0-999 $10.24 $9.94 $10.58 $10.27 $12.19 $11.83

5 85547 0-999 $10.24 $9.94 $10.58 $10.27 $12.19 $11.83

5 85549 0-999 $22.32 $21.66 $23.07 $22.38 $26.57 $25.78

5 85555 0-999 $7.95 $7.71 $8.22 $7.97 $9.46 $9.18

5 85557 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 85576 0-999 $25.56 $24.81 $26.41 $25.63 $30.43 $29.53

5 85597 0-999 $17.27 $16.76 $17.85 $17.32 $20.56 $19.95

5 85598 0-999 $17.27 $16.76 $17.85 $17.32 $20.56 $19.95

5 85610 0-999 $4.67 $4.54 $4.83 $4.69 $5.56 $5.40

5 85611 0-999 $4.69 $4.55 $4.85 $4.70 $5.58 $5.42

5 85612 0-999 $8.32 $8.07 $8.59 $8.34 $9.90 $9.61

5 85613 0-999 $8.32 $8.07 $8.59 $8.34 $9.90 $9.61

5 85635 0-999 $11.72 $11.37 $12.10 $11.74 $13.95 $13.53

5 85651 0-999 $4.22 $4.10 $4.36 $4.24 $5.02 $4.88

5 85652 0-999 $3.22 $3.12 $3.33 $3.22 $3.83 $3.71

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 85660 0-999 $6.56 $6.38 $6.78 $6.59 $7.81 $7.59

5 85670 0-999 $6.87 $6.66 $7.10 $6.88 $8.18 $7.93

5 85675 0-999 $7.64 $7.41 $7.89 $7.66 $9.09 $8.82

5 85705 0-999 $10.11 $9.81 $10.45 $10.14 $12.04 $11.68

5 85730 0-999 $7.14 $6.93 $7.38 $7.16 $8.50 $8.25

5 85732 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 85810 0-999 $13.89 $13.47 $14.35 $13.92 $16.53 $16.04

5 86000 0-999 $8.31 $8.06 $8.58 $8.33 $9.89 $9.60

5 86001 0-999 $5.69 $5.52 $5.88 $5.70 $6.77 $6.57

5 86003 0-999 $5.69 $5.52 $5.88 $5.70 $6.77 $6.57

5 86005 0-999 $9.48 $9.21 $9.80 $9.51 $11.29 $10.96

5 86021 0-999 $17.92 $17.39 $18.51 $17.97 $21.33 $20.70

5 86022 0-999 $11.64 $11.30 $12.03 $11.67 $13.86 $13.45

5 86023 0-999 $6.86 $6.66 $7.09 $6.88 $8.17 $7.93

5 86038 0-999 $14.38 $13.96 $14.86 $14.43 $17.12 $16.62

5 86039 0-999 $13.28 $12.89 $13.73 $13.32 $15.81 $15.35

5 86060 0-999 $8.69 $8.43 $8.97 $8.71 $10.34 $10.03

5 86063 0-999 $6.87 $6.66 $7.10 $6.88 $8.18 $7.93

5 86140 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 86141 0-999 $15.41 $14.95 $15.92 $15.45 $18.34 $17.80

5 86146 0-999 $9.34 $9.06 $9.65 $9.37 $11.12 $10.79

5 86147 0-999 $9.34 $9.06 $9.65 $9.37 $11.12 $10.79

5 86148 0-999 $9.34 $9.06 $9.65 $9.37 $11.12 $10.79

5 86155 0-999 $19.02 $18.45 $19.65 $19.07 $22.64 $21.97

5 86156 0-999 $7.97 $7.74 $8.24 $7.99 $9.49 $9.21

5 86157 0-999 $9.60 $9.32 $9.92 $9.63 $11.43 $11.09

5 86160 0-999 $14.29 $13.86 $14.77 $14.32 $17.01 $16.50

5 86161 0-999 $14.29 $13.86 $14.77 $14.32 $17.01 $16.50

5 86162 0-999 $22.35 $21.70 $23.10 $22.42 $26.61 $25.83

5 86171 0-999 $7.64 $7.41 $7.89 $7.66 $9.09 $8.82

5 86185 0-999 $10.64 $10.32 $11.00 $10.67 $12.67 $12.29

5 86200 0-999 $15.41 $14.95 $15.92 $15.45 $18.34 $17.80

5 86215 0-999 $15.77 $15.30 $16.30 $15.81 $18.77 $18.21

5 86225 0-999 $16.34 $15.86 $16.88 $16.39 $19.45 $18.88

5 86226 0-999 $14.41 $13.99 $14.88 $14.45 $17.15 $16.65

5 86235 0-999 $21.34 $20.71 $22.05 $21.40 $25.40 $24.65

5 86243 0-999 $24.41 $23.69 $25.23 $24.48 $29.06 $28.20

5 86255 0-999 $14.34 $13.92 $14.82 $14.38 $17.07 $16.57

5 86256 0-999 $14.34 $13.92 $14.82 $14.38 $17.07 $16.57

5 86277 0-999 $18.72 $18.17 $19.35 $18.77 $22.29 $21.63

5 86280 0-999 $9.74 $9.46 $10.07 $9.77 $11.60 $11.26

5 86294 0-999 $23.34 $22.65 $24.12 $23.41 $27.79 $26.97

5 86300 0-999 $24.76 $24.03 $25.59 $24.83 $29.48 $28.61

5 86301 0-999 $24.76 $24.03 $25.59 $24.83 $29.48 $28.61

5 86304 0-999 $24.76 $24.03 $25.59 $24.83 $29.48 $28.61

5 86305 0-999 $24.76 $24.03 $25.59 $24.83 $29.48 $28.61

5 86308 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 86309 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 86310 0-999 $8.77 $8.51 $9.06 $8.79 $10.44 $10.13

5 86316 0-999 $24.76 $24.03 $25.59 $24.83 $29.48 $28.61

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 86317 0-999 $17.84 $17.31 $18.44 $17.89 $21.24 $20.61

5 86318 0-999 $15.41 $14.95 $15.92 $15.45 $18.34 $17.80

5 86320 0-999 $26.67 $25.88 $27.56 $26.74 $31.75 $30.81

5 86325 0-999 $26.60 $25.82 $27.49 $26.68 $31.67 $30.74

5 86327 0-999 $27.00 $26.20 $27.90 $27.07 $32.14 $31.19

5 86329 0-999 $10.95 $10.63 $11.31 $10.99 $13.04 $12.66

5 86331 0-999 $14.26 $13.83 $14.74 $14.30 $16.98 $16.47

5 86332 0-999 $29.00 $28.14 $29.96 $29.08 $34.52 $33.50

5 86334 0-999 $26.58 $25.80 $27.46 $26.66 $31.64 $30.71

5 86334 0-999 $26.58 $25.80 $27.46 $26.66 $31.64 $30.71

5 86335 0-999 $34.92 $33.89 $36.09 $35.02 $41.57 $40.34

5 86336 0-999 $18.54 $17.99 $19.16 $18.59 $22.07 $21.42

5 86337 0-999 $20.59 $19.98 $21.28 $20.65 $24.51 $23.79

5 86340 0-999 $17.93 $17.40 $18.53 $17.98 $21.35 $20.72

5 86341 0-999 $20.59 $19.98 $21.28 $20.65 $24.51 $23.79

5 86343 0-999 $14.83 $14.39 $15.32 $14.87 $17.65 $17.13

5 86344 0-999 $9.50 $9.22 $9.82 $9.53 $11.31 $10.98

5 86352 0-999 $161.64 $156.87 $167.03 $162.10 $192.43 $186.75

5 86353 0-999 $58.33 $56.61 $60.27 $58.49 $69.44 $67.39

5 86355 0-999 $44.88 $43.55 $46.38 $45.01 $53.43 $51.85

5 86356 0-999 $31.85 $30.91 $32.91 $31.94 $37.92 $36.80

5 86357 0-999 $44.88 $43.55 $46.38 $45.01 $53.43 $51.85

5 86359 0-999 $44.88 $43.55 $46.38 $45.01 $53.43 $51.85

5 86360 0-999 $55.90 $54.26 $57.77 $56.06 $66.55 $64.59

5 86361 0-999 $31.85 $30.91 $32.91 $31.94 $37.92 $36.80

5 86367 0-999 $44.88 $43.55 $46.38 $45.01 $53.43 $51.85

5 86376 0-999 $17.31 $16.79 $17.89 $17.35 $20.61 $19.99

5 86378 0-999 $23.42 $22.73 $24.20 $23.49 $27.88 $27.06

5 86382 0-999 $20.12 $19.53 $20.79 $20.18 $23.95 $23.25

5 86384 0-999 $13.54 $13.15 $13.99 $13.58 $16.12 $15.65

5 86386 0-999 $18.99 $18.44 $19.62 $19.05 $22.61 $21.95

5 86403 0-999 $12.13 $11.77 $12.53 $12.16 $14.44 $14.01

5 86406 0-999 $10.68 $10.37 $11.03 $10.71 $12.71 $12.34

5 86430 0-999 $6.75 $6.55 $6.98 $6.77 $8.04 $7.80

5 86431 0-999 $6.75 $6.55 $6.98 $6.77 $8.04 $7.80

5 86480 0-999 $73.74 $71.57 $76.20 $73.95 $87.79 $85.20

5 86481 0-999 $73.74 $86.51 $76.20 $89.40 $87.79 $102.99

5 86590 0-999 $13.14 $12.75 $13.57 $13.18 $15.64 $15.18

5 86592 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 86593 0-999 $5.23 $5.08 $5.41 $5.25 $6.23 $6.05

5 86602 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86603 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86606 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86609 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86611 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86612 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86615 0-999 $15.69 $15.23 $16.21 $15.74 $18.68 $18.13

5 86617 0-999 $18.43 $17.89 $19.04 $18.49 $21.94 $21.30

5 86618 0-999 $20.26 $19.66 $20.93 $20.32 $24.12 $23.41

5 86619 0-999 $15.92 $15.45 $16.45 $15.96 $18.95 $18.39

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 86622 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86625 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86628 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86631 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86632 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86635 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86638 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86641 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86644 0-999 $17.13 $16.62 $17.70 $17.18 $20.39 $19.79

5 86645 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86648 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86651 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86652 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86653 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86654 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86658 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86663 0-999 $15.61 $15.15 $16.13 $15.65 $18.58 $18.03

5 86664 0-999 $18.20 $17.67 $18.81 $18.25 $21.67 $21.03

5 86665 0-999 $21.58 $20.95 $22.30 $21.65 $25.69 $24.94

5 86666 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86668 0-999 $12.37 $12.01 $12.78 $12.41 $14.73 $14.30

5 86671 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86674 0-999 $17.51 $17.00 $18.10 $17.57 $20.85 $20.24

5 86677 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86682 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86684 0-999 $18.85 $18.30 $19.48 $18.91 $22.44 $21.78

5 86687 0-999 $9.98 $9.69 $10.32 $10.02 $11.88 $11.54

5 86688 0-999 $11.87 $11.52 $12.26 $11.90 $14.13 $13.71

5 86689 0-999 $23.02 $22.34 $23.79 $23.09 $27.41 $26.60

5 86692 0-999 $20.42 $19.82 $21.10 $20.48 $24.31 $23.59

5 86694 0-999 $17.13 $16.62 $17.70 $17.18 $20.39 $19.79

5 86695 0-999 $15.69 $15.23 $16.21 $15.74 $18.68 $18.13

5 86696 0-999 $23.02 $22.34 $23.79 $23.09 $27.41 $26.60

5 86698 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86701 0-999 $10.57 $10.26 $10.92 $10.60 $12.58 $12.21

D 86701 0-999 $10.57 $10.26 $10.92 $10.60 $12.58 $12.21

5 86702 0-999 $12.57 $12.20 $12.99 $12.60 $14.96 $14.52

5 86703 0-999 $16.32 $15.83 $16.87 $16.36 $19.43 $18.85

D 86703 0-999 $16.32 $15.83 $16.87 $16.36 $19.43 $18.85

5 86704 0-999 $14.34 $13.92 $14.82 $14.38 $17.07 $16.57

5 86705 0-999 $14.00 $13.59 $14.47 $14.04 $16.67 $16.18

5 86706 0-999 $12.78 $12.40 $13.20 $12.81 $15.21 $14.76

5 86707 0-999 $13.76 $13.36 $14.22 $13.80 $16.38 $15.90

5 86708 0-999 $14.74 $14.31 $15.23 $14.78 $17.55 $17.03

5 86709 0-999 $13.40 $12.99 $13.84 $13.43 $15.95 $15.47

5 86710 0-999 $16.13 $15.65 $16.67 $16.17 $19.20 $18.63

5 86713 0-999 $18.20 $17.67 $18.81 $18.26 $21.67 $21.04

5 86717 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86720 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86723 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 86727 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86729 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86732 0-999 $15.69 $15.23 $16.21 $15.74 $18.68 $18.13

5 86735 0-999 $15.53 $15.07 $16.05 $15.57 $18.49 $17.94

5 86738 0-999 $15.76 $15.29 $16.29 $15.80 $18.76 $18.20

5 86741 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86744 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86747 0-999 $17.89 $17.36 $18.49 $17.94 $21.30 $20.67

5 86750 0-999 $15.69 $15.23 $16.21 $15.74 $18.68 $18.13

5 86753 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86756 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86757 0-999 $23.02 $22.34 $23.79 $23.09 $27.41 $26.60

5 86759 0-999 $15.69 $15.23 $16.21 $15.74 $18.68 $18.13

5 86762 0-999 $17.13 $16.62 $17.70 $17.18 $20.39 $19.79

5 86765 0-999 $15.33 $14.88 $15.84 $15.37 $18.25 $17.71

5 86768 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86771 0-999 $15.69 $15.23 $16.21 $15.74 $18.68 $18.13

5 86774 0-999 $17.61 $17.09 $18.19 $17.66 $20.96 $20.34

5 86777 0-999 $17.13 $16.62 $17.70 $17.18 $20.39 $19.79

5 86778 0-999 $15.20 $14.75 $15.70 $15.24 $18.09 $17.56

5 86780 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 86784 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86787 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86788 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86789 0-999 $17.13 $16.62 $17.70 $17.18 $20.39 $19.79

5 86790 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86793 0-999 $9.73 $9.44 $10.05 $9.76 $11.58 $11.24

5 86800 0-999 $18.93 $18.36 $19.56 $18.97 $22.53 $21.86

5 86803 0-999 $16.98 $16.48 $17.55 $17.03 $20.22 $19.62

5 86804 0-999 $18.43 $17.89 $19.04 $18.49 $21.94 $21.30

5 86805 0-999 $62.21 $60.38 $64.29 $62.39 $74.06 $71.88

5 86806 0-999 $56.62 $54.95 $58.51 $56.78 $67.41 $65.42

5 86807 0-999 $47.08 $45.70 $48.65 $47.22 $56.05 $54.40

5 86808 0-999 $35.31 $34.27 $36.49 $35.41 $42.04 $40.80

5 86812 0-999 $30.71 $29.80 $31.74 $30.80 $36.56 $35.48

5 86813 0-999 $61.76 $59.93 $63.81 $61.93 $73.52 $71.35

5 86816 0-999 $33.15 $32.17 $34.26 $33.24 $39.46 $38.30

5 86817 0-999 $61.76 $59.93 $63.81 $61.93 $73.52 $71.35

5 86821 0-999 $61.76 $59.93 $63.81 $61.93 $73.52 $71.35

5 86822 0-999 $43.50 $42.21 $44.95 $43.62 $51.78 $50.25

5 86825 0-999 $95.56 $92.74 $98.74 $95.83 $113.76 $110.40

5 86826 0-999 $31.85 $30.91 $32.91 $31.94 $37.92 $36.80

5 86880 0-999 $6.39 $6.21 $6.60 $6.41 $7.61 $7.39

5 86885 0-999 $6.81 $6.61 $7.04 $6.83 $8.11 $7.87

5 86886 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 86900 0-999 $3.55 $3.44 $3.67 $3.56 $4.23 $4.10

5 86901 0-999 $3.55 $3.44 $3.67 $3.56 $4.23 $4.10

5 86902 0-999 $4.55 $4.41 $4.70 $4.56 $5.42 $5.25

5 86904 0-999 $11.31 $10.98 $11.69 $11.34 $13.47 $13.07

5 86905 0-999 $4.55 $4.41 $4.70 $4.56 $5.42 $5.25

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 86906 0-999 $9.22 $8.95 $9.53 $9.25 $10.98 $10.66

5 86940 0-999 $9.75 $9.47 $10.08 $9.78 $11.61 $11.27

5 86941 0-999 $14.41 $13.99 $14.88 $14.45 $17.15 $16.65

5 87001 0-999 $15.72 $15.25 $16.24 $15.76 $18.71 $18.16

5 87003 0-999 $17.27 $16.76 $17.85 $17.32 $20.56 $19.95

5 87015 0-999 $7.95 $7.71 $8.22 $7.97 $9.46 $9.18

5 87040 0-999 $12.28 $11.92 $12.69 $12.32 $14.62 $14.19

5 87045 0-999 $11.22 $10.89 $11.60 $11.26 $13.36 $12.97

5 87046 0-999 $11.22 $10.89 $11.60 $11.26 $13.36 $12.97

5 87070 0-999 $10.25 $9.95 $10.59 $10.28 $12.20 $11.84

5 87071 0-999 $11.22 $10.89 $11.60 $11.26 $13.36 $12.97

5 87073 0-999 $11.22 $10.89 $11.60 $11.26 $13.36 $12.97

5 87075 0-999 $11.26 $10.93 $11.63 $11.29 $13.40 $13.01

5 87076 0-999 $9.62 $9.33 $9.94 $9.64 $11.45 $11.11

5 87077 0-999 $9.62 $9.33 $9.94 $9.64 $11.45 $11.11

5 87081 0-999 $7.89 $7.66 $8.15 $7.92 $9.39 $9.12

5 87084 0-999 $10.25 $9.95 $10.59 $10.28 $12.20 $11.84

5 87086 0-999 $9.60 $9.32 $9.92 $9.63 $11.43 $11.10

5 87088 0-999 $9.63 $9.35 $9.95 $9.66 $11.47 $11.13

5 87101 0-999 $9.18 $8.90 $9.48 $9.20 $10.93 $10.60

5 87102 0-999 $10.00 $9.70 $10.33 $10.03 $11.90 $11.55

5 87103 0-999 $10.73 $10.42 $11.09 $10.76 $12.77 $12.40

5 87106 0-999 $12.28 $11.92 $12.69 $12.32 $14.62 $14.19

5 87107 0-999 $12.28 $11.92 $12.69 $12.32 $14.62 $14.19

5 87109 0-999 $12.41 $12.04 $12.82 $12.44 $14.77 $14.33

5 87110 0-999 $23.31 $22.62 $24.09 $23.38 $27.75 $26.93

5 87116 0-999 $12.85 $12.47 $13.28 $12.89 $15.30 $14.85

5 87118 0-999 $13.02 $12.63 $13.46 $13.05 $15.50 $15.04

5 87140 0-999 $6.64 $6.44 $6.85 $6.66 $7.90 $7.67

5 87143 0-999 $14.91 $14.46 $15.41 $14.95 $17.75 $17.22

5 87147 0-999 $6.16 $5.97 $6.36 $6.17 $7.33 $7.11

5 87149 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87150 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87152 0-999 $6.22 $6.04 $6.43 $6.24 $7.40 $7.19

5 87153 0-999 $137.25 $133.20 $141.83 $137.64 $163.39 $158.57

5 87158 0-999 $6.22 $6.04 $6.43 $6.24 $7.40 $7.19

5 87164 0-999 $12.78 $12.40 $13.20 $12.81 $15.21 $14.76

5 87166 0-999 $13.44 $13.05 $13.89 $13.48 $16.00 $15.53

5 87168 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 87169 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 87172 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 87176 0-999 $7.00 $6.80 $7.23 $7.02 $8.33 $8.09

5 87177 0-999 $10.41 $10.10 $10.75 $10.43 $12.39 $12.02

5 87181 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

5 87184 0-999 $8.22 $7.97 $8.49 $8.24 $9.78 $9.49

5 87185 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

5 87186 0-999 $10.29 $9.98 $10.63 $10.31 $12.25 $11.88

5 87187 0-999 $12.33 $11.97 $12.74 $12.37 $14.68 $14.25

5 87188 0-999 $7.90 $7.66 $8.16 $7.92 $9.40 $9.12

5 87190 0-999 $6.73 $6.53 $6.96 $6.74 $8.01 $7.77

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 87197 0-999 $17.88 $17.35 $18.47 $17.92 $21.28 $20.65

5 87205 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 87206 0-999 $6.39 $6.21 $6.60 $6.41 $7.61 $7.39

5 87207 0-999 $7.13 $6.92 $7.37 $7.15 $8.49 $8.24

5 87209 0-999 $21.39 $20.76 $22.10 $21.45 $25.46 $24.71

5 87210 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 87220 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 87230 0-999 $23.49 $22.80 $24.27 $23.56 $27.96 $27.14

5 87250 0-999 $23.27 $22.58 $24.04 $23.33 $27.70 $26.88

5 87252 0-999 $31.01 $30.10 $32.05 $31.10 $36.92 $35.83

5 87253 0-999 $20.21 $19.61 $20.88 $20.27 $24.06 $23.35

5 87254 0-999 $23.27 $22.58 $24.04 $23.33 $27.70 $26.88

5 87255 0-999 $40.29 $39.10 $41.64 $40.41 $47.97 $46.55

5 87260 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87265 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87267 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87269 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87270 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87271 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87272 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87273 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87274 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87275 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87276 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87277 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87278 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87279 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87280 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87281 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87283 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87285 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87290 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87299 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87300 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87301 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87305 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87320 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87324 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87327 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87328 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87329 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87332 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87335 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87336 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87337 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87338 0-999 $17.11 $16.61 $17.68 $17.16 $20.37 $19.77

5 87340 0-999 $12.29 $11.93 $12.70 $12.33 $14.63 $14.20

5 87341 0-999 $12.29 $11.93 $12.70 $12.33 $14.63 $14.20

5 87350 0-999 $13.71 $13.31 $14.16 $13.75 $16.32 $15.84

5 87380 0-999 $19.53 $18.95 $20.19 $19.58 $23.25 $22.56

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 87385 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87389 0-999 $28.66 $27.81 $29.62 $28.74 $34.12 $33.11

5 87390 0-999 $20.99 $20.37 $21.69 $21.05 $24.99 $24.25

5 87391 0-999 $20.99 $20.37 $21.69 $21.05 $24.99 $24.25

5 87400 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87420 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87425 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87427 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87430 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87449 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87450 0-999 $11.41 $11.07 $11.79 $11.44 $13.58 $13.18

5 87451 0-999 $11.41 $11.07 $11.79 $11.44 $13.58 $13.18

5 87470 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87471 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87472 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87475 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87476 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87477 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87480 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87481 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87482 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87485 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87486 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87487 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87490 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87491 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87492 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87493 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87495 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87496 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87497 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87498 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87500 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87501 0-999 $61.05 $59.25 $63.08 $61.23 $72.68 $70.54

5 87502 0-999 $101.24 $98.25 $104.61 $101.52 $120.52 $116.96

5 87503 0-999 $24.22 $23.50 $25.02 $24.29 $28.83 $27.98

5 87510 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87511 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87512 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87515 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87516 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87517 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87520 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87521 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87522 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87525 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87526 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87527 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87528 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87529 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 87530 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87531 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87532 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87533 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87534 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87535 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87536 0-999 $101.24 $98.25 $104.61 $101.52 $120.52 $116.96

5 87537 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87538 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87539 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87540 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87541 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87542 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87550 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87551 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87552 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87555 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87556 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87557 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87560 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87561 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87562 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87580 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87581 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87582 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87590 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87591 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87592 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87620 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87621 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87622 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87640 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87641 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87650 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87651 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87652 0-999 $33.76 $32.76 $34.89 $33.85 $40.19 $39.00

5 87653 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87660 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87797 0-999 $23.86 $23.16 $24.65 $23.93 $28.40 $27.57

5 87798 0-999 $41.76 $40.52 $43.15 $41.87 $49.71 $48.24

5 87799 0-999 $50.96 $49.46 $52.66 $51.11 $60.67 $58.88

5 87800 0-999 $47.72 $46.32 $49.31 $47.86 $56.81 $55.14

5 87801 0-999 $83.51 $81.05 $86.29 $83.75 $99.42 $96.49

5 87802 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87803 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87804 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87807 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87808 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87809 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87810 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 87850 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87880 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87899 0-999 $14.27 $13.85 $14.75 $14.31 $16.99 $16.49

5 87900 0-999 $155.08 $150.50 $160.25 $155.52 $184.62 $179.17

5 87901 0-999 $218.05 $211.61 $225.31 $218.67 $259.58 $251.92

5 87902 0-999 $218.05 $211.61 $225.31 $218.67 $259.58 $251.92

5 87903 0-999 $581.36 $564.21 $600.74 $583.02 $692.10 $671.68

5 87904 0-999 $31.01 $30.10 $32.05 $31.10 $36.92 $35.83

5 87906 0-999 $109.02 $105.81 $112.66 $109.33 $129.79 $125.96

5 88142 0-999 $24.11 $23.39 $24.91 $24.17 $28.70 $27.85

5 88143 0-999 $24.11 $23.39 $24.91 $24.17 $28.70 $27.85

5 88147 0-999 $13.54 $13.15 $13.99 $13.58 $16.12 $15.65

5 88148 0-999 $18.09 $17.55 $18.69 $18.13 $21.53 $20.89

5 88150 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88152 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88153 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88154 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88155 0-999 $7.13 $6.92 $7.37 $7.15 $8.49 $8.24

5 88164 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88165 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88166 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88167 0-999 $12.57 $12.21 $12.99 $12.61 $14.97 $14.53

5 88174 0-999 $25.42 $24.67 $26.27 $25.49 $30.26 $29.37

5 88175 0-999 $31.52 $30.58 $32.57 $31.60 $37.52 $36.41

5 88230 0-999 $138.61 $134.52 $143.23 $139.00 $165.01 $160.14

5 88233 0-999 $167.44 $162.49 $173.01 $167.91 $199.33 $193.44

5 88235 0-999 $175.20 $170.03 $181.04 $175.70 $208.57 $202.42

5 88237 0-999 $150.28 $145.84 $155.28 $150.70 $178.90 $173.62

5 88239 0-999 $175.52 $170.34 $181.36 $176.01 $208.95 $202.78

5 88240 0-999 $10.11 $9.81 $10.44 $10.14 $12.03 $11.68

5 88241 0-999 $10.11 $9.81 $10.44 $10.14 $12.03 $11.68

5 88245 0-999 $177.11 $171.88 $183.02 $177.61 $210.85 $204.62

5 88248 0-999 $206.04 $199.95 $212.91 $206.62 $245.28 $238.04

5 88249 0-999 $206.04 $199.95 $212.91 $206.62 $245.28 $238.04

5 88261 0-999 $210.27 $204.06 $217.27 $210.86 $250.32 $242.93

5 88262 0-999 $148.29 $143.92 $153.23 $148.71 $176.54 $171.33

5 88263 0-999 $178.80 $173.53 $184.77 $179.31 $212.86 $206.58

5 88264 0-999 $148.29 $143.92 $153.23 $148.71 $176.54 $171.33

5 88267 0-999 $182.65 $177.27 $188.74 $183.17 $217.44 $211.03

5 88269 0-999 $197.89 $192.05 $204.48 $198.45 $235.58 $228.63

5 88271 0-999 $25.48 $24.73 $26.33 $25.55 $30.33 $29.44

5 88272 0-999 $31.85 $30.91 $32.91 $31.94 $37.92 $36.80

5 88273 0-999 $38.23 $37.10 $39.51 $38.34 $45.51 $44.17

5 88274 0-999 $41.42 $40.19 $42.80 $41.53 $49.31 $47.85

5 88275 0-999 $47.78 $46.37 $49.38 $47.91 $56.88 $55.20

5 88280 0-999 $29.86 $28.98 $30.85 $29.95 $35.55 $34.50

5 88283 0-999 $81.61 $79.21 $84.34 $81.85 $97.16 $94.30

5 88285 0-999 $22.60 $21.93 $23.36 $22.66 $26.91 $26.11

5 88289 0-999 $40.97 $39.77 $42.34 $41.09 $48.77 $47.34

5 88371 0-999 $26.44 $25.66 $27.33 $26.52 $31.48 $30.55

Type of

Service

(TOS)*

Procedure

Code Age Range

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee

Current

Medicaid Fee

4/1/2013

Medicaid Fee



5 88372 0-999 $27.06 $26.27 $27.96 $27.14 $32.22 $31.27

5 88720 0-999 $5.96 $5.80 $6.17 $5.99 $7.10 $6.90

5 89050 0-999 $5.63 $5.46 $5.81 $5.64 $6.70 $6.50

5 89051 0-999 $6.55 $6.36 $6.77 $6.57 $7.80 $7.57

5 89055 0-999 $5.08 $4.93 $5.25 $5.10 $6.05 $5.87

5 89060 0-999 $8.51 $8.26 $8.79 $8.53 $10.13 $9.83

5 89125 0-999 $5.13 $4.98 $5.30 $5.15 $6.11 $5.93

5 89160 0-999 $4.38 $4.26 $4.53 $4.40 $5.22 $5.07

5 89190 0-999 $5.65 $5.49 $5.84 $5.67 $6.73 $6.53

5 G0103 0-999 $21.89 $21.24 $22.62 $21.95 $26.06 $25.29

5 G0306 0-999 $9.26 $8.98 $9.57 $9.28 $11.02 $10.69

5 G0307 0-999 $7.70 $7.47 $7.96 $7.72 $9.17 $8.89

5 G0328 0-999 $18.93 $18.36 $19.56 $18.97 $22.53 $21.86

TOS*: 5 = Laboratory, I = Professional Component, D = Tuberculosis Clinic, S = THSteps Medical

HCPC Current Rate 4/1/2013 Medicaid Fee

ATP02 $7.16 $6.01

ATP03 $9.13 $7.67

ATP04 $9.64 $8.10

ATP05 $10.76 $9.04

ATP06 $10.79 $9.06

ATP07 $11.23 $9.43

ATP08 $11.63 $9.77

ATP09 $11.94 $10.03

ATP10 $11.94 $10.03

ATP11 $12.14 $10.20

ATP12 $12.41 $10.42

ATP13 $14.53 $12.21

ATP14 $14.53 $12.21

ATP15 $14.53 $12.21

ATP16 $14.53 $12.21

ATP17 $14.63 $12.29

ATP18 $14.63 $12.29

ATP19 $15.21 $12.78

ATP20 $15.69 $13.18

ATP21 $16.19 $13.60

ATP22 $16.68 $14.01

ATP23 $16.68 $14.01

Clinical Diagnostic Laboratory Panels

Type of

Service

(TOS)* Procedure Code Modifier

Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013

J E0100 0-20 $16.60 $15.27 $15.27 $15.27

J E0100 21-999 $16.60 $15.27 $15.27 $15.27

J E0105 0-20 $39.51 $36.35 $36.35 $36.35

J E0105 21-999 $39.51 $36.35 $36.35 $36.35

J E0110 0-20 $59.06 $54.34 $54.34 $54.34

J E0110 21-999 $59.06 $54.34 $54.34 $54.34

L E0110 0-20 $10.20 $9.38 $9.38 $9.38

L E0110 21-999 $10.20 $9.38 $9.38 $9.38

J E0111 0-20 $38.99 $35.87 $35.87 $35.87

J E0111 21-999 $38.99 $35.87 $35.87 $35.87

L E0111 0-20 $7.13 $6.56 $6.56 $6.56

L E0111 21-999 $7.13 $6.56 $6.56 $6.56

J E0112 0-20 $31.28 $28.78 $28.78 $28.78

J E0112 21-999 $31.28 $28.78 $28.78 $28.78

L E0112 0-20 $6.71 $6.17 $6.17 $6.17

L E0112 21-999 $6.71 $6.17 $6.17 $6.17

J E0113 0-20 $18.22 $16.76 $16.76 $16.76

J E0113 21-999 $18.22 $16.76 $16.76 $16.76

L E0113 0-20 $4.35 $4.00 $4.00 $4.00

L E0113 21-999 $4.35 $4.00 $4.00 $4.00

J E0114 0-20 $35.11 $32.30 $32.30 $32.30

J E0114 21-999 $35.11 $32.30 $32.30 $32.30

L E0114 0-20 $7.25 $6.67 $6.67 $6.67

L E0114 21-999 $7.25 $6.67 $6.67 $6.67

J E0116 0-20 $22.52 $20.72 $20.72 $20.72

J E0116 21-999 $22.52 $20.72 $20.72 $20.72

L E0116 0-20 $4.56 $4.20 $4.20 $4.20

L E0116 21-999 $4.56 $4.20 $4.20 $4.20

J E0130 0-20 $59.07 $54.34 $54.34 $54.34

J E0130 21-999 $59.07 $54.34 $54.34 $54.34

L E0130 0-20 $10.27 $9.45 $9.45 $9.45

L E0130 21-999 $10.27 $9.45 $9.45 $9.45

J E0135 0-20 $75.88 $69.81 $69.81 $69.81

J E0135 21-999 $75.88 $69.81 $69.81 $69.81

L E0135 0-20 $12.08 $11.11 $11.11 $11.11

L E0135 21-999 $12.08 $11.11 $11.11 $11.11

J E0140 0-20 $360.71 $331.85 $360.71 $331.85

J E0140 21-999 $360.71 $331.85 $360.71 $331.85

J E0141 0-20 $96.08 $88.39 $88.39 $88.39

J E0141 21-999 $96.08 $88.39 $88.39 $88.39

L E0141 0-20 $17.20 $15.82 $15.82 $15.82

L E0141 21-999 $17.20 $15.82 $15.82 $15.82

J E0143 0-20 $104.80 $92.22 $92.22 $92.22

J E0143 21-999 $104.80 $92.22 $92.22 $92.22

L E0143 0-20 $16.61 $14.62 $14.62 $14.62

L E0143 21-999 $16.61 $14.62 $14.62 $14.62

J E0144 0-20 $164.06 $150.94 $150.94 $150.94

J E0144 21-999 $164.06 $150.94 $150.94 $150.94

L E0144 0-20 $16.41 $15.10 $15.10 $15.10

L E0144 21-999 $16.41 $15.10 $15.10 $15.10

J E0147 0-20 $520.20 $478.58 $478.58 $478.58

J E0147 21-999 $520.20 $478.58 $478.58 $478.58

L E0147 0-20 $52.02 $47.86 $47.86 $47.86

L E0147 21-999 $52.02 $47.86 $47.86 $47.86

J E0148 0-20 $114.98 $105.78 $105.78 $105.78

J E0148 21-999 $114.98 $105.78 $105.78 $105.78

L E0148 0-20 $11.51 $10.59 $10.59 $10.59

L E0148 21-999 $11.51 $10.59 $10.59 $10.59

J E0149 0-20 $202.00 $157.56 $157.56 $157.56

J E0149 21-999 $202.00 $157.56 $157.56 $157.56

L E0149 0-20 $20.20 $15.76 $15.76 $15.76

L E0149 21-999 $20.20 $15.76 $15.76 $15.76

J E0153 0-20 $69.04 $63.52 $63.52 $63.52

J E0153 21-999 $69.04 $63.52 $63.52 $63.52

"E CODES" (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies [DMEPOS])

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E0154 0-20 $63.81 $58.71 $58.71 $58.71

J E0154 21-999 $63.81 $58.71 $58.71 $58.71

J E0155 0-20 $27.41 $25.22 $25.22 $25.22

J E0155 21-999 $27.41 $25.22 $25.22 $25.22

J E0157 0-20 $45.59 $41.94 $41.94 $41.94

J E0157 21-999 $45.59 $41.94 $41.94 $41.94

J E0158 0-20 $23.28 $21.42 $21.42 $21.42

J E0158 21-999 $23.28 $21.42 $21.42 $21.42

J E0159 0-20 $16.17 $14.88 $14.88 $14.88

J E0159 21-999 $16.17 $14.88 $14.88 $14.88

J E0160 0-20 $22.62 $20.81 $20.81 $20.81

J E0160 21-999 $22.62 $20.81 $20.81 $20.81

J E0161 0-20 $23.41 $21.54 $21.54 $21.54

J E0161 21-999 $23.41 $21.54 $21.54 $21.54

J E0162 0-20 $130.04 $119.64 $119.64 $119.64

J E0162 21-999 $130.04 $119.64 $119.64 $119.64

L E0162 0-20 $13.64 $12.55 $12.55 $12.55

L E0162 21-999 $13.64 $12.55 $12.55 $12.55

J E0163 0-20 $110.29 $97.06 $97.06 $97.06

J E0163 21-999 $110.29 $97.06 $97.06 $97.06

J E0163 TG 0-20 Manually Priced Manually Priced Manually Priced Manually Priced


J E0165 0-20 $195.10 $171.69 $171.69 $171.69

J E0165 21-999 $195.10 $171.69 $171.69 $171.69



J E0167 0-20 $9.88 $9.09 $9.09 $9.09

J E0167 21-999 $9.88 $9.09 $9.09 $9.09

L E0167 0-20 $0.99 $0.91 $0.91 $0.91

L E0167 21-999 $0.99 $0.91 $0.91 $0.91

J E0168 0-20 $150.92 $132.81 $132.81 $132.81

J E0168 21-999 $150.92 $132.81 $132.81 $132.81

J E0168 TF 0-20 $162.45 $142.96 $319.26 $319.26

J E0168 TF 21-999 $162.45 $142.96 $319.26 $319.26

J E0168 TG 0-20 $1,509.20 $1,328.10 $1,544.22 $1,544.22

J E0168 TG 21-999 $1,509.20 $1,328.10 $1,544.22 $1,544.22

J E0170 0-20 $1,687.60 $1,653.85 $1,653.85 $1,653.85

J E0170 21-999 $1,687.60 $1,653.85 $1,653.85 $1,653.85

J E0171 0-20 $303.70 $297.63 $297.63 $297.63

J E0171 21-999 $303.70 $297.63 $297.63 $297.63

J E0172 0-20 $1,963.90 $1,806.79 $1,806.79 $1,806.79

J E0172 21-999 $1,963.90 $1,806.79 $1,806.79 $1,806.79

J E0175 0-20 $52.10 $51.06 $51.06 $51.06

J E0175 21-999 $52.10 $51.06 $51.06 $51.06

L E0175 0-20 $5.21 $5.11 $5.11 $5.11

L E0175 21-999 $5.21 $5.11 $5.11 $5.11

J E0181 0-20 $273.60 $251.71 $251.71 $251.71

J E0181 21-999 $273.60 $251.71 $251.71 $251.71

L E0181 0-20 $27.36 $25.17 $25.17 $25.17

L E0181 21-999 $27.36 $25.17 $25.17 $25.17

L E0182 0-20 $19.54 $17.98 $17.98 $17.98

L E0182 21-999 $19.54 $17.98 $17.98 $17.98

J E0184 0-20 $479.07 $440.74 $440.74 $440.74

J E0184 21-999 $479.07 $440.74 $440.74 $440.74

L E0184 0-20 $24.57 $22.60 $22.60 $22.60

L E0184 21-999 $24.57 $22.60 $22.60 $22.60

J E0185 0-20 $305.09 $280.68 $280.68 $280.68

J E0185 21-999 $305.09 $280.68 $280.68 $280.68

L E0185 0-20 $42.86 $39.43 $39.43 $39.43

L E0185 21-999 $42.86 $39.43 $39.43 $39.43

J E0186 0-999 $1,716.28 $1,578.98 $1,778.79 $1,778.79

L E0186 0-20 $19.36 $17.81 $17.81 $17.81

L E0186 21-999 $19.36 $17.81 $17.81 $17.81

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E0187 0-20 $243.70 $224.20 $224.20 $224.20

J E0187 21-999 $243.70 $224.20 $224.20 $224.20

L E0187 0-20 $24.37 $22.42 $22.42 $22.42

L E0187 21-999 $24.37 $22.42 $22.42 $22.42

J E0188 0-20 $22.47 $20.67 $20.67 $20.67

J E0188 21-999 $22.47 $20.67 $20.67 $20.67

J E0189 0-20 $51.96 $47.80 $47.80 $47.80

J E0189 21-999 $51.96 $47.80 $47.80 $47.80

J E0190 0-20 $50.00 $46.00 $47.99 $47.99

J E0190 21-999 $50.00 $46.00 $47.99 $47.99

J E0190 UD 0-20 Manually Priced Manually Priced Manually Priced Manually Priced

J E0190 UD 21-999 Manually Priced Manually Priced Manually Priced Manually Priced

J E0191 0-20 $8.41 $7.74 $7.74 $7.74

J E0191 21-999 $8.41 $7.74 $7.74 $7.74

L E0193 0-20 $817.63 $752.22 $752.22 $752.22

L E0193 21-999 $817.63 $752.22 $752.22 $752.22

L E0194 0-20 $2,454.42 $2,258.07 $2,258.07 $2,258.07

L E0194 21-999 $2,454.42 $2,258.07 $2,258.07 $2,258.07

J E0196 0-20 $341.10 $313.81 $313.81 $313.81

J E0196 21-999 $341.10 $313.81 $313.81 $313.81

L E0196 0-20 $34.11 $31.38 $31.38 $31.38

L E0196 21-999 $34.11 $31.38 $31.38 $31.38

J E0197 0-20 $188.34 $173.27 $173.27 $173.27

J E0197 21-999 $188.34 $173.27 $173.27 $173.27

L E0197 0-20 $18.83 $17.32 $17.32 $17.32

L E0197 21-999 $18.83 $17.32 $17.32 $17.32

J E0198 0-20 $129.07 $126.49 $126.49 $126.49

J E0198 21-999 $129.07 $126.49 $126.49 $126.49

L E0198 0-20 $18.65 $18.28 $18.28 $18.28

L E0198 21-999 $18.65 $18.28 $18.28 $18.28

J E0199 0-20 $32.77 $30.15 $30.15 $30.15

J E0199 21-999 $32.77 $30.15 $30.15 $30.15

L E0202 0-999 $55.00 $53.90 $53.90 $53.90

J E0210 0-20 $26.19 $24.09 $24.09 $24.09

J E0210 21-999 $26.19 $24.09 $24.09 $24.09

J E0217 0-20 $473.55 $435.67 $435.67 $435.67

J E0217 21-999 $473.55 $435.67 $435.67 $435.67

L E0217 0-20 $47.36 $43.57 $43.57 $43.57

L E0217 21-999 $47.36 $43.57 $43.57 $43.57

J E0218 0-20 $391.84 $360.49 $360.49 $360.49

J E0218 21-999 $391.84 $360.49 $360.49 $360.49

L E0218 0-20 $54.99 $50.59 $50.59 $50.59

L E0218 21-999 $54.99 $50.59 $50.59 $50.59

L E0225 0-20 $40.23 $37.01 $37.01 $37.01

L E0225 21-999 $40.23 $37.01 $37.01 $37.01

J E0235 0-20 $181.20 $166.70 $166.70 $166.70

J E0235 21-999 $181.20 $166.70 $166.70 $166.70

L E0235 0-20 $18.12 $16.67 $16.67 $16.67

L E0235 21-999 $18.12 $16.67 $16.67 $16.67

J E0236 0-20 $464.60 $427.43 $427.43 $427.43

J E0236 21-999 $464.60 $427.43 $427.43 $427.43

J E0240 0-20 $95.00 $83.13 $95.00 $83.13

J E0240 21-999 $95.00 $83.13 $95.00 $83.13

J E0240 TF 0-20 $1,639.18 $1,434.28 $1,639.18 $1,434.28

J E0240 TF 21-999 $1,639.18 $1,434.28 $1,639.18 $1,434.28

J E0240 TG 0-20 $2,209.90 $1,933.66 $1,935.82 $1,935.82

J E0240 TG 21-999 $2,209.90 $1,933.66 $1,935.82 $1,935.82

J E0243 0-20 $29.98 $27.58 $28.14 $28.14

J E0243 21-999 $29.98 $27.58 $28.14 $28.14

J E0244 0-20 $28.90 $25.29 $28.90 $25.29

J E0244 21-999 $28.90 $25.29 $28.90 $25.29

J E0245 0-20 $32.20 $29.62 $32.20 $29.62

J E0245 21-999 $32.20 $29.62 $32.20 $29.62

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E0246 0-20 $45.10 $41.49 $41.49 $41.49

J E0246 21-999 $45.10 $41.49 $41.49 $41.49

J E0247 0-20 $96.41 $88.70 $88.70 $88.70

J E0247 21-999 $96.41 $88.70 $88.70 $88.70

J E0248 0-20 $150.67 $138.62 $138.62 $138.62

J E0248 21-999 $150.67 $138.62 $138.62 $138.62

J E0250 0-20 $877.16 $767.52 $738.59 $738.59

J E0250 21-999 $877.16 $767.52 $738.59 $738.59

L E0250 0-20 $84.41 $73.86 $73.86 $73.86

L E0250 21-999 $84.41 $73.86 $73.86 $73.86

J E0255 0-20 $1,063.20 $930.30 $930.30 $930.30

J E0255 21-999 $1,063.20 $930.30 $930.30 $930.30

L E0255 0-20 $106.32 $93.03 $93.03 $93.03

L E0255 21-999 $106.32 $93.03 $93.03 $93.03

J E0260 0-20 $1,271.20 $1,118.66 $1,118.66 $1,118.66

J E0260 21-999 $1,271.20 $1,118.66 $1,118.66 $1,118.66

L E0260 0-20 $127.12 $111.87 $111.87 $111.87

L E0260 21-999 $127.12 $111.87 $111.87 $111.87

J E0265 0-20 $1,808.90 $1,772.72 $1,772.72 $1,772.72

J E0265 21-999 $1,808.90 $1,772.72 $1,772.72 $1,772.72

L E0265 0-20 $180.89 $177.27 $177.27 $177.27

L E0265 21-999 $180.89 $177.27 $177.27 $177.27

J E0271 0-20 $169.69 $148.48 $148.48 $148.48

J E0271 21-999 $169.69 $148.48 $148.48 $148.48

J E0275 0-20 $16.08 $14.07 $14.07 $14.07

J E0275 21-999 $16.08 $14.07 $14.07 $14.07

J E0276 0-20 $13.97 $12.22 $12.22 $12.22

J E0276 21-999 $13.97 $12.22 $12.22 $12.22

L E0277 0-20 $636.64 $506.13 $506.13 $506.13

L E0277 21-999 $636.64 $506.13 $506.13 $506.13

J E0280 0-20 $34.57 $30.25 $30.25 $30.25

J E0280 21-999 $34.57 $30.25 $30.25 $30.25

L E0280 0-20 $3.72 $3.26 $3.26 $3.26

L E0280 21-999 $3.72 $3.26 $3.26 $3.26

J E0300 0-999 $2,838.62 $2,483.79 $2,838.62 $2,483.79

L E0300 0-999 $256.89 $224.78 $256.89 $224.78

J E0303 0-20 $4,883.62 $4,273.17 $4,273.17 $4,273.17

J E0303 21-999 $4,883.62 $4,273.17 $4,273.17 $4,273.17

L E0303 0-20 $488.36 $427.32 $427.32 $427.32

L E0303 21-999 $488.36 $427.32 $427.32 $427.32

J E0304 0-20 $4,059.76 $3,978.56 $3,978.56 $3,978.56

J E0304 21-999 $4,059.76 $3,978.56 $3,978.56 $3,978.56

L E0304 0-20 $697.46 $610.28 $610.28 $610.28

L E0304 21-999 $697.46 $610.28 $610.28 $610.28

J E0305 0-20 $161.00 $140.88 $140.88 $140.88

J E0305 21-999 $161.00 $140.88 $140.88 $140.88

J E0310 0-20 $139.36 $121.94 $121.94 $121.94

J E0310 21-999 $139.36 $121.94 $121.94 $121.94

J E0315 0-20 $172.20 $150.68 $150.68 $150.68

J E0315 21-999 $172.20 $150.68 $150.68 $150.68

J E0316 0-999 $1,929.60 $1,865.73 $1,865.73 $1,865.73

L E0316 0-999 $174.63 $168.85 $168.85 $168.85

J E0325 0-20 $9.94 $8.70 $13.91 $13.91

J E0325 21-999 $9.94 $8.70 $13.91 $13.91

L E0325 0-20 $1.59 $1.39 $1.39 $1.39

L E0325 21-999 $1.59 $1.39 $1.39 $1.39

J E0326 0-20 $8.93 $7.81 $7.81 $7.81

J E0326 21-999 $8.93 $7.81 $7.81 $7.81

J E0328 0-20 $5,232.73 $5,059.53 $5,059.53 $5,059.53

J E0328 21-999 $5,232.73 $5,059.53 $5,059.53 $5,059.53

L E0328 0-20 $523.27 $505.95 $505.95 $505.95

L E0328 21-999 $523.27 $505.95 $505.95 $505.95

J E0329 0-20 $6,976.97 $6,746.03 $6,746.03 $6,746.03

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E0329 21-999 $6,976.97 $6,746.03 $6,746.03 $6,746.03

L E0329 0-20 $697.70 $674.61 $674.61 $674.61

L E0329 21-999 $697.70 $674.61 $674.61 $674.61

9 E0350 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

9 E0352 0-999 $10.00 $9.80 $56.25 $56.25

J E0370 0-20 $24.89 $21.78 $21.78 $21.78

J E0370 21-999 $24.89 $21.78 $21.78 $21.78

L E0370 0-20 $2.50 $2.19 $2.18 $2.18

L E0370 21-999 $2.50 $2.19 $2.18 $2.18

J E0371 0-20 $4,022.50 $3,519.69 $3,519.69 $3,519.69

J E0371 21-999 $4,022.50 $3,519.69 $3,519.69 $3,519.69

L E0371 0-20 $402.25 $351.97 $351.97 $351.97

L E0371 21-999 $402.25 $351.97 $351.97 $351.97

J E0372 0-20 $4,881.00 $4,270.88 $4,270.88 $4,270.88

J E0372 21-999 $4,881.00 $4,270.88 $4,270.88 $4,270.88

L E0372 0-20 $488.10 $427.09 $427.09 $427.09

L E0372 21-999 $488.10 $427.09 $427.09 $427.09

J E0373 0-20 $5,561.00 $4,865.88 $4,865.88 $4,865.88

J E0373 21-999 $5,561.00 $4,865.88 $4,865.88 $4,865.88

L E0373 0-20 $556.10 $486.59 $486.59 $486.59

L E0373 21-999 $556.10 $486.59 $486.59 $486.59

L E0424 0-20 $173.17 $159.32 $159.32 $159.32

L E0424 21-999 $173.17 $159.32 $159.32 $159.32

L E0431 0-20 $28.77 $26.47 $26.47 $26.47

L E0431 21-999 $28.77 $26.47 $26.47 $26.47

L E0433 0-20 $51.63 $47.50 $47.50 $47.50

L E0433 21-999 $51.63 $47.50 $47.50 $47.50

L E0434 0-20 $28.77 $26.47 $26.47 $26.47

L E0434 21-999 $28.77 $26.47 $26.47 $26.47

L E0439 0-20 $173.17 $159.32 $159.32 $159.32

L E0439 21-999 $173.17 $159.32 $159.32 $159.32

L E0441 0-20 $38.50 $35.42 $7.13 $7.13

L E0441 21-999 $38.50 $35.42 $7.13 $7.13

L E0442 0-20 $77.45 $71.25 $7.13 $7.13

L E0442 21-999 $77.45 $71.25 $7.13 $7.13

L E0443 0-20 $38.50 $35.42 $7.13 $7.13

L E0443 21-999 $38.50 $35.42 $7.13 $7.13

L E0444 0-20 $38.50 $35.42 $7.13 $7.13

L E0444 21-999 $38.50 $35.42 $7.13 $7.13

J E0445 0-999 $553.50 $509.22 $553.50 $509.22

J E0445 TF 0-999 $1,336.60 $1,229.67 Not A Benefit Not A Benefit

J E0445 TG 0-999 $2,214.00 $2,036.88 $2,214.00 $2,036.88

L E0445 0-999 $55.35 $50.92 $55.35 $50.92

L E0445 TF 0-999 $133.66 $122.97 Not A Benefit Not A Benefit

L E0445 TG 0-999 $221.40 $203.69 $221.40 $203.69

L E0450 0-20 $949.79 $873.81 $873.81 $873.81

L E0450 21-999 $949.79 $873.81 $873.81 $873.81

J E0457 0-20 $586.13 $574.41 $574.41 $574.41

J E0457 21-999 $586.13 $574.41 $574.41 $574.41

L E0457 0-20 $58.61 $57.44 $57.44 $57.44

L E0457 21-999 $58.61 $57.44 $57.44 $57.44

J E0459 0-20 $454.20 $445.12 $445.12 $445.12

J E0459 21-999 $454.20 $445.12 $445.12 $445.12

L E0459 0-20 $45.42 $44.51 $44.51 $44.51

L E0459 21-999 $45.42 $44.51 $44.51 $44.51

L E0460 0-20 $699.70 $643.72 $643.72 $643.72

L E0460 21-999 $699.70 $643.72 $643.72 $643.72

L E0463 0-20 $949.79 $873.81 $1,058.00 $1,058.00

L E0463 21-999 $949.79 $873.81 $1,058.00 $1,058.00

L E0464 0-20 $1,476.70 $1,358.56 $1,058.00 $1,058.00

L E0464 21-999 $1,476.70 $1,358.56 $1,058.00 $1,058.00

J E0470 0-20 $3,018.86 $2,777.35 $2,777.35 $2,777.35

J E0470 21-999 $3,018.86 $2,777.35 $2,777.35 $2,777.35

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


L E0470 0-20 $232.22 $213.64 $213.64 $213.64

L E0470 21-999 $232.22 $213.64 $213.64 $213.64

L E0471 0-20 $395.22 $363.60 $363.60 $363.60

L E0471 21-999 $395.22 $363.60 $363.60 $363.60

L E0472 0-20 $395.22 $363.60 $363.60 $363.60

L E0472 21-999 $395.22 $363.60 $363.60 $363.60

J E0480 0-20 $390.28 $359.06 $359.08 $359.08

J E0480 21-999 $390.28 $359.06 $359.08 $359.08

L E0480 0-20 $39.03 $35.91 $35.91 $35.91

L E0480 21-999 $39.03 $35.91 $35.91 $35.91

L E0482 0-20 $289.96 $266.76 $266.76 $266.76

L E0482 21-999 $289.96 $266.76 $266.76 $266.76

J E0483 0-20 $10,058.10 $9,253.45 $9,253.45 $9,253.45

J E0483 21-999 $10,058.10 $9,253.45 $9,253.45 $9,253.45

L E0483 0-20 $1,005.81 $925.35 $925.35 $925.35

L E0483 21-999 $1,005.81 $925.35 $925.35 $925.35

L E0500 0-20 $103.69 $95.39 $95.39 $95.39

L E0500 21-999 $103.69 $95.39 $95.39 $95.39

J E0550 0-20 $464.64 $427.47 $427.43 $427.43

J E0550 21-999 $464.64 $427.47 $427.43 $427.43

L E0550 0-20 $46.46 $42.74 $42.74 $42.74

L E0550 21-999 $46.46 $42.74 $42.74 $42.74

J E0561 0-20 $96.84 $89.09 $89.09 $89.09

J E0561 21-999 $96.84 $89.09 $89.09 $89.09

L E0561 0-20 $9.67 $8.90 $8.90 $8.90

L E0561 21-999 $9.67 $8.90 $8.90 $8.90

J E0562 0-20 $272.60 $250.79 $250.79 $250.79

J E0562 21-999 $272.60 $250.79 $250.79 $250.79

L E0562 0-20 $27.25 $25.07 $25.07 $25.07

L E0562 21-999 $27.25 $25.07 $25.07 $25.07

J E0565 0-20 $640.60 $589.35 $589.35 $589.35

J E0565 21-999 $640.60 $589.35 $589.35 $589.35

L E0565 0-20 $64.06 $58.94 $58.94 $58.94

L E0565 21-999 $64.06 $58.94 $58.94 $58.94

J E0570 0-20 $139.39 $129.63 $129.63 $129.63

J E0570 21-999 $139.39 $129.63 $129.63 $129.63

J E0574 0-20 $422.70 $388.88 $388.88 $388.88

J E0574 21-999 $422.70 $388.88 $388.88 $388.88

J E0575 0-20 $1,079.20 $992.86 $992.86 $992.86

J E0575 21-999 $1,079.20 $992.86 $992.86 $992.86

J E0580 0-20 $121.31 $118.88 $118.88 $118.88

J E0580 21-999 $121.31 $118.88 $118.88 $118.88

L E0580 0-20 $12.13 $11.89 $11.89 $11.89

L E0580 21-999 $12.13 $11.89 $11.89 $11.89

J E0585 0-20 $350.70 $322.64 $322.64 $322.64

J E0585 21-999 $350.70 $322.64 $322.64 $322.64

J E0600 0-20 $480.80 $442.34 $442.34 $442.34

J E0600 21-999 $480.80 $442.34 $442.34 $442.34

J E0601 0-20 $1,209.26 $1,112.52 $1,112.52 $1,112.52

J E0601 21-999 $1,209.26 $1,112.52 $1,112.52 $1,112.52

L E0601 0-20 $93.02 $85.58 $85.58 $85.58

L E0601 21-999 $93.02 $85.58 $85.58 $85.58

J E0602 0-20 $17.00 $16.66 $16.66 $16.66

J E0602 21-999 $17.00 $16.66 $16.66 $16.66

J E0603 0-20 $156.00 $152.88 $152.88 $152.88

J E0603 21-999 $156.00 $152.88 $152.88 $152.88

L E0604 0-20 $75.16 $69.15 $69.15 $69.15

L E0604 21-999 $75.16 $69.15 $69.15 $69.15

J E0605 0-20 $26.30 $24.20 $24.20 $24.20

J E0605 21-999 $26.30 $24.20 $24.20 $24.20

J E0606 0-20 $171.90 $158.15 $158.15 $158.15

J E0606 21-999 $171.90 $158.15 $158.15 $158.15

J E0610 0-20 $249.75 $229.77 $229.77 $229.77

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E0610 21-999 $249.75 $229.77 $229.77 $229.77

J E0615 0-20 $459.46 $450.27 $450.27 $450.27

J E0615 21-999 $459.46 $450.27 $450.27 $450.27

9 E0616 0-20 $3,095.50 $3,033.59 $3,033.59 $3,033.59

J E0616 0-20 $3,095.50 $3,033.59 $3,033.59 $3,033.59

J E0617 0-20 $2,394.40 $2,346.51 $2,346.51 $2,346.51

L E0617 0-20 $239.44 $234.65 $234.65 $234.65

J E0618 0-999 $2,383.00 $2,335.34 $2,335.34 $2,335.34

J E0619 0-999 $2,276.20 $2,094.10 $2,276.20 $2,094.10

L E0619 0-999 $227.62 $209.41 $227.62 $209.41

J E0621 0-20 $95.52 $87.88 $87.88 $87.88

J E0621 21-999 $95.52 $87.88 $87.88 $87.88

J E0625 0-20 $409.18 $376.45 $463.75 $463.75

J E0625 21-999 $409.18 $376.45 $463.75 $463.75

J E0625 0-20 $795.39 $731.76 $980.71 $980.71

J E0625 21-999 $795.39 $731.76 $980.71 $980.71

J E0625 0-20 $2,911.00 $2,678.12 $2,376.36 $2,376.36

J E0625 21-999 $2,911.00 $2,678.12 $2,376.36 $2,376.36

J E0625 0-20 $4,614.96 $4,245.76 Manually Priced Manually Priced


L E0625 0-20 $40.92 $37.65 $46.38 $46.38

L E0625 21-999 $40.92 $37.65 $46.38 $46.38

J E0628 0-20 $347.26 $319.48 $319.48 $319.48

J E0628 21-999 $347.26 $319.48 $319.48 $319.48

J E0629 0-20 $347.25 $319.47 $319.47 $319.47

J E0629 21-999 $347.25 $319.47 $319.47 $319.47

J E0630 0-20 $1,069.80 $984.22 $984.22 $984.22

J E0630 21-999 $1,069.80 $984.22 $984.22 $984.22

L E0630 0-20 $106.98 $98.42 $98.42 $98.42

L E0630 21-999 $106.98 $98.42 $98.42 $98.42

J E0635 0-20 $2,177.65 $2,003.44 $2,177.65 $2,003.44

J E0635 21-999 $2,177.65 $2,003.44 $2,177.65 $2,003.44



L E0635 0-20 $122.36 $112.57 $112.57 $112.57

L E0635 21-999 $122.36 $112.57 $112.57 $112.57

J E0637 0-20 $3,556.34 $3,271.83 $3,556.34 $3,271.83

J E0637 21-999 $3,556.34 $3,271.83 $3,556.34 $3,271.83

J E0638 UA 0-20 $2,349.30 $2,161.36 $2,349.30 $2,161.36

J E0638 UA 21-999 $2,349.30 $2,161.36 $2,349.30 $2,161.36

J E0638 UB 0-20 $2,927.40 $2,693.21 $2,927.40 $2,693.21

J E0638 UB 21-999 $2,927.40 $2,693.21 $2,927.40 $2,693.21

J E0641 0-20 $2,813.58 $2,588.49 $2,813.58 $2,588.49

J E0641 21-999 $2,813.58 $2,588.49 $2,813.58 $2,588.49

J E0642 0-999 $3,001.20 $2,761.10 $3,452.89 $3,452.89

J E0650 0-20 $578.44 $532.16 $532.16 $532.16

J E0650 21-999 $578.44 $532.16 $532.16 $532.16

L E0650 0-20 $57.84 $53.21 $53.21 $53.21

L E0650 21-999 $57.84 $53.21 $53.21 $53.21

J E0651 0-20 $964.34 $887.19 $887.19 $887.19

J E0651 21-999 $964.34 $887.19 $887.19 $887.19

L E0651 0-20 $96.44 $88.72 $88.72 $88.72

L E0651 21-999 $96.44 $88.72 $88.72 $88.72

J E0652 0-20 $4,533.05 $4,170.41 $4,170.41 $4,170.41

J E0652 21-999 $4,533.05 $4,170.41 $4,170.41 $4,170.41

L E0652 0-20 $453.31 $417.05 $417.05 $417.05

L E0652 21-999 $453.31 $417.05 $417.05 $417.05

J E0655 0-20 $86.50 $84.77 $84.77 $84.77

J E0655 21-999 $86.50 $84.77 $84.77 $84.77

L E0655 0-20 $8.65 $8.48 $8.48 $8.48

L E0655 21-999 $8.65 $8.48 $8.48 $8.48

J E0660 0-20 $131.43 $120.92 $120.92 $120.92

J E0660 21-999 $131.43 $120.92 $120.92 $120.92

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


L E0660 0-20 $13.14 $12.09 $12.09 $12.09

L E0660 21-999 $13.14 $12.09 $12.09 $12.09

J E0665 0-20 $112.32 $103.33 $103.33 $103.33

J E0665 21-999 $112.32 $103.33 $103.33 $103.33

L E0665 0-20 $11.23 $10.33 $10.33 $10.33

L E0665 21-999 $11.23 $10.33 $10.33 $10.33

J E0666 0-20 $107.43 $98.84 $98.84 $98.84

J E0666 21-999 $107.43 $98.84 $98.84 $98.84

L E0666 0-20 $10.74 $9.88 $9.88 $9.88

L E0666 21-999 $10.74 $9.88 $9.88 $9.88

J E0667 0-20 $339.96 $312.76 $312.76 $312.76

J E0667 21-999 $339.96 $312.76 $312.76 $312.76

L E0667 0-20 $38.39 $35.32 $35.32 $35.32

L E0667 21-999 $38.39 $35.32 $35.32 $35.32

J E0668 0-20 $434.08 $399.35 $399.35 $399.35

J E0668 21-999 $434.08 $399.35 $399.35 $399.35

L E0668 0-20 $43.41 $39.94 $39.94 $39.94

L E0668 21-999 $43.41 $39.94 $39.94 $39.94

J E0669 0-20 $166.03 $152.75 $152.75 $152.75

J E0669 21-999 $166.03 $152.75 $152.75 $152.75

L E0669 0-20 $16.61 $15.28 $15.28 $15.28

L E0669 21-999 $16.61 $15.28 $15.28 $15.28

J E0671 0-20 $396.17 $364.48 $364.48 $364.48

J E0671 21-999 $396.17 $364.48 $364.48 $364.48

L E0671 0-20 $39.62 $36.45 $36.45 $36.45

L E0671 21-999 $39.62 $36.45 $36.45 $36.45

J E0672 0-20 $307.83 $301.67 $301.67 $301.67

J E0672 21-999 $307.83 $301.67 $301.67 $301.67

L E0672 0-20 $30.79 $30.17 $30.17 $30.17

L E0672 21-999 $30.79 $30.17 $30.17 $30.17

J E0673 0-20 $255.79 $235.33 $235.33 $235.33

J E0673 21-999 $255.79 $235.33 $235.33 $235.33

L E0673 0-20 $25.58 $23.53 $23.53 $23.53

L E0673 21-999 $25.58 $23.53 $23.53 $23.53

J E0676 0-20 Manually Priced Manually Priced Manually Priced Manually Priced


L E0676 0-20 Manually Priced Manually Priced Manually Priced Manually Priced


J E0700 0-20 $26.00 $23.92 $23.92 $23.92

J E0700 21-999 $26.00 $23.92 $23.92 $23.92

J E0705 0-20 $37.91 $34.88 $34.88 $34.88

J E0705 21-999 $37.91 $34.88 $34.88 $34.88

J E0710 0-20 $34.57 $31.80 $31.80 $31.80

J E0710 21-999 $34.57 $31.80 $31.80 $31.80

L E0710 0-20 $3.46 $3.18 $3.18 $3.18

L E0710 21-999 $3.46 $3.18 $3.18 $3.18

J E0720 0-20 $349.75 $321.77 $321.77 $321.77

J E0720 21-999 $349.75 $321.77 $321.77 $321.77

L E0720 0-20 $34.98 $32.18 $32.18 $32.18

L E0720 21-999 $34.98 $32.18 $32.18 $32.18

J E0730 0-20 $357.76 $329.14 $329.14 $329.14

J E0730 21-999 $357.76 $329.14 $329.14 $329.14

L E0730 0-20 $35.78 $32.92 $32.92 $32.92

L E0730 21-999 $35.78 $32.92 $32.92 $32.92

J E0731 0-20 $303.19 $278.93 $278.93 $278.93

J E0731 21-999 $303.19 $278.93 $278.93 $278.93

L E0731 0-20 $30.32 $27.89 $27.89 $27.89

L E0731 21-999 $30.32 $27.89 $27.89 $27.89

9 E0740 0-20 $522.87 $481.04 $481.04 $481.04

9 E0740 21-999 $522.87 $481.04 $481.04 $481.04

J E0740 0-20 $522.87 $481.04 $481.04 $481.04

J E0740 21-999 $522.87 $481.04 $481.04 $481.04

J E0745 0-20 $895.10 $823.49 $823.49 $823.49

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E0745 21-999 $895.10 $823.49 $823.49 $823.49

L E0745 0-20 $89.51 $82.35 $82.35 $82.35

L E0745 21-999 $89.51 $82.35 $82.35 $82.35

J E0747 0-20 $3,916.07 $3,602.78 $3,602.78 $3,602.78

J E0747 21-999 $3,916.07 $3,602.78 $3,602.78 $3,602.78

J E0748 0-20 $3,890.70 $3,579.44 $3,579.44 $3,579.44

J E0748 21-999 $3,890.70 $3,579.44 $3,579.44 $3,579.44

9 E0749 0-20 $2,843.70 $2,786.83 $2,786.83 $2,786.83

9 E0749 21-999 $2,843.70 $2,786.83 $2,786.83 $2,786.83

J E0760 0-20 $3,233.10 $2,974.45 $2,974.45 $2,974.45

J E0760 21-999 $3,233.10 $2,974.45 $2,974.45 $2,974.45

J E0762 0-20 $934.63 $915.94 $915.94 $915.94

J E0762 21-999 $934.63 $915.94 $915.94 $915.94

L E0762 0-20 $93.47 $91.60 $91.60 $91.60

L E0762 21-999 $93.47 $91.60 $91.60 $91.60

J E0764 0-20 $11,066.82 $10,845.48 $10,845.48 $10,845.48

J E0764 21-999 $11,066.82 $10,845.48 $10,845.48 $10,845.48

L E0764 0-20 $1,106.67 $1,084.54 $1,084.54 $1,084.54

L E0764 21-999 $1,106.67 $1,084.54 $1,084.54 $1,084.54

J E0776 0-20 $90.99 $79.62 $79.62 $79.62

J E0776 21-999 $90.99 $79.62 $79.62 $79.62

L E0776 0-20 $11.90 $10.41 $10.41 $10.41

L E0776 21-999 $11.90 $10.41 $10.41 $10.41

J E0779 0-20 $175.70 $153.74 $153.74 $153.74

J E0779 21-999 $175.70 $153.74 $153.74 $153.74

L E0779 0-20 $17.57 $15.37 $15.37 $15.37

L E0779 21-999 $17.57 $15.37 $15.37 $15.37

J E0780 0-20 $10.89 $9.53 $9.53 $9.53

J E0780 21-999 $10.89 $9.53 $9.53 $9.53

L E0780 0-20 $1.09 $0.95 $0.95 $0.95

L E0780 21-999 $1.09 $0.95 $0.95 $0.95

J E0781 0-20 $2,435.72 $2,106.90 $2,106.90 $2,106.90

J E0781 21-999 $2,435.72 $2,106.90 $2,106.90 $2,106.90

L E0781 0-20 $243.57 $210.69 $210.69 $210.69

L E0781 21-999 $243.57 $210.69 $210.69 $210.69

9 E0782 0-20 $3,830.11 $3,753.51 $3,753.51 $3,753.51

9 E0782 21-999 $3,830.11 $3,753.51 $3,753.51 $3,753.51

J E0782 0-20 $3,830.11 $3,753.51 $3,753.51 $3,753.51

J E0782 21-999 $3,830.11 $3,753.51 $3,753.51 $3,753.51

9 E0783 0-20 $8,130.87 $7,480.40 $7,480.40 $7,480.40

9 E0783 21-999 $8,130.87 $7,480.40 $7,480.40 $7,480.40

J E0783 0-20 $8,130.87 $7,480.40 $7,480.40 $7,480.40

J E0783 21-999 $8,130.87 $7,480.40 $7,480.40 $7,480.40

J E0784 0-20 $4,383.60 $4,032.91 $4,032.91 $4,032.91

J E0784 21-999 $4,383.60 $4,032.91 $4,032.91 $4,032.91

J E0784 0-20 $663.33 $610.26 $602.77 $602.77

J E0784 21-999 $663.33 $610.26 $602.77 $602.77

L E0784 0-20 $438.36 $403.29 $403.29 $403.29

L E0784 21-999 $438.36 $403.29 $403.29 $403.29

L E0784 0-20 $66.33 $61.02 $60.28 $60.28

L E0784 21-999 $66.33 $61.02 $60.28 $60.28

J E0786 0-20 $6,055.80 $5,571.34 $5,571.34 $5,571.34

J E0786 21-999 $6,055.80 $5,571.34 $5,571.34 $5,571.34

J E0791 0-20 $3,320.10 $3,054.49 $3,054.49 $3,054.49

J E0791 21-999 $3,320.10 $3,054.49 $3,054.49 $3,054.49

L E0791 0-20 $332.01 $305.45 $305.45 $305.45

L E0791 21-999 $332.01 $305.45 $305.45 $305.45

J E0840 0-20 $54.19 $53.11 $53.11 $53.11

J E0840 21-999 $54.19 $53.11 $53.11 $53.11

L E0840 0-20 $16.10 $15.78 $15.78 $15.78

L E0840 21-999 $16.10 $15.78 $15.78 $15.78

J E0850 0-20 $84.18 $82.50 $82.50 $82.50

J E0850 21-999 $84.18 $82.50 $82.50 $82.50

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


L E0850 0-20 $12.88 $12.62 $12.62 $12.62

L E0850 21-999 $12.88 $12.62 $12.62 $12.62

J E0855 0-20 $471.40 $461.97 $461.97 $461.97

J E0855 21-999 $471.40 $461.97 $461.97 $461.97

L E0855 0-20 $47.16 $46.22 $46.22 $46.22

L E0855 21-999 $47.16 $46.22 $46.22 $46.22

J E0856 0-20 $154.03 $150.95 $150.95 $150.95

J E0856 21-999 $154.03 $150.95 $150.95 $150.95

J E0860 0-20 $26.98 $24.82 $24.82 $24.82

J E0860 21-999 $26.98 $24.82 $24.82 $24.82

L E0860 0-20 $5.81 $5.35 $5.35 $5.35

L E0860 21-999 $5.81 $5.35 $5.35 $5.35

J E0880 0-20 $97.66 $89.85 $89.85 $89.85

J E0880 21-999 $97.66 $89.85 $89.85 $89.85

L E0880 0-20 $17.60 $16.19 $16.19 $16.19

L E0880 21-999 $17.60 $16.19 $16.19 $16.19

J E0900 0-20 $98.32 $90.45 $90.45 $90.45

J E0900 21-999 $98.32 $90.45 $90.45 $90.45

L E0900 0-20 $16.77 $15.43 $15.43 $15.43

L E0900 21-999 $16.77 $15.43 $15.43 $15.43

J E0910 0-20 $181.00 $150.23 $150.23 $150.23

J E0910 21-999 $181.00 $150.23 $150.23 $150.23

L E0910 0-20 $18.10 $15.02 $15.02 $15.02

L E0910 21-999 $18.10 $15.02 $15.02 $15.02

J E0911 0-20 $451.10 $415.01 $415.01 $415.01

J E0911 21-999 $451.10 $415.01 $415.01 $415.01

L E0911 0-20 $45.11 $41.50 $41.50 $41.50

L E0911 21-999 $45.11 $41.50 $41.50 $41.50

J E0912 0-20 $1,036.00 $953.12 $953.12 $953.12

J E0912 21-999 $1,036.00 $953.12 $953.12 $953.12

L E0912 0-20 $103.60 $95.31 $95.31 $95.31

L E0912 21-999 $103.60 $95.31 $95.31 $95.31

J E0920 0-20 $484.50 $445.74 $445.74 $445.74

J E0920 21-999 $484.50 $445.74 $445.74 $445.74

L E0920 0-20 $48.45 $44.57 $44.57 $44.57

L E0920 21-999 $48.45 $44.57 $44.57 $44.57

J E0930 0-20 $479.70 $441.32 $441.32 $441.32

J E0930 21-999 $479.70 $441.32 $441.32 $441.32

L E0930 0-20 $47.97 $44.13 $44.13 $44.13

L E0930 21-999 $47.97 $44.13 $44.13 $44.13

L E0935 0-20 $23.87 $19.81 $19.81 $19.81

L E0935 21-999 $23.87 $19.81 $19.81 $19.81

J E0940 0-20 $311.72 $286.78 $286.78 $286.78

J E0940 21-999 $311.72 $286.78 $286.78 $286.78

L E0940 0-20 $31.17 $28.68 $28.68 $28.68

L E0940 21-999 $31.17 $28.68 $28.68 $28.68

J E0941 0-20 $455.80 $419.34 $419.34 $419.34

J E0941 21-999 $455.80 $419.34 $419.34 $419.34

L E0941 0-20 $45.58 $41.93 $41.93 $41.93

L E0941 21-999 $45.58 $41.93 $41.93 $41.93

J E0942 0-20 $19.00 $18.62 $18.62 $18.62

J E0942 21-999 $19.00 $18.62 $18.62 $18.62

J E0944 0-20 $31.41 $28.90 $28.90 $28.90

J E0944 21-999 $31.41 $28.90 $28.90 $28.90

J E0945 0-20 $26.58 $24.45 $24.45 $24.45

J E0945 21-999 $26.58 $24.45 $24.45 $24.45

J E0946 0-20 $380.40 $372.79 $372.79 $372.79

J E0946 21-999 $380.40 $372.79 $372.79 $372.79

L E0946 0-20 $38.04 $37.28 $37.28 $37.28

L E0946 21-999 $38.04 $37.28 $37.28 $37.28

J E0950 0-20 $171.93 $171.93 $171.93 $171.93

J E0950 21-999 $171.93 $171.93 $171.93 $171.93

J E0951 0-20 $12.05 $12.05 $12.05 $12.05

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E0951 21-999 $12.05 $12.05 $12.05 $12.05

J E0952 0-20 $12.58 $12.58 $12.58 $12.58

J E0952 21-999 $12.58 $12.58 $12.58 $12.58

J E0955 0-20 $182.29 $182.29 $182.29 $182.29

J E0955 21-999 $182.29 $182.29 $182.29 $182.29

L E0956 0-20 $9.87 $208.84 $208.84 $208.84

L E0956 21-999 $208.84 $208.84 $208.84 $208.84

J E0957 0-20 $208.84 $134.51 $134.51 $134.51

J E0957 21-999 $134.51 $134.51 $134.51 $134.51

J E0958 0-20 $134.51 $679.71 $679.71 $679.71

J E0958 21-999 $679.71 $679.71 $679.71 $679.71

J E0960 0-20 $679.71 $88.72 $88.72 $88.72

J E0960 21-999 $88.72 $88.72 $88.72 $88.72

J E0961 0-20 $16.63 $16.63 $16.63 $16.63

J E0961 21-999 $16.63 $16.63 $16.63 $16.63

J E0969 0-999 $149.65 $146.66 $146.66 $146.66

J E0970 0-20 $51.98 $51.98 $51.98 $51.98

J E0970 21-999 $51.98 $51.98 $51.98 $51.98

J E0971 0-20 $53.98 $53.98 $53.98 $53.98

J E0971 21-999 $53.98 $53.98 $53.98 $53.98

J E0973 0-20 $68.33 $68.33 $68.33 $68.33

J E0973 21-999 $68.33 $68.33 $68.33 $68.33

J E0974 0-20 $71.75 $71.75 $71.75 $71.75

J E0974 21-999 $71.75 $71.75 $71.75 $71.75

J E0978 0-20 $35.40 $35.40 $35.40 $35.40

J E0978 21-999 $35.40 $35.40 $35.40 $35.40

J E0980 0-20 $28.79 $28.79 $28.79 $28.79

J E0980 21-999 $28.79 $28.79 $28.79 $28.79

J E0981 0-20 $34.42 $34.42 $34.42 $34.42

J E0981 21-999 $34.42 $34.42 $34.42 $34.42

J E0982 0-20 $50.25 $50.25 $50.25 $50.25

J E0982 21-999 $50.25 $50.25 $50.25 $50.25

J E0990 0-20 $130.44 $130.44 $130.44 $130.44

J E0990 21-999 $130.44 $130.44 $130.44 $130.44

J E0992 0-20 $82.82 $82.72 $82.82 $82.82

J E0992 21-999 $82.82 $82.72 $82.82 $82.82

J E0994 0-20 $13.24 $13.24 $13.24 $13.24

J E0994 21-999 $13.24 $13.24 $13.24 $13.24

J E0995 0-20 $22.13 $22.12 $22.12 $22.12

J E0995 21-999 $22.13 $22.12 $22.12 $22.12

J E1002 0-20 $3,661.00 $3,661.00 $3,661.00 $3,661.00

J E1002 21-999 $3,661.00 $3,661.00 $3,661.00 $3,661.00

J E1003 0-20 $4,282.40 $4,282.40 $4,282.40 $4,282.40

J E1003 21-999 $4,282.40 $4,282.40 $4,282.40 $4,282.40

J E1004 0-20 $4,748.30 $4,748.30 $4,748.30 $4,748.30

J E1004 21-999 $4,748.30 $4,748.30 $4,748.30 $4,748.30

J E1005 0-20 $5,270.36 $5,164.95 $4,781.68 $4,781.68

J E1005 21-999 $5,270.36 $5,164.95 $4,781.68 $4,781.68

J E1006 0-20 $6,295.59 $6,295.59 $6,295.60 $6,295.60

J E1006 21-999 $6,295.59 $6,295.59 $6,295.60 $6,295.60

J E1007 0-20 $7,861.03 $7,861.03 $7,861.02 $7,861.02

J E1007 21-999 $7,861.03 $7,861.03 $7,861.02 $7,861.02

J E1008 0-20 $7,881.83 $7,881.83 $7,881.83 $7,881.83

J E1008 21-999 $7,881.83 $7,881.83 $7,881.83 $7,881.83



J E1010 0-20 $1,595.33 $1,595.33 $1,595.33 $1,595.33

J E1010 21-999 $1,595.33 $1,595.33 $1,595.33 $1,595.33



J E1014 0-20 $319.87 $319.87 $319.87 $319.87

J E1014 21-999 $319.87 $319.87 $319.87 $319.87

J E1015 0-20 $117.45 $117.45 $117.46 $117.46

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E1015 21-999 $117.45 $117.45 $117.46 $117.46

J E1016 0-20 $130.38 $127.15 $127.15 $127.15

J E1016 21-999 $127.15 $127.15 $127.15 $127.15

J E1017 0-20 $127.15 $120.14 Manually Priced Manually Priced

J E1017 21-999 $122.59 $120.14 Manually Priced Manually Priced



J E1020 0-20 $223.90 $223.90 $223.91 $223.91

J E1020 21-999 $223.90 $223.90 $223.91 $223.91

L E1020 0-20 $21.47 $21.47 $21.47 $21.47

L E1020 21-999 $21.47 $21.47 $21.47 $21.47

J E1028 0-20 $186.22 $186.22 $186.22 $186.22

J E1028 21-999 $186.22 $186.22 $186.22 $186.22

J E1029 0-20 $326.14 $326.14 $326.14 $326.14

J E1029 21-999 $326.14 $326.14 $326.14 $326.14

L E1031 0-20 $45.56 $41.92 $41.92 $41.92

L E1031 21-999 $45.56 $41.92 $41.92 $41.92

J E1035 0-999 $3,335.96 $3,069.08 $3,069.08 $3,069.08



J E1050 0-20 $726.14 $668.05 $668.05 $668.05

J E1050 21-999 $726.14 $668.05 $668.05 $668.05

L E1050 0-20 $72.61 $66.80 $66.80 $66.80

L E1050 21-999 $72.61 $66.80 $66.80 $66.80

J E1060 0-20 $1,162.94 $1,069.90 $1,069.90 $1,069.90

J E1060 21-999 $1,162.94 $1,069.90 $1,069.90 $1,069.90

L E1060 0-20 $116.29 $106.99 $106.99 $106.99

L E1060 21-999 $116.29 $106.99 $106.99 $106.99

J E1070 0-20 $915.30 $842.08 $842.08 $842.08

J E1070 21-999 $915.30 $842.08 $842.08 $842.08

L E1070 0-20 $91.53 $84.21 $84.21 $84.21

L E1070 21-999 $91.53 $84.21 $84.21 $84.21

J E1083 0-20 $492.74 $453.32 $453.32 $453.32

J E1083 21-999 $492.74 $453.32 $453.32 $453.32

L E1083 0-20 $49.27 $45.33 $45.33 $45.33

L E1083 21-999 $49.27 $45.33 $45.33 $45.33

J E1084 0-20 $837.72 $770.70 $770.70 $770.70

J E1084 21-999 $837.72 $770.70 $770.70 $770.70

L E1084 0-20 $83.77 $77.07 $77.07 $77.07

L E1084 21-999 $83.77 $77.07 $77.07 $77.07

J E1085 0-20 $653.83 $640.75 $861.32 $861.32

J E1085 21-999 $653.83 $640.75 $861.32 $861.32

L E1085 0-20 $65.38 $64.07 $86.13 $86.13

L E1085 21-999 $65.38 $64.07 $86.13 $86.13

J E1086 0-20 $786.65 $723.72 $808.59 $808.59

J E1086 21-999 $786.65 $723.72 $808.59 $808.59

L E1086 0-20 $78.67 $72.38 $80.86 $80.86

L E1086 21-999 $78.67 $72.38 $80.86 $80.86

J E1087 0-20 $1,190.42 $1,095.19 $1,095.19 $1,095.19

J E1087 21-999 $1,190.42 $1,095.19 $1,095.19 $1,095.19

L E1087 0-20 $119.04 $109.52 $109.52 $109.52

L E1087 21-999 $119.04 $109.52 $109.52 $109.52

J E1088 0-20 $1,470.58 $1,147.05 $1,147.05 $1,147.05

J E1088 21-999 $1,470.58 $1,147.05 $1,147.05 $1,147.05

L E1088 0-20 $147.06 $114.71 $114.71 $114.71

L E1088 21-999 $147.06 $114.71 $114.71 $114.71

J E1089 0-20 $1,187.10 $1,092.13 $1,320.57 $1,320.57

J E1089 21-999 $1,187.10 $1,092.13 $1,320.57 $1,320.57

L E1089 0-20 $118.71 $109.21 $132.06 $132.06

L E1089 21-999 $118.71 $109.21 $132.06 $132.06

J E1090 0-20 $1,268.95 $1,167.43 $1,320.57 $1,320.57

J E1090 21-999 $1,268.95 $1,167.43 $1,320.57 $1,320.57

L E1090 0-20 $126.90 $116.75 $126.90 $116.75

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


L E1090 21-999 $126.90 $116.75 $126.90 $116.75

J E1092 0-20 $1,349.40 $1,052.53 $1,052.53 $1,052.53

J E1092 21-999 $1,349.40 $1,052.53 $1,052.53 $1,052.53

L E1092 0-20 $134.94 $105.25 $105.25 $105.25

L E1092 21-999 $134.94 $105.25 $105.25 $105.25

J E1093 0-20 $1,160.50 $1,067.66 $1,067.66 $1,067.66

J E1093 21-999 $1,160.50 $1,067.66 $1,067.66 $1,067.66

L E1093 0-20 $116.05 $106.77 $106.77 $106.77

L E1093 21-999 $116.05 $106.77 $106.77 $106.77

J E1100 0-20 $1,090.00 $1,002.80 $1,002.80 $1,002.80

J E1100 21-999 $1,090.00 $1,002.80 $1,002.80 $1,002.80

L E1100 0-20 $109.00 $100.28 $100.28 $100.28

L E1100 21-999 $109.00 $100.28 $100.28 $100.28

J E1110 0-20 $1,067.40 $982.01 $982.01 $982.01

J E1110 21-999 $1,067.40 $982.01 $982.01 $982.01

L E1110 0-20 $106.74 $98.20 $98.20 $98.20

L E1110 21-999 $106.74 $98.20 $98.20 $98.20

J E1130 0-20 $456.12 $419.63 $526.33 $526.33

J E1130 21-999 $456.12 $419.63 $526.33 $526.33

L E1130 0-20 $45.61 $41.96 $45.61 $41.96

L E1130 21-999 $45.61 $41.96 $45.61 $41.96

J E1140 0-20 $636.11 $496.17 $446.24 $446.24

J E1140 21-999 $636.11 $496.17 $446.24 $446.24

L E1140 0-20 $63.61 $49.62 $44.62 $44.62

L E1140 21-999 $63.61 $49.62 $44.62 $44.62

J E1150 0-20 $753.72 $587.90 $587.90 $587.90

J E1150 21-999 $753.72 $587.90 $587.90 $587.90

L E1150 0-20 $75.37 $58.79 $58.79 $58.79

L E1150 21-999 $75.37 $58.79 $58.79 $58.79

J E1160 0-20 $553.60 $509.31 $509.31 $509.31

J E1160 21-999 $553.60 $509.31 $509.31 $509.31

L E1160 0-20 $55.36 $50.93 $50.93 $50.93

L E1160 21-999 $55.36 $50.93 $50.93 $50.93

J E1161 0-20 $2,422.78 $2,422.78 $2,422.78 $2,422.78

J E1161 21-999 $2,422.78 $2,422.78 $2,422.78 $2,422.78

L E1161 0-20 $242.27 $242.27 $242.27 $242.27

L E1161 21-999 $242.27 $242.27 $242.27 $242.27

J E1170 0-20 $937.80 $919.04 $919.04 $919.04

J E1170 21-999 $937.80 $919.04 $919.04 $919.04

L E1170 0-20 $93.78 $91.90 $91.90 $91.90

L E1170 21-999 $93.78 $91.90 $91.90 $91.90

J E1171 0-20 $841.60 $824.77 $824.77 $824.77

J E1171 21-999 $841.60 $824.77 $824.77 $824.77

L E1171 0-20 $84.16 $82.48 $82.48 $82.48

L E1171 21-999 $84.16 $82.48 $82.48 $82.48

J E1172 0-20 $847.33 $779.54 $779.54 $779.54

J E1172 21-999 $847.33 $779.54 $779.54 $779.54

L E1172 0-20 $84.73 $77.95 $77.95 $77.95

L E1172 21-999 $84.73 $77.95 $77.95 $77.95

J E1180 0-20 $1,002.78 $922.56 $922.56 $922.56

J E1180 21-999 $1,002.78 $922.56 $922.56 $922.56

L E1180 0-20 $100.28 $92.26 $92.26 $92.26

L E1180 21-999 $100.28 $92.26 $92.26 $92.26

J E1190 0-20 $1,215.49 $1,118.25 $1,028.84 $1,028.84

J E1190 21-999 $1,215.49 $1,118.25 $1,028.84 $1,028.84

L E1190 0-20 $111.83 $111.83 $111.83 $111.83

L E1190 21-999 $111.83 $111.83 $111.83 $111.83

J E1195 0-20 $1,157.68 $1,065.07 $979.89 $979.89

J E1195 21-999 $1,157.68 $1,065.07 $979.89 $979.89

L E1195 0-20 $106.51 $106.51 $106.51 $106.51

L E1195 21-999 $106.51 $106.51 $106.51 $106.51

J E1200 0-20 $707.03 $692.89 $692.89 $692.89

J E1200 21-999 $707.03 $692.89 $692.89 $692.89

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


L E1200 0-20 $70.70 $69.29 $69.29 $69.29

L E1200 21-999 $70.70 $69.29 $69.29 $69.29





J E1230 0-20 $1,353.72 $1,353.72 $1,353.82 $1,353.82

J E1230 21-999 $1,353.72 $1,353.72 $1,353.82 $1,353.82

L E1230 0-20 $141.41 $141.41 $141.41 $141.41

L E1230 21-999 $141.41 $141.41 $141.41 $141.41

J E1231 0-20 $2,968.35 $2,968.35 $2,968.35 $2,968.35

J E1231 21-999 $2,968.35 $2,968.35 $2,968.35 $2,968.35

L E1231 0-20 $296.83 $296.83 $296.83 $296.83

L E1231 21-999 $296.83 $296.83 $296.83 $296.83

J E1232 0-20 $2,189.64 $2,189.64 $2,189.65 $2,189.65

J E1232 21-999 $2,189.64 $2,189.64 $2,189.65 $2,189.65

L E1232 0-20 $218.96 $218.96 $218.96 $218.96

L E1232 21-999 $218.96 $218.96 $218.96 $218.96

J E1233 0-20 $2,268.82 $2,268.82 $2,268.82 $2,268.82

J E1233 21-999 $2,268.82 $2,268.82 $2,268.82 $2,268.82

L E1233 0-20 $226.88 $226.88 $226.88 $226.88

L E1233 21-999 $226.88 $226.88 $226.88 $226.88

J E1234 0-20 $1,975.17 $1,975.17 $1,975.17 $1,975.17

J E1234 21-999 $1,975.17 $1,975.17 $1,975.17 $1,975.17

L E1234 0-20 $197.53 $197.53 $197.53 $197.53

L E1234 21-999 $197.53 $197.53 $197.53 $197.53

J E1235 0-20 $2,825.15 $2,825.15 $2,825.15 $2,825.15

J E1235 21-999 $2,825.15 $2,825.15 $2,825.15 $2,825.15

L E1235 0-20 $190.21 $190.21 $190.20 $190.20

L E1235 21-999 $190.21 $190.21 $190.20 $190.20

J E1236 0-20 $3,103.09 $3,103.09 $3,103.09 $3,103.09

J E1236 21-999 $3,103.09 $3,103.09 $3,103.09 $3,103.09

L E1236 0-20 $167.80 $167.80 $167.80 $167.80

L E1236 21-999 $167.80 $167.80 $167.80 $167.80

J E1237 0-20 $1,439.40 $1,439.40 $1,439.40 $1,439.40

J E1237 21-999 $1,439.40 $1,439.40 $1,439.40 $1,439.40

L E1237 0-20 $143.94 $143.94 $143.94 $143.94

L E1237 21-999 $143.94 $143.94 $143.94 $143.94

J E1238 0-20 $1,599.33 $1,599.33 $1,599.33 $1,599.33

J E1238 21-999 $1,599.33 $1,599.33 $1,599.33 $1,599.33

L E1238 0-20 $159.93 $159.93 $159.93 $159.93

L E1238 21-999 $159.93 $159.93 $159.93 $159.93



J E1240 0-20 $979.81 $764.25 $764.25 $764.25

J E1240 21-999 $979.81 $764.25 $764.25 $764.25

L E1240 0-20 $97.98 $76.42 $76.42 $76.42

L E1240 21-999 $97.98 $76.42 $76.42 $76.42

J E1250 0-20 $729.30 $670.96 $885.41 $885.41

J E1250 21-999 $729.30 $670.96 $885.41 $885.41

L E1250 0-20 $72.93 $67.10 $88.54 $88.54

L E1250 21-999 $72.93 $67.10 $88.54 $88.54

J E1260 0-20 $900.94 $702.73 $750.67 $750.67

J E1260 21-999 $900.94 $702.73 $750.67 $750.67

L E1260 0-20 $90.09 $70.27 $75.07 $75.07

L E1260 21-999 $90.09 $70.27 $75.07 $75.07

J E1270 0-20 $828.90 $762.59 $762.59 $762.59

J E1270 21-999 $828.90 $762.59 $762.59 $762.59

L E1270 0-20 $82.89 $76.26 $76.26 $76.26

L E1270 21-999 $82.89 $76.26 $76.26 $76.26

J E1280 0-20 $1,378.20 $1,075.00 $1,075.00 $1,075.00

J E1280 21-999 $1,378.20 $1,075.00 $1,075.00 $1,075.00

L E1280 0-20 $137.82 $107.50 $107.50 $107.50

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


L E1280 21-999 $137.82 $107.50 $107.50 $107.50

J E1285 0-20 $1,183.63 $1,088.94 $1,239.33 $1,239.33

J E1285 21-999 $1,183.63 $1,088.94 $1,239.33 $1,239.33

L E1285 0-20 $118.36 $108.89 $123.93 $123.93

L E1285 21-999 $118.36 $108.89 $123.93 $123.93

J E1290 0-20 $1,034.51 $951.75 $1,034.51 $951.75

J E1290 21-999 $1,034.51 $951.75 $1,034.51 $951.75

L E1290 0-20 $103.45 $95.17 $103.45 $95.17

L E1290 21-999 $103.45 $95.17 $103.45 $95.17

J E1295 0-20 $1,113.60 $1,024.51 $1,113.60 $1,024.51

J E1295 21-999 $1,113.60 $1,024.51 $1,113.60 $1,024.51

L E1295 0-20 $111.36 $102.45 $102.45 $102.45

L E1295 21-999 $111.36 $102.45 $102.45 $102.45

J E1296 0-20 $417.92 $384.49 $384.49 $384.49

J E1296 21-999 $417.92 $384.49 $384.49 $384.49

J E1297 0-20 $88.92 $81.81 $81.81 $81.81

J E1297 21-999 $88.92 $81.81 $81.81 $81.81

J E1298 0-20 $360.10 $331.29 $331.29 $331.29

J E1298 21-999 $360.10 $331.29 $331.29 $331.29

J E1300 0-999 $170.00 $156.40 $156.40 $156.40

L E1300 0-999 $17.00 $15.64 $15.64 $15.64

J E1310 0-999 $2,254.77 $2,074.39 $2,074.39 $2,074.39

J E1353 0-20 $29.75 $27.37 $27.37 $27.37

J E1353 21-999 $29.75 $27.37 $27.37 $27.37

J E1355 0-20 $22.40 $20.61 $20.61 $20.61

J E1355 21-999 $22.40 $20.61 $20.61 $20.61

L E1355 0-20 $2.24 $2.06 $2.06 $2.06

L E1355 21-999 $2.24 $2.06 $2.06 $2.06

J E1372 0-20 $163.03 $149.99 $149.99 $149.99

J E1372 21-999 $163.03 $149.99 $149.99 $149.99

L E1390 0-20 $173.17 $161.05 $161.05 $161.05

L E1390 21-999 $173.17 $161.05 $161.05 $161.05





J E1510 0-999 $10,131.32 $9,928.69 $9,928.69 $9,928.69

L E1510 0-999 $1,013.13 $992.87 $992.87 $992.87

J E1520 0-999 $380.31 $372.70 $372.70 $372.70

L E1520 0-999 $38.03 $37.27 $37.27 $37.27

J E1530 0-999 $547.22 $536.28 $536.28 $536.28

J E1540 0-999 $22.96 $22.50 $22.50 $22.50


J E1550 0-999 $297.91 $274.08 $274.08 $274.08

L E1550 0-999 $29.79 $27.41 $27.41 $27.41



J E1570 0-999 $200.23 $184.21 $184.21 $184.21

L E1570 0-999 $20.02 $18.42 $18.42 $18.42

J E1575 0-999 $1.63 $1.60 $1.60 $1.60

L E1575 0-999 $0.16 $0.16 $0.16 $0.16




L E1590 0-999 $290.00 $284.20 $284.20 $284.20



J E1594 0-999 $6,544.00 $6,020.48 $6,020.48 $6,020.48

L E1594 0-999 $654.40 $602.05 $602.05 $602.05

L E1600 0-999 $364.75 $357.46 $35.75 $35.75

J E1620 0-999 $1,754.74 $1,719.65 $1,719.65 $1,719.65

L E1620 0-999 $175.47 $171.96 $171.96 $171.96


Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013






L E1635 0-999 $628.88 $616.30 $616.30 $616.30

J E1637 0-999 $5.33 $5.22 $3.92 $3.92

J E1639 0-999 $214.68 $210.39 $210.39 $210.39

L E1639 0-999 $21.47 $21.04 $21.04 $21.04



L E1700 0-999 $30.18 $27.77 $27.77 $27.77

L E1701 0-999 $9.47 $9.28 $1.06 $1.06

L E1702 0-999 $23.70 $23.23 $2.02 $2.02

J E1800 0-999 $1,115.60 $1,026.35 $1,026.35 $1,026.35

L E1800 0-999 $111.56 $102.64 $102.64 $102.64

J E1801 0-999 $1,354.50 $1,327.41 $1,327.41 $1,327.41

J E1802 0-999 $3,431.00 $3,156.52 $3,156.89 $3,156.89

L E1802 0-999 $343.14 $315.69 $315.69 $315.69

J E1805 0-999 $1,127.60 $1,037.39 $1,037.39 $1,037.39

L E1805 0-999 $112.76 $103.74 $103.74 $103.74

J E1806 0-999 $1,059.10 $974.37 $974.37 $974.37

J E1810 0-999 $1,130.90 $1,040.43 $1,040.43 $1,040.43

L E1810 0-999 $113.09 $104.04 $104.04 $104.04

J E1811 0-999 $1,341.20 $1,314.38 $1,314.38 $1,314.38

J E1812 0-999 $859.90 $842.70 $842.70 $842.70

L E1812 0-999 $85.99 $84.27 $84.27 $84.27

J E1815 0-999 $1,130.90 $1,040.43 $1,040.43 $1,040.43

L E1815 0-999 $113.09 $104.04 $104.04 $104.04

J E1816 0-999 $1,362.40 $1,335.15 $1,335.15 $1,335.15

J E1818 0-999 $1,390.90 $1,363.08 $1,363.08 $1,363.08

J E1820 0-999 $75.85 $69.78 $69.78 $69.78

L E1820 0-999 $7.58 $6.97 $6.97 $6.97

J E1821 0-999 $110.51 $108.30 $108.30 $108.30

J E1825 0-999 $1,127.60 $1,037.39 $1,037.39 $1,037.39

L E1825 0-999 $112.76 $103.74 $103.74 $103.74

J E1830 0-999 $1,127.60 $1,037.39 $1,037.39 $1,037.39

L E1830 0-999 $112.76 $103.74 $103.74 $103.74

L E1831 0-999 $172.12 $158.35 $62.79 $62.79

J E1840 0-999 $4,018.50 $3,697.02 $3,697.02 $3,697.02

L E1840 0-999 $401.85 $369.70 $369.70 $369.70

L E1841 0-20 Manually Priced Manually Priced $476.84 $476.84

L E1841 21-999 Manually Priced Manually Priced $476.84 $476.84

J E2100 0-20 $340.00 $312.80 $312.80 $312.80

J E2100 21-999 $340.00 $312.80 $312.80 $312.80

J E2101 0-20 $188.56 $173.48 $173.48 $173.48

J E2101 21-999 $188.56 $173.48 $173.48 $173.48

J E2201 0-20 $363.85 $363.85 $363.85 $363.85

J E2201 21-999 $363.85 $363.85 $363.85 $363.85

J E2202 0-20 $462.22 $462.22 $462.23 $462.23

J E2202 21-999 $462.22 $462.22 $462.23 $462.23

J E2203 0-20 $431.92 $431.92 $431.91 $431.91

J E2203 21-999 $431.92 $431.92 $431.91 $431.91

J E2204 0-20 $651.05 $651.05 $651.05 $651.05

J E2204 21-999 $651.05 $651.05 $651.05 $651.05

J E2205 0-20 $33.45 $33.45 $33.45 $33.45

J E2205 21-999 $33.45 $33.45 $33.45 $33.45

J E2206 0-20 $41.65 $41.65 $41.65 $41.65

J E2206 21-999 $41.65 $41.65 $41.65 $41.65

J E2207 0-20 $42.27 $42.27 $42.25 $42.25

J E2207 21-999 $42.27 $42.27 $42.25 $42.25

L E2207 0-20 $4.23 $4.23 $4.23 $4.23

L E2207 21-999 $4.23 $4.23 $4.23 $4.23

J E2208 0-20 $115.84 $115.84 $115.83 $115.83

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E2208 21-999 $115.84 $115.84 $115.83 $115.83

L E2208 0-20 $11.58 $11.58 $11.58 $11.58

L E2208 21-999 $11.58 $11.58 $11.58 $11.58

J E2209 0-20 $104.51 $104.51 $104.51 $104.51

J E2209 21-999 $104.51 $104.51 $104.51 $104.51

L E2209 0-20 $10.47 $10.47 $10.47 $10.47

L E2209 21-999 $10.47 $10.47 $10.47 $10.47

J E2210 0-20 $6.39 $6.39 $6.39 $6.39

J E2210 21-999 $6.39 $6.39 $6.39 $6.39

J E2211 0-20 $28.51 $28.51 $28.51 $28.51

J E2211 21-999 $28.51 $28.51 $28.51 $28.51

J E2212 0-20 $5.73 $5.73 $5.73 $5.73

J E2212 21-999 $5.73 $5.73 $5.73 $5.73

J E2213 0-20 $28.51 $28.51 $28.51 $28.51

J E2213 21-999 $28.51 $28.51 $28.51 $28.51

J E2214 0-20 $29.84 $29.84 $29.84 $29.84

J E2214 21-999 $29.84 $29.84 $29.84 $29.84

J E2215 0-20 $9.36 $9.36 $9.36 $9.36

J E2215 21-999 $9.36 $9.36 $9.36 $9.36

J E2216 0-20 $28.51 $28.51 $28.51 $28.51

J E2216 21-999 $28.51 $28.51 $28.51 $28.51

J E2217 0-20 $32.07 $32.07 $32.07 $32.07

J E2217 21-999 $32.07 $32.07 $32.07 $32.07

J E2218 0-20 $43.98 $43.98 $43.98 $43.98

J E2218 21-999 $43.98 $43.98 $43.98 $43.98

J E2219 0-20 $32.07 $32.07 $32.07 $32.07

J E2219 21-999 $32.07 $32.07 $32.07 $32.07

J E2220 0-20 $23.64 $23.64 $23.64 $23.64

J E2220 21-999 $23.64 $23.64 $23.64 $23.64

J E2221 0-20 $24.92 $24.92 $24.92 $24.92

J E2221 21-999 $24.92 $24.92 $24.92 $24.92

J E2222 0-20 $59.18 $59.18 $59.18 $59.18

J E2222 21-999 $59.18 $59.18 $59.18 $59.18

J E2224 0-20 $43.91 $43.91 $43.91 $43.91

J E2224 21-999 $43.91 $43.91 $43.91 $43.91

J E2225 0-20 $39.98 $39.98 $39.98 $39.98

J E2225 21-999 $39.98 $39.98 $39.98 $39.98

J E2226 0-20 $50.63 $50.63 $50.63 $50.63

J E2226 21-999 $50.63 $50.63 $50.63 $50.63

J E2227 0-20 $1,530.22 $1,530.22 $1,530.22 $1,530.22

J E2227 21-999 $1,530.22 $1,530.22 $1,530.22 $1,530.22

J E2228 0-20 $913.04 $913.04 $913.04 $913.04

J E2228 21-999 $913.04 $913.04 $913.04 $913.04











J E2310 0-20 $1,141.22 $1,141.22 $1,141.22 $1,141.22

J E2310 21-999 $1,141.22 $1,141.22 $1,141.22 $1,141.22

J E2311 0-20 $2,136.07 $2,136.07 $2,136.07 $2,136.07

J E2311 21-999 $2,136.07 $2,136.07 $2,136.07 $2,136.07

J E2312 0-20 $1,891.09 $1,891.09 $1,891.09 $1,891.09

J E2312 21-999 $1,891.09 $1,891.09 $1,891.09 $1,891.09

J E2312 0-20 $2,411.85 $2,411.85 $2,411.85 $2,411.85

J E2312 21-999 $2,411.85 $2,411.85 $2,411.85 $2,411.85

L E2312 0-20 $189.11 $189.11 $189.11 $189.11

L E2312 21-999 $189.11 $189.11 $189.11 $189.11

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


L E2312 0-20 $241.18 $241.18 $241.19 $241.19

L E2312 21-999 $241.18 $241.18 $241.19 $241.19

J E2313 0-20 $300.30 $300.30 $300.29 $300.29

J E2313 21-999 $300.30 $300.30 $300.29 $300.29

J E2321 0-20 $1,719.28 $1,719.28 $1,719.28 $1,719.28

J E2321 21-999 $1,719.28 $1,719.28 $1,719.28 $1,719.28

J E2321 0-20 $2,284.46 $2,284.46 $2,284.45 $2,284.45

J E2321 21-999 $2,284.46 $2,284.46 $2,284.45 $2,284.45

J E2323 0-20 $63.04 $63.04 $63.04 $63.04

J E2323 21-999 $63.04 $63.04 $63.04 $63.04

J E2324 0-20 $43.39 $43.39 $43.39 $43.39

J E2324 21-999 $43.39 $43.39 $43.39 $43.39

J E2325 0-20 $1,313.42 $1,313.42 $1,313.43 $1,313.43

J E2325 21-999 $1,313.42 $1,313.42 $1,313.43 $1,313.43

J E2326 0-20 $311.67 $311.67 $311.67 $311.67

J E2326 21-999 $311.67 $311.67 $311.67 $311.67

J E2327 0-20 $2,248.95 $2,248.95 $2,248.95 $2,248.95

J E2327 21-999 $2,248.95 $2,248.95 $2,248.95 $2,248.95

J E2328 0-20 $3,781.16 $3,781.16 $3,781.16 $3,781.16

J E2328 21-999 $3,781.16 $3,781.16 $3,781.16 $3,781.16

J E2329 0-20 $2,181.89 $2,181.89 $2,181.89 $2,181.89

J E2329 21-999 $2,181.89 $2,181.89 $2,181.89 $2,181.89

J E2330 0-20 $3,250.61 $3,250.61 $3,250.60 $3,250.60

J E2330 21-999 $3,250.61 $3,250.61 $3,250.60 $3,250.60

J E2340 0-20 $306.42 $306.42 $306.43 $306.43

J E2340 21-999 $306.42 $306.42 $306.43 $306.43

J E2341 0-20 $451.49 $451.49 $451.49 $451.49

J E2341 21-999 $451.49 $451.49 $451.49 $451.49

J E2342 0-20 $436.92 $436.92 $436.92 $436.92

J E2342 21-999 $436.92 $436.92 $436.92 $436.92

J E2343 0-20 $733.95 $733.95 $733.96 $733.96

J E2343 21-999 $733.95 $733.95 $733.96 $733.96

J E2351 0-20 $681.30 $681.30 $681.30 $681.30

J E2351 21-999 $681.30 $681.30 $681.30 $681.30

J E2359 0-20 $134.87 $132.17 $134.87 $134.87

J E2359 21-999 $134.87 $132.17 $134.87 $134.87

J E2361 0-20 $151.41 $151.41 $151.41 $151.41

J E2361 21-999 $151.41 $151.41 $151.41 $151.41

J E2363 0-20 $196.79 $196.79 $196.79 $196.79

J E2363 21-999 $196.79 $196.79 $196.79 $196.79

J E2366 0-20 $237.68 $237.68 $237.68 $237.68

J E2366 21-999 $237.68 $237.68 $237.68 $237.68

J E2368 0-20 $455.91 $455.91 $455.91 $455.91

J E2368 21-999 $455.91 $455.91 $455.91 $455.91

J E2369 0-20 $397.10 $397.10 $397.10 $397.10

J E2369 21-999 $397.10 $397.10 $397.10 $397.10

J E2370 0-20 $854.42 $854.42 $854.42 $854.42

J E2370 21-999 $854.42 $854.42 $854.42 $854.42

J E2371 0-20 $181.39 $181.39 $181.39 $181.39

J E2371 21-999 $181.39 $181.39 $181.39 $181.39

J E2373 0-20 $1,067.83 $1,067.83 $1,067.83 $1,067.83

J E2373 21-999 $1,067.83 $1,067.83 $1,067.83 $1,067.83

J E2373 0-20 $1,179.93 $1,179.93 $1,179.92 $1,179.92

J E2373 21-999 $1,179.93 $1,179.93 $1,179.92 $1,179.92

J E2374 0-20 $520.78 $520.78 $520.78 $520.78

J E2374 21-999 $520.78 $520.78 $520.78 $520.78

J E2375 0-20 $835.32 $835.32 $835.33 $835.33

J E2375 21-999 $835.32 $835.32 $835.33 $835.33

J E2376 0-20 $1,259.56 $1,259.56 $1,259.56 $1,259.56

J E2376 21-999 $1,259.56 $1,259.56 $1,259.56 $1,259.56

J E2377 0-20 $473.66 $473.66 $473.66 $473.66

J E2377 21-999 $473.66 $473.66 $473.66 $473.66

J E2381 0-20 $57.47 $57.47 $57.47 $57.47

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E2381 21-999 $57.47 $57.47 $57.47 $57.47

J E2382 0-20 $20.26 $20.26 $20.26 $20.26

J E2382 21-999 $20.26 $20.26 $20.26 $20.26

J E2383 0-20 $113.88 $113.88 $113.88 $113.88

J E2383 21-999 $113.88 $113.88 $113.88 $113.88

J E2384 0-20 $60.67 $60.67 $60.67 $60.67

J E2384 21-999 $60.67 $60.67 $60.67 $60.67

J E2385 0-20 $48.27 $48.27 $48.27 $48.27

J E2385 21-999 $48.27 $48.27 $48.27 $48.27

J E2386 0-20 $150.51 $138.47 $139.34 $139.34

J E2386 21-999 $150.51 $138.47 $139.34 $139.34

J E2387 0-20 $58.55 $58.55 $58.55 $58.55

J E2387 21-999 $58.55 $58.55 $58.55 $58.55

J E2388 0-20 $49.14 $49.14 $49.14 $49.14

J E2388 21-999 $49.14 $49.14 $49.14 $49.14

J E2389 0-20 $26.68 $26.68 $26.68 $26.68

J E2389 21-999 $26.68 $26.68 $26.68 $26.68

J E2390 0-20 $41.73 $41.73 $41.73 $41.73

J E2390 21-999 $41.73 $41.73 $41.73 $41.73

J E2391 0-20 $19.99 $19.99 $19.99 $19.99

J E2391 21-999 $19.99 $19.99 $19.99 $19.99

J E2392 0-20 $52.54 $52.54 $52.54 $52.54

J E2392 21-999 $52.54 $52.54 $52.54 $52.54

J E2394 0-20 $74.85 $74.85 $74.85 $74.85

J E2394 21-999 $74.85 $74.85 $74.85 $74.85

J E2395 0-20 $53.20 $53.20 $53.20 $53.20

J E2395 21-999 $53.20 $53.20 $53.20 $53.20

J E2396 0-20 $44.74 $44.74 $44.74 $44.74

J E2396 21-999 $44.74 $44.74 $44.74 $44.74

L E2402 0-20 $1,553.40 $1,289.32 $1,289.32 $1,289.32

L E2402 21-999 $1,553.40 $1,289.32 $1,289.32 $1,289.32

J E2500 0-20 $374.13 $344.20 $344.20 $344.20

J E2500 21-999 $374.13 $344.20 $344.20 $344.20

L E2500 0-20 $37.41 $34.42 $34.42 $34.42

L E2500 21-999 $37.41 $34.42 $34.42 $34.42

J E2502 0-20 $1,255.59 $1,155.14 $1,155.14 $1,155.14

J E2502 21-999 $1,255.59 $1,155.14 $1,155.14 $1,155.14

L E2502 0-20 $125.57 $115.52 $115.52 $115.52

L E2502 21-999 $125.57 $115.52 $115.52 $115.52

J E2504 0-20 $1,577.42 $1,545.87 $1,545.87 $1,545.87

J E2504 21-999 $1,577.42 $1,545.87 $1,545.87 $1,545.87

L E2504 0-20 $157.76 $154.60 $154.60 $154.60

L E2504 21-999 $157.76 $154.60 $154.60 $154.60

J E2506 0-20 $2,312.96 $2,127.92 $2,127.92 $2,127.92

J E2506 21-999 $2,312.96 $2,127.92 $2,127.92 $2,127.92

L E2506 0-20 $231.29 $212.79 $212.79 $212.79

L E2506 21-999 $231.29 $212.79 $212.79 $212.79

J E2508 0-20 $3,576.61 $3,290.48 $3,290.48 $3,290.48

J E2508 21-999 $3,576.61 $3,290.48 $3,290.48 $3,290.48

L E2508 0-20 $357.67 $329.06 $329.06 $329.06

L E2508 21-999 $357.67 $329.06 $329.06 $329.06

J E2510 0-20 $6,768.25 $6,226.79 $6,226.79 $6,226.79

J E2510 21-999 $6,768.25 $6,226.79 $6,226.79 $6,226.79

L E2510 0-20 $676.82 $622.67 $622.67 $622.67

L E2510 21-999 $676.82 $622.67 $622.67 $622.67

J E2511 0-20 $361.60 $354.37 $354.37 $354.37

J E2511 21-999 $361.60 $354.37 $354.37 $354.37



L E2512 0-20 $89.90 $82.71 $82.71 $82.71

L E2512 21-999 $89.90 $82.71 $82.71 $82.71



Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee

Eff.

4-1-2013

Adjusted Fee Eff.

4-1-2013


J E2599 0-20 $87.40 $80.41 $80.41 $80.41

J E2599 21-999 $87.40 $80.41 $80.41 $80.41



J E2601 0-20 $53.98 $53.98 $53.98 $53.98

J E2601 21-999 $53.98 $53.98 $53.98 $53.98



































J E2621 0-20 $507.26 $507.26 $507.26 $507.26

J E2621 21-999 $507.26 $507.26 $507.26 $507.26

J E2622 0-20 $323.25 $323.25 $323.25 $323.25

J E2622 21-999 $323.25 $323.25 $323.25 $323.25

J E2623 0-20 $411.32 $411.32 $411.32 $411.32

J E2623 21-999 $411.32 $411.32 $411.32 $411.32

J E2624 0-20 $325.90 $325.90 $325.89 $325.89

J E2624 21-999 $325.90 $325.90 $325.89 $325.89

J E2625 0-20 $412.57 $412.57 $412.58 $412.58

J E2625 21-999 $412.57 $412.57 $412.58 $412.58

J E2626 0-999 $455.78 $446.66 $446.66 $446.66

J E2627 0-999 $789.09 $773.31 $773.31 $773.31

J E2628 0-999 $538.63 $527.86 $527.86 $527.86

J E2629 0-999 $719.75 $705.36 $705.36 $705.36

J E2630 0-999 $524.41 $513.92 $513.92 $513.92

J E2631 0-999 $208.60 $204.43 $204.43 $204.43

J E2632 0-999 $176.47 $172.94 $172.94 $172.94

J E2633 0-999 $141.39 $138.56 $138.56 $138.56





TOS*: J= DME Purchase- New, L = DME Rental - Monthly

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee

5 80050 0-999 $42.95 $42.09 $42.09 $42.09

5 80055 0-999 $34.23 $33.55 $33.55 $33.55

5 80101 0-999 $15.90 $15.90 $15.90 $15.90

5 80104 0-999 $15.01 $14.71 $14.71 $14.71

3 80500 0-20 NF 0.58 $27.276 $15.82 $15.50 0.60 $28.0672 $16.84 $16.84

3 80500 0-20 F 0.58 $27.276 $15.82 $15.50 0.53 $28.0672 $14.88 $14.88

3 80500 21-999 NF 0.58 $27.276 $15.82 $15.50 0.60 $26.7305 $16.04 $16.04

3 80500 21-999 F 0.58 $27.276 $15.82 $15.50 0.53 $26.7305 $14.17 $14.17

3 80502 0-20 NF 1.86 $27.276 $50.73 $49.72 1.92 $28.0672 $53.89 $53.89

3 80502 0-20 F 1.86 $27.276 $50.73 $49.72 1.85 $28.0672 $51.92 $51.92

3 80502 21-999 NF 1.86 $27.276 $50.73 $49.72 1.92 $26.7305 $51.32 $51.32

3 80502 21-999 F 1.86 $27.276 $50.73 $49.72 1.85 $26.7305 $49.45 $49.45

5 81099 0-999 $5.01 $4.91 $5.01 $4.91

5 81099 0-999 71 $5.01 $4.66 $5.01 $4.76

5 81200 0-999 $117.00 $114.66 $114.66 $114.66

5 81205 0-999 $1,128.36 $1,105.79 $1,105.79 $1,105.79

5 81206 0-999 $98.60 $96.63 $55.40 $55.40

5 81207 0-999 $98.60 $96.63 $55.40 $55.40

5 81208 0-999 $98.60 $96.63 $96.48 $96.48

5 81209 0-999 $1,128.36 $1,105.79 $55.40 $55.40

5 81210 0-20 $323.88 $317.40 $171.17 $171.17

5 81210 21-999 $323.88 $317.40 $153.06 $153.06

5 81211 0-999 $3,340.00 $3,273.20 $3,273.20 $3,273.20

5 81212 0-999 $575.00 $563.50 $563.50 $563.50

5 81214 0-999 $1,750.00 $1,715.00 $1,715.00 $1,715.00

5 81215 0-999 $475.00 $465.50 $465.50 $465.50

5 81216 0-999 $2,090.00 $2,048.20 $2,048.20 $2,048.20

5 81217 0-999 $475.00 $465.50 $465.50 $465.50

5 81220 0-999 $1,744.07 $1,709.19 $796.35 $796.35

5 81221 0-999 $36.72 $35.99 $35.96 $35.96

5 81222 0-999 $385.86 $378.14 $57.96 $57.96

5 81223 0-999 $1,719.72 $1,685.33 $796.33 $796.33

5 81224 0-999 $76.48 $74.95 $445.32 $445.32

5 81225 0-999 $214.84 $210.54 $300.06 $300.06

5 81226 0-999 $321.35 $314.92 $251.65 $251.65

5 81227 0-999 $214.84 $210.54 $43.29 $43.29

5 81240 0-999 $26.98 $26.44 $26.42 $26.42

5 81241 0-999 $90.00 $88.20 $26.42 $26.42

5 81242 0-999 $82.44 $80.79 $624.32 $624.32

5 81243 0-999 $82.44 $80.79 $33.75 $33.75

5 81244 0-999 $82.44 $80.79 $74.48 $74.48

5 81245 0-999 $54.37 $53.28 $62.73 $62.73

5 81250 0-999 $415.07 $406.77 $406.07 $406.07

5 81251 0-999 $138.00 $135.24 $624.32 $624.32

5 81255 0-999 $138.00 $135.24 $176.46 $176.46

5 81256 0-999 $44.23 $43.35 $43.31 $43.31

5 81257 0-999 $355.25 $348.15 $135.37 $135.37

NONCLINICAL LABORATORY SERVICES

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 81260 0-999 $1,128.36 $1,105.79 $67.50 $67.50

5 81261 0-999 $128.62 $126.05 $96.48 $96.48

5 81262 0-999 $128.62 $126.05 $58.83 $58.83

5 81263 0-999 $128.62 $126.05 $125.83 $125.83

5 81264 0-999 $128.62 $126.05 $125.83 $125.83

5 81265 0-999 $96.36 $94.43 $215.33 $215.33

5 81266 0-999 $133.49 $130.82 $130.60 $130.60

5 81267 0-999 $215.24 $210.94 $215.33 $215.33

5 81268 0-999 $215.24 $210.94 $215.33 $215.33

5 81270 0-999 $52.72 $51.67 $38.52 $38.52

5 81275 0-999 $348.33 $341.36 $61.75 $61.75

5 81280 0-20 $628.57 $616.00 $640.94 $640.94

5 81280 21-999 $628.57 $616.00 $616.90 $616.90

5 81281 0-20 $628.57 $616.00 $640.94 $640.94

5 81281 21-999 $628.57 $616.00 $616.90 $616.90

5 81282 0-20 $628.57 $616.00 $640.94 $640.94

5 81282 21-999 $628.57 $616.00 $616.90 $616.90

5 81290 0-999 $1,128.36 $1,105.79 $79.62 $79.62

5 81291 0-999 $101.23 $99.21 $52.85 $52.85

5 81292 0-999 $1,130.00 $1,107.40 $1,107.40 $1,107.40

5 81293 0-999 $475.00 $465.50 $465.50 $465.50

5 81294 0-999 $270.00 $264.60 $264.60 $264.60

5 81295 0-999 $930.00 $911.40 $911.40 $911.40

5 81296 0-999 $475.00 $465.50 $465.50 $465.50

5 81297 0-999 $270.00 $264.60 $264.60 $264.60

5 81298 0-999 $1,090.00 $1,068.20 $1,068.20 $1,068.20

5 81299 0-999 $475.00 $465.50 $465.50 $465.50

5 81300 0-999 $270.00 $264.60 $264.60 $264.60

5 81301 0-20 $353.99 $346.91 $346.91 $346.91

5 81301 21-999 $337.13 $330.39 $330.39 $330.39

5 81302 0-999 $2,197.28 $2,153.33 $2,153.33 $2,153.33

5 81303 0-999 $2,197.28 $2,153.33 $2,153.33 $2,153.33

5 81304 0-999 $2,197.28 $2,153.33 $2,153.33 $2,153.33

5 81310 0-999 $91.09 $89.27 $89.27 $89.27

5 81315 0-999 $68.98 $67.60 $67.60 $67.60

5 81316 0-999 $68.98 $67.60 $67.60 $67.60

5 81317 0-999 $1,130.00 $1,107.40 $1,107.40 $1,107.40

5 81318 0-999 $475.00 $465.50 $465.50 $465.50

5 81319 0-999 $270.00 $264.60 $264.60 $264.60

5 81330 0-999 $615.30 $602.99 $103.83 $103.83

5 81331 0-999 $852.66 $835.61 $21.65 $21.65

5 81332 0-999 $331.08 $324.46 $68.82 $68.82

5 81340 0-999 $1,036.10 $1,015.38 $1,015.38 $1,015.38

5 81341 0-999 $4.87 $4.77 $54.06 $54.06

5 81342 0-999 $24.95 $24.45 $136.58 $136.58

5 81350 0-999 $32.54 $31.89 $33.75 $33.75

5 81355 0-999 $214.84 $210.54 $60.17 $60.17

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 81370 0-999 $63.12 $61.86 $61.76 $61.76

5 81371 0-999 $63.12 $61.86 $61.76 $61.76

5 81372 0-999 $63.12 $61.86 $61.76 $61.76

5 81373 0-20 $31.38 $30.75 $651.91 $651.91

5 81373 21-999 $31.38 $30.75 $630.80 $630.80

5 81374 0-20 $31.38 $30.75 $651.91 $651.91

5 81374 21-999 $31.38 $30.75 $630.80 $630.80

5 81375 0-999 $63.12 $61.86 $61.76 $61.76

5 81376 0-999 $33.88 $33.20 $33.15 $33.15

5 81377 0-999 $44.44 $43.55 $43.50 $43.50

5 81378 0-999 $63.12 $61.86 $61.76 $61.76

5 81379 0-999 $63.12 $61.86 $154.80 $154.80

5 81380 0-999 $31.38 $30.75 $70.06 $70.06

5 81381 0-999 $180.56 $176.95 $176.90 $176.90

5 81382 0-20 $33.88 $33.20 $615.56 $615.56

5 81382 21-999 $33.88 $33.20 $594.45 $594.45

5 81383 0-999 $33.88 $33.20 $21.65 $21.65

5 81400 0-20 $452.23 $443.19 $52.84 $52.84

5 81400 21-999 $430.69 $422.08 $52.84 $52.84

5 81401 0-20 $452.23 $443.19 $88.17 $88.17

5 81401 21-999 $430.69 $422.08 $88.17 $88.17

5 81402 0-20 $904.45 $886.36 $179.02 $179.02

5 81402 21-999 $861.38 $844.15 $179.02 $179.02

5 81403 0-20 $1,356.68 $1,329.55 $45.86 $45.86

5 81403 21-999 $1,292.06 $1,266.22 $45.86 $45.86

5 81404 0-20 $1,808.90 $1,772.72 $118.48 $118.48

5 81404 21-999 $1,722.75 $1,688.30 $118.48 $118.48

5 81405 0-20 $2,261.13 $2,215.91 $50.63 $50.63

5 81405 21-999 $2,153.44 $2,110.37 $50.63 $50.63

5 81406 0-20 $2,713.35 $2,659.08 $287.94 $287.94

5 81406 21-999 $2,584.13 $2,532.45 $287.94 $287.94

5 81407 0-20 $3,165.58 $3,102.27 $1,026.31 $1,026.31

5 81407 21-999 $3,014.82 $2,954.52 $1,026.31 $1,026.31

5 81408 0-20 $3,617.80 $3,545.44 $1,522.59 $1,522.59

5 81408 21-999 $3,445.50 $3,376.59 $1,522.59 $1,522.59

5 84999 0-999 $5.01 $4.91 Manually Priced Manually Priced

5 85060 0-20 0.70 $28.640 $20.05 $19.65 0.71 $28.0672 $19.93 $19.93

5 85060 21-999 0.70 $27.276 $19.09 $18.71 0.71 $26.7305 $18.98 $18.98

5 85097 0-20 NF 2.35 $27.276 $64.10 $62.82 2.53 $28.0672 $71.01 $71.01

5 85097 0-20 F 2.35 $27.276 $64.10 $62.82 1.39 $28.0672 $39.01 $39.01

5 85097 21-999 NF 2.35 $27.276 $64.10 $62.82 2.53 $26.7305 $67.63 $67.63

5 85097 21-999 F 2.35 $27.276 $64.10 $62.82 1.39 $26.7305 $37.16 $37.16

5 85396 0-20 0.57 $27.276 $15.55 $15.24 0.59 $28.0672 $16.56 $16.56

5 85396 21-999 0.57 $27.276 $15.55 $15.24 0.59 $26.7305 $15.77 $15.77


5 86077 0-20 NF 1.54 $27.276 $42.01 $41.17 1.57 $28.0672 $44.07 $44.07

5 86077 0-20 F 1.54 $27.276 $42.01 $41.17 1.46 $28.0672 $40.98 $40.98

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 86077 21-999 NF 1.54 $27.276 $42.01 $41.17 1.57 $26.7305 $41.97 $41.97

5 86077 21-999 F 1.54 $27.276 $42.01 $41.17 1.46 $26.7305 $39.03 $39.03

5 86078 0-20 NF 1.54 $27.276 $42.01 $41.17 1.58 $28.0672 $44.35 $44.35

5 86078 0-20 F 1.54 $27.276 $42.01 $41.17 1.46 $28.0672 $40.98 $40.98

5 86078 21-999 NF 1.54 $27.276 $42.01 $41.17 1.58 $26.7305 $42.23 $42.23

5 86078 21-999 F 1.54 $27.276 $42.01 $41.17 1.46 $26.7305 $39.03 $39.03

5 86079 0-999 NF 1.53 $27.276 $41.73 $40.90 1.57 $26.7305 $41.97 $41.97

5 86079 0-999 F 1.53 $27.276 $41.73 $40.90 1.45 $26.7305 $38.76 $38.76

5 86079 0-999 NF 1.53 $27.276 $41.73 $40.90 1.57 $26.7305 $41.97 $41.97

5 86079 0-999 F 1.53 $27.276 $41.73 $40.90 1.45 $26.7305 $38.76 $38.76

5 86485 0-999 $4.91 $4.81 $7.15 $7.15

5 86486 0-20 0.14 $27.276 $3.82 $3.74 0.17 $28.0672 $4.77 $4.77

5 86486 21-999 0.14 $27.276 $3.82 $3.74 0.17 $26.7305 $4.54 $4.54

5 86490 0-20 0.18 $27.276 $4.91 $4.81 0.15 $28.0672 $4.21 $4.21

5 86490 21-999 0.18 $27.276 $4.91 $4.81 0.15 $26.7305 $4.01 $4.01

5 86510 0-20 0.17 $27.276 $4.64 $4.55 0.19 $28.0672 $5.33 $5.33

5 86510 21-999 0.17 $27.276 $4.64 $4.55 0.19 $26.7305 $5.08 $5.08

5 86580 0-20 0.21 $27.276 $5.73 $5.62 0.24 $28.0672 $6.74 $6.74

5 86580 21-999 0.21 $27.276 $5.73 $5.62 0.24 $26.7305 $6.42 $6.42

5 86580 0-20 71 0.21 $27.276 $5.73 $5.33 0.24 $28.0672 $6.74 $6.40

5 86580 21-999 71 0.21 $27.276 $5.73 $5.33 0.24 $26.7305 $6.42 $6.10

D 86580 0-20 AB/AC 0.21 $27.276 $5.73 $5.33 0.24 $28.0672 $6.74 $6.40

D 86580 21-999 AB/AC 0.21 $27.276 $5.73 $5.33 0.24 $26.7305 $6.42 $6.10

S 86580 0-999 0.21 $27.276 $5.73 $5.62 0.24 $26.7305 $6.42 $6.42

5 86849 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

5 86850 0-999 $7.70 $7.55 $7.15 $7.15

5 86850 0-999 71 $7.70 $7.16 $7.15 $6.79

5 86860 0-999 $29.71 $29.12 $26.55 $26.55

5 86870 0-999 $16.98 $16.64 $9.87 $9.87

5 86920 0-999 $14.06 $13.78 $12.25 $12.25

5 86921 0-999 $16.00 $15.68 $14.30 $14.30

5 86922 0-999 $34.02 $33.34 $14.30 $14.30

5 86923 0-999 $15.62 $15.31 $13.96 $13.96

5 86950 0-999 $24.82 $24.32 $55.14 $55.14

5 86960 0-999 $25.52 $25.01 $22.81 $22.81



5 88104 0-20 1.94 $27.276 $52.92 $51.86 2.24 $28.0672 $62.87 $62.87

5 88104 21-999 1.94 $27.276 $52.92 $51.86 2.24 $26.7305 $59.88 $59.88

I 88104 0-20 PATH 0.82 $28.640 $23.48 $23.01 0.84 $28.0672 $23.58 $23.58

I 88104 21-999 PATH 0.82 $27.276 $22.37 $21.92 0.84 $26.7305 $22.45 $22.45

I 88104 0-20 0.82 $27.276 $22.37 $21.92 0.84 $28.0672 $23.58 $23.58

I 88104 21-999 0.82 $27.276 $22.37 $21.92 0.84 $26.7305 $22.45 $22.45

T 88104 0-20 PATH 1.12 $27.276 $30.55 $29.94 1.40 $28.0672 $39.29 $39.29

T 88104 21-999 PATH 1.12 $27.276 $30.55 $29.94 1.40 $26.7305 $37.42 $37.42

5 88106 0-20 2.32 $27.276 $63.28 $62.01 2.51 $28.0672 $70.45 $70.45

5 88106 21-999 2.32 $27.276 $63.28 $62.01 2.51 $26.7305 $67.09 $67.09

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 88106 0-20 PATH 0.82 $28.640 $23.48 $23.01 0.56 $28.0672 $15.72 $15.72

I 88106 21-999 PATH 0.82 $27.276 $22.37 $21.92 0.56 $26.7305 $14.97 $14.97

I 88106 0-20 0.82 $27.276 $22.37 $21.92 0.56 $28.0672 $15.72 $15.72

I 88106 21-999 0.82 $27.276 $22.37 $21.92 0.56 $26.7305 $14.97 $14.97

T 88106 0-20 1.50 $27.276 $40.91 $40.09 1.95 $28.0672 $54.73 $54.73

T 88106 21-999 1.50 $27.276 $40.91 $40.09 1.95 $26.7305 $52.12 $52.12

5 88108 0-20 2.16 $27.276 $58.92 $57.74 2.32 $28.0672 $65.12 $65.12

5 88108 21-999 2.16 $27.276 $58.92 $57.74 2.32 $26.7305 $62.01 $62.01

I 88108 0-20 PATH 0.81 $28.640 $23.20 $22.74 0.65 $28.0672 $18.24 $18.24

I 88108 21-999 PATH 0.81 $27.276 $22.09 $21.65 0.65 $26.7305 $17.37 $17.37

I 88108 0-20 0.81 $27.276 $22.09 $21.65 0.65 $28.0672 $18.24 $18.24

I 88108 21-999 0.81 $27.276 $22.09 $21.65 0.65 $26.7305 $17.37 $17.37

T 88108 0-20 1.35 $27.276 $36.82 $36.08 1.67 $28.0672 $46.87 $46.87

T 88108 21-999 1.35 $27.276 $36.82 $36.08 1.67 $26.7305 $44.64 $44.64

5 88112 0-20 2.90 $27.276 $79.10 $77.52 3.22 $28.0672 $90.38 $90.38

5 88112 21-999 2.90 $27.276 $79.10 $77.52 3.22 $26.7305 $86.07 $86.07

I 88112 0-20 1.68 $27.276 $45.82 $44.90 1.71 $28.0672 $47.99 $47.99

I 88112 21-999 1.68 $27.276 $45.82 $44.90 1.71 $26.7305 $45.71 $45.71

T 88112 0-20 1.22 $27.276 $33.28 $32.61 1.51 $28.0672 $42.38 $42.38

T 88112 21-999 1.22 $27.276 $33.28 $32.61 1.51 $26.7305 $40.36 $40.36

5 88120 0-20 13.47 $28.640 $385.78 $378.06 18.27 $28.0672 $512.79 $512.79

5 88120 21-999 13.47 $27.276 $367.41 $360.06 18.27 $26.7305 $488.37 $488.37

I 88120 0-20 1.54 $28.640 $44.11 $43.23 1.66 $28.0672 $46.59 $46.59

I 88120 21-999 1.54 $27.276 $42.01 $41.17 1.66 $26.7305 $44.37 $44.37

T 88120 0-20 11.93 $28.640 $341.68 $334.85 16.61 $28.0672 $466.20 $466.20

T 88120 21-999 11.93 $27.276 $325.40 $318.89 16.61 $26.7305 $443.99 $443.99

5 88121 0-20 11.37 $28.640 $325.64 $319.13 16.44 $28.0672 $461.42 $461.42

5 88121 21-999 11.37 $27.276 $310.13 $303.93 16.44 $26.7305 $439.45 $439.45

I 88121 0-20 1.36 $28.640 $38.95 $38.17 1.45 $28.0672 $40.70 $40.70

I 88121 21-999 1.36 $27.276 $37.10 $36.36 1.45 $26.7305 $38.76 $38.76

T 88121 0-20 10.01 $28.640 $286.69 $280.96 14.99 $28.0672 $420.73 $420.73

T 88121 21-999 10.01 $27.276 $273.03 $267.57 14.99 $26.7305 $400.69 $400.69

5 88141 0-20 0.87 $28.640 $24.92 $24.42 0.93 $28.0672 $26.10 $26.10

5 88141 21-999 0.87 $27.276 $23.73 $23.26 0.93 $26.7305 $24.86 $24.86

5 88141 0-20 PATH 0.87 $27.276 $23.73 $23.26 0.93 $28.0672 $26.10 $26.10

5 88141 21-999 PATH 0.87 $27.276 $23.73 $23.26 0.93 $26.7305 $24.86 $24.86

5 88141 0-20 71 0.87 $27.276 $23.73 $22.07 0.93 $28.0672 $26.10 $24.80

5 88141 21-999 71 0.87 $27.276 $23.73 $22.07 0.93 $26.7305 $24.86 $23.62

5 88160 0-20 1.60 $27.276 $43.64 $42.77 1.86 $28.0672 $52.20 $52.20

5 88160 21-999 1.60 $27.276 $43.64 $42.77 1.86 $26.7305 $49.72 $49.72

I 88160 0-20 PATH 0.73 $28.640 $20.91 $20.49 0.74 $28.0672 $20.77 $20.77

I 88160 21-999 PATH 0.73 $27.276 $19.91 $19.51 0.74 $26.7305 $19.78 $19.78

I 88160 0-20 0.73 $27.276 $19.91 $19.51 0.74 $28.0672 $20.77 $20.77

I 88160 21-999 0.73 $27.276 $19.91 $19.51 0.74 $26.7305 $19.78 $19.78

T 88160 0-20 0.87 $27.276 $23.73 $23.26 1.12 $28.0672 $31.44 $31.44

T 88160 21-999 0.87 $27.276 $23.73 $23.26 1.12 $26.7305 $29.94 $29.94

5 88161 0-20 1.52 $27.276 $41.46 $40.63 1.78 $28.0672 $49.96 $49.96

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 88161 21-999 1.52 $27.276 $41.46 $40.63 1.78 $26.7305 $47.58 $47.58

I 88161 0-20 $21.48 $21.05 0.72 $28.0672 $20.21 $20.21

I 88161 21-999 0.70 $27.276 $19.09 $18.71 0.72 $26.7305 $19.25 $19.25

I 88161 0-20 PATH 0.70 $27.276 $19.09 $18.71 0.72 $28.0672 $20.21 $20.21

I 88161 21-999 PATH 0.70 $27.276 $19.09 $18.71 0.72 $26.7305 $19.25 $19.25

T 88161 0-20 0.82 $27.276 $22.37 $21.92 1.06 $28.0672 $29.75 $29.75

T 88161 21-999 0.82 $27.276 $22.37 $21.92 1.06 $26.7305 $28.33 $28.33

5 88162 0-20 2.18 $27.276 $59.46 $58.27 2.83 $28.0672 $79.43 $79.43

5 88162 21-999 2.18 $27.276 $59.46 $58.27 2.83 $26.7305 $75.65 $75.65

I 88162 0-20 PATH $36.09 $35.37 1.15 $28.0672 $32.28 $32.28

I 88162 21-999 PATH 1.08 $27.276 $29.46 $28.87 1.15 $26.7305 $30.74 $30.74

I 88162 0-20 1.08 $27.276 $29.46 $28.87 1.15 $28.0672 $32.28 $32.28

I 88162 21-999 1.08 $27.276 $29.46 $28.87 1.15 $26.7305 $30.74 $30.74

T 88162 0-20 1.10 $27.276 $30.00 $29.40 1.68 $28.0672 $47.15 $47.15

T 88162 21-999 1.10 $27.276 $30.00 $29.40 1.68 $26.7305 $44.91 $44.91

5 88172 0-20 1.36 $27.276 $37.10 $36.36 1.61 $28.0672 $45.19 $45.19

5 88172 21-999 1.36 $27.276 $37.10 $36.36 1.61 $26.7305 $43.04 $43.04

I 88172 0-20 PATH $29.57 $28.98 1.04 $28.0672 $29.19 $29.19

I 88172 21-999 PATH 0.89 $27.276 $24.28 $23.79 1.04 $26.7305 $27.80 $27.80

I 88172 0-20 0.89 $27.276 $24.28 $23.79 1.04 $28.0672 $29.19 $29.19

I 88172 21-999 0.89 $27.276 $24.28 $23.79 1.04 $26.7305 $27.80 $27.80

T 88172 0-20 0.47 $27.276 $12.82 $12.56 0.57 $28.0672 $16.00 $16.00

T 88172 21-999 0.47 $27.276 $12.82 $12.56 0.57 $26.7305 $15.24 $15.24

5 88173 0-20 3.98 $27.276 $108.56 $106.39 4.40 $28.0672 $123.50 $123.50

5 88173 21-999 3.98 $27.276 $108.56 $106.39 4.40 $26.7305 $117.61 $117.61

I 88173 0-20 PATH 2.03 $28.640 $58.14 $56.98 2.05 $28.0672 $57.54 $57.54

I 88173 21-999 PATH 2.03 $27.276 $55.37 $54.26 2.05 $26.7305 $54.80 $54.80

I 88173 0-20 2.03 $27.276 $55.37 $54.26 2.05 $28.0672 $57.54 $57.54

I 88173 21-999 2.03 $27.276 $55.37 $54.26 2.05 $26.7305 $54.80 $54.80

T 88173 0-20 1.95 $27.276 $53.19 $52.13 2.35 $28.0672 $65.96 $65.96

T 88173 21-999 1.95 $27.276 $53.19 $52.13 2.35 $26.7305 $62.82 $62.82

5 88177 0-20 0.82 $28.640 $23.48 $23.01 0.87 $28.0672 $24.42 $24.42

5 88177 21-999 0.82 $27.276 $22.37 $21.92 0.87 $26.7305 $23.26 $23.26

I 88177 0-20 PATH 0.63 $28.640 $18.04 $17.68 0.64 $28.0672 $17.96 $17.96

I 88177 21-999 PATH 0.63 $27.276 $17.18 $16.84 0.64 $26.7305 $17.11 $17.11

T 88177 0-20 0.19 $28.640 $5.44 $5.33 0.23 $28.0672 $6.46 $6.46

T 88177 21-999 0.19 $27.276 $5.18 $5.08 0.23 $26.7305 $6.15 $6.15

5 88182 0-20 2.89 $27.276 $78.83 $77.25 3.21 $28.0672 $90.10 $90.10

5 88182 21-999 2.89 $27.276 $78.83 $77.25 3.21 $26.7305 $85.80 $85.80

I 88182 0-20 PATH $35.35 $34.64 1.03 $28.0672 $28.91 $28.91

I 88182 21-999 PATH 1.01 $27.276 $27.55 $27.00 1.03 $26.7305 $27.53 $27.53

I 88182 0-20 1.01 $27.276 $27.55 $27.00 1.03 $28.0672 $28.91 $28.91

I 88182 21-999 1.01 $27.276 $27.55 $27.00 1.03 $26.7305 $27.53 $27.53

T 88182 0-20 1.88 $27.276 $51.28 $50.25 2.18 $28.0672 $61.19 $61.19

T 88182 21-999 1.88 $27.276 $51.28 $50.25 2.18 $26.7305 $58.27 $58.27

T 88184 0-20 2.30 $27.276 $62.73 $61.48 2.61 $28.0672 $73.26 $73.26

T 88184 21-999 2.30 $27.276 $62.73 $61.48 2.61 $26.7305 $69.77 $69.77

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


T 88185 0-20 1.40 $27.276 $38.19 $37.43 1.59 $28.0672 $44.63 $44.63

T 88185 21-999 1.40 $27.276 $38.19 $37.43 1.59 $26.7305 $42.50 $42.50

I 88187 0-20 PATH 2.03 $28.640 $58.14 $56.98 2.02 $28.0672 $56.70 $56.70

I 88187 21-999 PATH 2.03 $27.276 $55.37 $54.26 2.02 $26.7305 $54.00 $54.00

I 88187 0-20 2.03 $27.276 $55.37 $54.26 2.02 $28.0672 $56.70 $56.70

I 88187 21-999 2.03 $27.276 $55.37 $54.26 2.02 $26.7305 $54.00 $54.00

I 88188 0-20 PATH 2.55 $28.640 $73.03 $71.57 2.57 $28.0672 $72.13 $72.13

I 88188 21-999 PATH 2.55 $27.276 $69.55 $68.16 2.57 $26.7305 $68.70 $68.70

I 88188 0-20 2.55 $27.276 $69.55 $68.16 2.57 $28.0672 $72.13 $72.13

I 88188 21-999 2.55 $27.276 $69.55 $68.16 2.57 $26.7305 $68.70 $68.70

I 88189 0-20 PATH 3.05 $28.640 $87.35 $85.60 3.13 $28.0672 $87.85 $87.85

I 88189 21-999 PATH 3.05 $27.276 $83.19 $81.53 3.13 $26.7305 $83.67 $83.67

I 88189 0-20 3.05 $27.276 $83.19 $81.53 3.13 $28.0672 $87.85 $87.85

I 88189 21-999 3.05 $27.276 $83.19 $81.53 3.13 $26.7305 $83.67 $83.67


5 88291 21-999 0.86 $27.276 $23.46 $22.99 0.90 $26.7305 $24.06 $24.06

5 88291 0-20 0.86 $27.276 $23.46 $22.99 0.90 $28.0672 $25.26 $25.26


5 88300 0-20 0.81 $27.276 $22.09 $21.65 0.43 $28.0672 $12.07 $12.07

5 88300 21-999 0.81 $27.276 $22.09 $21.65 0.43 $26.7305 $11.49 $11.49

I 88300 0-20 PATH $4.33 $4.24 0.13 $28.0672 $3.65 $3.65

I 88300 21-999 PATH 0.13 $27.276 $3.55 $3.48 0.13 $26.7305 $3.47 $3.47

I 88300 0-20 0.13 $27.276 $3.55 $3.48 0.13 $28.0672 $3.65 $3.65

I 88300 21-999 0.13 $27.276 $3.55 $3.48 0.13 $26.7305 $3.47 $3.47

I 88300 0-20 RADS $4.33 $4.24 0.13 $28.0672 $3.65 $3.65

I 88300 21-999 RADS 0.13 $27.276 $3.55 $3.48 0.13 $26.7305 $3.47 $3.47

T 88300 0-20 0.68 $27.276 $18.55 $18.18 0.30 $28.0672 $8.42 $8.42

T 88300 21-999 0.68 $27.276 $18.55 $18.18 0.30 $26.7305 $8.02 $8.02

5 88302 0-20 1.55 $27.276 $42.28 $41.43 0.91 $28.0672 $25.54 $25.54

5 88302 21-999 1.55 $27.276 $42.28 $41.43 0.91 $26.7305 $24.32 $24.32

5 88302 0-20 71 1.55 $27.276 $42.28 $39.32 0.91 $28.0672 $25.54 $24.26

5 88302 21-999 71 1.55 $27.276 $42.28 $39.32 0.91 $26.7305 $24.32 $23.10

I 88302 0-20 PATH $6.49 $6.36 0.20 $28.0672 $5.61 $5.61

I 88302 21-999 PATH 0.20 $27.276 $5.46 $5.35 0.20 $26.7305 $5.35 $5.35

I 88302 0-20 0.20 $27.276 $5.46 $5.35 0.20 $28.0672 $5.61 $5.61

I 88302 21-999 0.20 $27.276 $5.46 $5.35 0.20 $26.7305 $5.35 $5.35

I 88302 0-20 RADS $6.49 $6.36 0.20 $28.0672 $5.61 $5.61

I 88302 21-999 RADS 0.20 $27.276 $5.46 $5.35 0.20 $26.7305 $5.35 $5.35

T 88302 0-20 1.35 $27.276 $36.82 $36.08 0.71 $28.0672 $19.93 $19.93

T 88302 21-999 1.35 $27.276 $36.82 $36.08 0.71 $26.7305 $18.98 $18.98

5 88304 0-20 1.68 $27.276 $45.82 $44.90 1.31 $28.0672 $36.77 $36.77

5 88304 21-999 1.68 $27.276 $45.82 $44.90 1.31 $26.7305 $35.02 $35.02

I 88304 0-20 PATH $10.82 $10.60 0.33 $28.0672 $9.26 $9.26

I 88304 21-999 PATH 0.33 $27.276 $9.00 $8.82 0.33 $26.7305 $8.82 $8.82

I 88304 0-20 0.33 $27.276 $9.00 $8.82 0.33 $28.0672 $9.26 $9.26

I 88304 21-999 0.33 $27.276 $9.00 $8.82 0.33 $26.7305 $8.82 $8.82

I 88304 0-20 RADS $10.82 $10.60 0.33 $28.0672 $9.26 $9.26

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 88304 21-999 RADS 0.33 $27.276 $9.00 $8.82 0.33 $26.7305 $8.82 $8.82

T 88304 0-20 1.35 $27.276 $36.82 $36.08 0.98 $28.0672 $27.51 $27.51

T 88304 21-999 1.35 $27.276 $36.82 $36.08 0.98 $26.7305 $26.20 $26.20

5 88305 0-20 2.95 $27.276 $80.46 $78.85 2.07 $28.0672 $58.10 $58.10

5 88305 21-999 2.95 $27.276 $80.46 $78.85 2.07 $26.7305 $55.33 $55.33

I 88305 0-20 PATH $37.15 $36.41 1.08 $28.0672 $30.31 $30.31

I 88305 21-999 PATH 1.08 $27.276 $29.46 $28.87 1.08 $26.7305 $28.87 $28.87

I 88305 0-20 1.08 $27.276 $29.46 $28.87 1.08 $28.0672 $30.31 $30.31

I 88305 21-999 1.08 $27.276 $29.46 $28.87 1.08 $26.7305 $28.87 $28.87

I 88305 0-20 RADS $37.15 $36.41 1.08 $28.0672 $30.31 $30.31

I 88305 21-999 RADS 1.08 $27.276 $29.46 $28.87 1.08 $26.7305 $28.87 $28.87

T 88305 0-20 1.87 $27.276 $51.01 $49.99 0.99 $28.0672 $27.79 $27.79

T 88305 21-999 1.87 $27.276 $51.01 $49.99 0.99 $26.7305 $26.46 $26.46

5 88307 0-20 6.71 $27.276 $183.02 $179.36 8.74 $28.0672 $245.31 $245.31

5 88307 21-999 6.71 $27.276 $183.02 $179.36 8.74 $26.7305 $233.62 $233.62

I 88307 0-20 PATH $73.32 $71.85 2.41 $28.0672 $67.64 $67.64

I 88307 21-999 PATH 2.38 $27.276 $64.92 $63.62 2.41 $26.7305 $64.42 $64.42

I 88307 0-20 2.38 $27.276 $64.92 $63.62 2.41 $28.0672 $67.64 $67.64

I 88307 21-999 2.38 $27.276 $64.92 $63.62 2.41 $26.7305 $64.42 $64.42

I 88307 0-20 RADS $73.32 $71.85 2.41 $28.0672 $67.64 $67.64

I 88307 21-999 RADS 2.38 $27.276 $64.92 $63.62 2.41 $26.7305 $64.42 $64.42

T 88307 0-20 4.33 $27.276 $118.11 $115.75 6.33 $28.0672 $177.67 $177.67

T 88307 21-999 4.33 $27.276 $118.11 $115.75 6.33 $26.7305 $169.20 $169.20

5 88309 0-20 10.26 $27.276 $279.85 $274.25 13.21 $28.0672 $370.77 $370.77

5 88309 21-999 10.26 $27.276 $279.85 $274.25 13.21 $26.7305 $353.11 $353.11

I 88309 0-20 PATH 4.21 $28.640 $120.57 $118.16 4.26 $28.0672 $119.57 $119.57

I 88309 21-999 PATH 4.21 $27.276 $114.83 $112.53 4.26 $26.7305 $113.87 $113.87

I 88309 0-20 4.21 $27.276 $114.83 $112.53 4.26 $28.0672 $119.57 $119.57

I 88309 21-999 4.21 $27.276 $114.83 $112.53 4.26 $26.7305 $113.87 $113.87

T 88309 0-20 6.05 $27.276 $165.02 $161.72 8.95 $28.0672 $251.20 $251.20

T 88309 21-999 6.05 $27.276 $165.02 $161.72 8.95 $26.7305 $239.24 $239.24

5 88311 0-20 0.56 $27.276 $15.27 $14.96 0.60 $28.0672 $16.84 $16.84

5 88311 21-999 0.56 $27.276 $15.27 $14.96 0.60 $26.7305 $16.04 $16.04

I 88311 0-20 PATH $10.59 $10.38 0.36 $28.0672 $10.10 $10.10

I 88311 21-999 PATH 0.36 $27.276 $9.82 $9.62 0.36 $26.7305 $9.62 $9.62

I 88311 0-20 0.36 $27.276 $9.82 $9.62 0.36 $28.0672 $10.10 $10.10

I 88311 21-999 0.36 $27.276 $9.82 $9.62 0.36 $26.7305 $9.62 $9.62

T 88311 0-20 0.20 $27.276 $5.46 $5.35 0.24 $28.0672 $6.74 $6.74

T 88311 21-999 0.20 $27.276 $5.46 $5.35 0.24 $26.7305 $6.42 $6.42

5 88312 0-20 3.08 $27.276 $84.01 $82.33 2.88 $28.0672 $80.83 $80.83

5 88312 21-999 3.08 $27.276 $84.01 $82.33 2.88 $26.7305 $76.98 $76.98

I 88312 0-20 PATH 0.77 $28.640 $22.05 $21.61 0.78 $28.0672 $21.89 $21.89

I 88312 21-999 PATH 0.77 $27.276 $21.00 $20.58 0.78 $26.7305 $20.85 $20.85

I 88312 0-20 0.77 $27.276 $21.00 $20.58 0.78 $28.0672 $21.89 $21.89

I 88312 21-999 0.77 $27.276 $21.00 $20.58 0.78 $26.7305 $20.85 $20.85

I 88312 0-20 RADS 0.77 $28.640 $22.05 $21.61 0.78 $28.0672 $21.89 $21.89

I 88312 21-999 RADS 0.77 $27.276 $21.00 $20.58 0.78 $26.7305 $20.85 $20.85

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


T 88312 0-20 2.31 $27.276 $63.01 $61.75 2.10 $28.0672 $58.94 $58.94

T 88312 21-999 2.31 $27.276 $63.01 $61.75 2.10 $26.7305 $56.13 $56.13

5 88313 0-20 2.21 $27.276 $60.28 $59.07 1.99 $28.0672 $55.85 $55.85

5 88313 21-999 2.21 $27.276 $60.28 $59.07 1.99 $26.7305 $53.19 $53.19

I 88313 0-20 PATH $10.59 $10.38 0.35 $28.0672 $9.82 $9.82

I 88313 21-999 PATH 0.34 $27.276 $9.27 $9.08 0.35 $26.7305 $9.36 $9.36

I 88313 0-20 0.34 $27.276 $9.27 $9.08 0.35 $28.0672 $9.82 $9.82

I 88313 21-999 0.34 $27.276 $9.27 $9.08 0.35 $26.7305 $9.36 $9.36

I 88313 0-20 RADS $10.59 $10.38 0.35 $28.0672 $9.82 $9.82

I 88313 21-999 RADS 0.34 $27.276 $9.27 $9.08 0.35 $26.7305 $9.36 $9.36

T 88313 0-20 1.87 $27.276 $51.01 $49.99 1.64 $28.0672 $46.03 $46.03

T 88313 21-999 1.87 $27.276 $51.01 $49.99 1.64 $26.7305 $43.84 $43.84

5 88314 0-20 2.46 $27.276 $67.10 $65.76 2.38 $28.0672 $66.80 $66.80

5 88314 21-999 2.46 $27.276 $67.10 $65.76 2.38 $26.7305 $63.62 $63.62

I 88314 0-20 PATH $22.36 $21.91 0.66 $28.0672 $18.52 $18.52

I 88314 21-999 PATH 0.67 $27.276 $18.27 $17.90 0.66 $26.7305 $17.64 $17.64

I 88314 0-20 0.67 $27.276 $18.27 $17.90 0.66 $28.0672 $18.52 $18.52

I 88314 21-999 0.67 $27.276 $18.27 $17.90 0.66 $26.7305 $17.64 $17.64

T 88314 0-20 1.79 $27.276 $48.82 $47.84 1.72 $28.0672 $48.28 $48.28

T 88314 21-999 1.79 $27.276 $48.82 $47.84 1.72 $26.7305 $45.98 $45.98

5 88319 0-20 4.13 $27.276 $112.65 $110.40 2.57 $28.0672 $72.13 $72.13

5 88319 21-999 4.13 $27.276 $112.65 $110.40 2.57 $26.7305 $68.70 $68.70

I 88319 0-20 PATH $23.46 $22.99 0.80 $28.0672 $22.45 $22.45

I 88319 21-999 PATH 0.80 $27.276 $21.82 $21.38 0.80 $26.7305 $21.38 $21.38

I 88319 0-20 0.80 $27.276 $21.82 $21.38 0.80 $28.0672 $22.45 $22.45

I 88319 21-999 0.80 $27.276 $21.82 $21.38 0.80 $26.7305 $21.38 $21.38

T 88319 0-20 3.33 $27.276 $90.83 $89.01 1.77 $28.0672 $49.68 $49.68

T 88319 21-999 3.33 $27.276 $90.83 $89.01 1.77 $26.7305 $47.31 $47.31

5 88331 0-20 2.73 $27.276 $74.46 $72.97 2.92 $28.0672 $81.96 $81.96

5 88331 21-999 2.73 $27.276 $74.46 $72.97 2.92 $26.7305 $78.05 $78.05

I 88331 0-20 PATH 1.79 $28.640 $51.27 $50.24 1.79 $28.0672 $50.24 $50.24

I 88331 21-999 PATH 1.79 $27.276 $48.82 $47.84 1.79 $26.7305 $47.85 $47.85

I 88331 0-20 1.79 $27.276 $48.82 $47.84 1.79 $28.0672 $50.24 $50.24

I 88331 21-999 1.79 $27.276 $48.82 $47.84 1.79 $26.7305 $47.85 $47.85

I 88331 0-20 RADS 1.79 $28.640 $51.27 $50.24 1.79 $28.0672 $50.24 $50.24

I 88331 21-999 RADS 1.79 $27.276 $48.82 $47.84 1.79 $26.7305 $47.85 $47.85

T 88331 0-20 0.94 $27.276 $25.64 $25.13 1.13 $28.0672 $31.72 $31.72

T 88331 21-999 0.94 $27.276 $25.64 $25.13 1.13 $26.7305 $30.21 $30.21

5 88332 0-20 1.20 $27.276 $32.73 $32.08 1.28 $28.0672 $35.93 $35.93

5 88332 21-999 1.20 $27.276 $32.73 $32.08 1.28 $26.7305 $34.22 $34.22

I 88332 0-20 PATH 0.88 $28.640 $25.20 $24.70 0.89 $28.0672 $24.98 $24.98

I 88332 21-999 PATH 0.88 $27.276 $24.00 $23.52 0.89 $26.7305 $23.79 $23.79

I 88332 0-20 0.88 $27.276 $24.00 $23.52 0.89 $28.0672 $24.98 $24.98

I 88332 21-999 0.88 $27.276 $24.00 $23.52 0.89 $26.7305 $23.79 $23.79

T 88332 0-20 0.32 $27.276 $8.73 $8.56 0.39 $28.0672 $10.95 $10.95

T 88332 21-999 0.32 $27.276 $8.73 $8.56 0.39 $26.7305 $10.42 $10.42

5 88342 0-20 3.00 $27.276 $81.83 $80.19 3.40 $28.0672 $95.43 $95.43

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 88342 21-999 3.00 $27.276 $81.83 $80.19 3.40 $26.7305 $90.88 $90.88

I 88342 0-20 PATH 1.22 $28.640 $34.94 $34.24 1.24 $28.0672 $34.80 $34.80

I 88342 21-999 PATH 1.22 $27.276 $33.28 $32.61 1.24 $26.7305 $33.15 $33.15

I 88342 0-20 1.22 $27.276 $33.28 $32.61 1.24 $28.0672 $34.80 $34.80

I 88342 21-999 1.22 $27.276 $33.28 $32.61 1.24 $26.7305 $33.15 $33.15

I 88342 0-20 RADS 1.22 $28.640 $34.94 $34.24 1.24 $28.0672 $34.80 $34.80

I 88342 21-999 RADS 1.22 $27.276 $33.28 $32.61 1.24 $26.7305 $33.15 $33.15

T 88342 0-20 1.78 $27.276 $48.55 $47.58 2.16 $28.0672 $60.63 $60.63

T 88342 21-999 1.78 $27.276 $48.55 $47.58 2.16 $26.7305 $57.74 $57.74

5 88346 0-20 2.90 $27.276 $79.10 $77.52 3.21 $28.0672 $90.10 $90.10

5 88346 21-999 2.90 $27.276 $79.10 $77.52 3.21 $26.7305 $85.80 $85.80

I 88346 0-20 PATH $33.55 $32.88 1.23 $28.0672 $34.52 $34.52

I 88346 21-999 PATH 1.22 $27.276 $33.28 $32.61 1.23 $26.7305 $32.88 $32.88

I 88346 0-20 1.22 $27.276 $33.28 $32.61 1.23 $28.0672 $34.52 $34.52

I 88346 21-999 1.22 $27.276 $33.28 $32.61 1.23 $26.7305 $32.88 $32.88

I 88346 0-20 RADS $33.55 $32.88 1.23 $28.0672 $34.52 $34.52

I 88346 21-999 RADS 1.22 $27.276 $33.28 $32.61 1.23 $26.7305 $32.88 $32.88

T 88346 0-20 1.68 $27.276 $45.82 $44.90 1.98 $28.0672 $55.57 $55.57

T 88346 21-999 1.68 $27.276 $45.82 $44.90 1.98 $26.7305 $52.93 $52.93

5 88347 0-20 2.15 $27.276 $58.64 $57.47 2.33 $28.0672 $65.40 $65.40

5 88347 21-999 2.15 $27.276 $58.64 $57.47 2.33 $26.7305 $62.28 $62.28

I 88347 0-20 PATH 1.11 $28.640 $31.79 $31.15 1.12 $28.0672 $31.44 $31.44

I 88347 21-999 PATH 1.11 $27.276 $30.28 $29.67 1.12 $26.7305 $29.94 $29.94

I 88347 0-20 $31.79 $31.15 1.12 $28.0672 $31.44 $31.44

I 88347 21-999 1.11 $27.276 $30.28 $29.67 1.12 $26.7305 $29.94 $29.94

T 88347 0-20 1.04 $27.276 $28.37 $27.80 1.21 $28.0672 $33.96 $33.96

T 88347 21-999 1.04 $27.276 $28.37 $27.80 1.21 $26.7305 $32.34 $32.34

5 88348 0-20 19.51 $27.276 $532.15 $521.51 21.32 $28.0672 $598.39 $598.39

5 88348 21-999 19.51 $27.276 $532.15 $521.51 21.32 $26.7305 $569.89 $569.89

I 88348 0-20 PATH $73.94 $72.46 2.18 $28.0672 $61.19 $61.19

I 88348 21-999 PATH 2.16 $27.276 $58.92 $57.74 2.18 $26.7305 $58.27 $58.27

I 88348 0-20 2.16 $27.276 $58.92 $57.74 2.18 $28.0672 $61.19 $61.19

I 88348 21-999 2.16 $27.276 $58.92 $57.74 2.18 $26.7305 $58.27 $58.27

T 88348 0-20 17.35 $27.276 $473.24 $463.78 19.14 $28.0672 $537.21 $537.21

T 88348 21-999 17.35 $27.276 $473.24 $463.78 19.14 $26.7305 $511.62 $511.62

5 88349 0-20 11.35 $27.276 $309.58 $303.39 12.86 $28.0672 $360.94 $360.94

5 88349 21-999 11.35 $27.276 $309.58 $303.39 12.86 $26.7305 $343.75 $343.75

I 88349 0-20 PATH $37.87 $37.11 1.18 $28.0672 $33.12 $33.12

I 88349 21-999 PATH 1.17 $27.276 $31.91 $31.27 1.18 $26.7305 $31.54 $31.54

I 88349 0-20 1.17 $27.276 $31.91 $31.27 1.18 $28.0672 $33.12 $33.12

I 88349 21-999 1.17 $27.276 $31.91 $31.27 1.18 $26.7305 $31.54 $31.54

T 88349 0-20 10.18 $27.276 $277.67 $272.12 11.68 $28.0672 $327.82 $327.82

T 88349 21-999 10.18 $27.276 $277.67 $272.12 11.68 $26.7305 $312.21 $312.21

5 88355 0-20 5.13 $27.276 $139.93 $137.13 5.37 $28.0672 $150.72 $150.72

5 88355 21-999 5.13 $27.276 $139.93 $137.13 5.37 $26.7305 $143.54 $143.54

I 88355 0-20 PATH $85.34 $83.63 2.43 $28.0672 $68.20 $68.20

I 88355 21-999 PATH 2.44 $27.276 $66.55 $65.22 2.43 $26.7305 $64.96 $64.96

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 88355 0-20 2.44 $27.276 $66.55 $65.22 2.43 $28.0672 $68.20 $68.20

I 88355 21-999 2.44 $27.276 $66.55 $65.22 2.43 $26.7305 $64.96 $64.96

T 88355 0-20 2.69 $27.276 $73.37 $71.90 2.94 $28.0672 $82.52 $82.52

T 88355 21-999 2.69 $27.276 $73.37 $71.90 2.94 $26.7305 $78.59 $78.59

5 88356 0-20 7.69 $27.276 $209.75 $205.56 8.16 $28.0672 $229.03 $229.03

5 88356 21-999 7.69 $27.276 $209.75 $205.56 8.16 $26.7305 $218.12 $218.12

I 88356 0-20 PATH $136.04 $133.32 3.75 $28.0672 $105.25 $105.25

I 88356 21-999 PATH 3.73 $27.276 $101.74 $99.71 3.75 $26.7305 $100.24 $100.24

I 88356 0-20 3.73 $27.276 $101.74 $99.71 3.75 $28.0672 $105.25 $105.25

I 88356 21-999 3.73 $27.276 $101.74 $99.71 3.75 $26.7305 $100.24 $100.24

T 88356 0-20 3.96 $27.276 $108.01 $105.85 4.41 $28.0672 $123.78 $123.78

T 88356 21-999 3.96 $27.276 $108.01 $105.85 4.41 $26.7305 $117.88 $117.88

5 88358 0-20 2.15 $27.276 $58.64 $57.47 2.41 $28.0672 $67.64 $67.64

5 88358 21-999 2.15 $27.276 $58.64 $57.47 2.41 $26.7305 $64.42 $64.42

5 88360 0-20 3.54 $27.276 $96.56 $94.63 3.74 $28.0672 $104.97 $104.97

5 88360 21-999 3.54 $27.276 $96.56 $94.63 3.74 $26.7305 $99.97 $99.97

I 88360 0-20 PATH $46.68 $45.75 1.54 $28.0672 $43.22 $43.22

I 88360 21-999 PATH 1.55 $27.276 $42.28 $41.43 1.54 $26.7305 $41.16 $41.16

I 88360 0-20 1.55 $27.276 $42.28 $41.43 1.54 $28.0672 $43.22 $43.22

I 88360 21-999 1.55 $27.276 $42.28 $41.43 1.54 $26.7305 $41.16 $41.16

T 88360 0-20 1.99 $27.276 $54.28 $53.19 2.20 $28.0672 $61.75 $61.75

T 88360 21-999 1.99 $27.276 $54.28 $53.19 2.20 $26.7305 $58.81 $58.81

5 88361 0-20 4.24 $27.276 $115.65 $113.34 4.60 $28.0672 $129.11 $129.11

5 88361 21-999 4.24 $27.276 $115.65 $113.34 4.60 $26.7305 $122.96 $122.96

I 88361 0-20 1.66 $27.276 $45.28 $44.37 1.68 $28.0672 $47.15 $47.15

I 88361 21-999 1.66 $27.276 $45.28 $44.37 1.68 $26.7305 $44.91 $44.91

T 88361 0-20 2.58 $27.276 $70.37 $68.96 2.92 $28.0672 $81.96 $81.96

T 88361 21-999 2.58 $27.276 $70.37 $68.96 2.92 $26.7305 $78.05 $78.05

5 88362 0-20 8.34 $27.276 $227.48 $222.93 9.16 $28.0672 $257.10 $257.10

5 88362 21-999 8.34 $27.276 $227.48 $222.93 9.16 $26.7305 $244.85 $244.85

I 88362 0-20 PATH $94.79 $92.89 3.20 $28.0672 $89.82 $89.82

I 88362 21-999 PATH 3.20 $27.276 $87.28 $85.53 3.20 $26.7305 $85.54 $85.54

I 88362 0-20 3.20 $27.276 $87.28 $85.53 3.20 $28.0672 $89.82 $89.82

I 88362 21-999 3.20 $27.276 $87.28 $85.53 3.20 $26.7305 $85.54 $85.54

5 88367 0-20 7.42 $27.276 $202.39 $198.34 7.60 $28.0672 $213.31 $213.31

5 88367 21-999 7.42 $27.276 $202.39 $198.34 7.60 $26.7305 $203.15 $203.15

I 88367 0-20 PATH $85.34 $83.63 1.76 $28.0672 $49.40 $49.40

I 88367 21-999 PATH 1.80 $27.276 $49.10 $48.12 1.76 $26.7305 $47.05 $47.05

I 88367 0-20 1.80 $27.276 $49.10 $48.12 1.76 $28.0672 $49.40 $49.40

I 88367 21-999 1.80 $27.276 $49.10 $48.12 1.76 $26.7305 $47.05 $47.05

5 88368 0-20 6.26 $27.276 $170.75 $167.34 6.82 $28.0672 $191.42 $191.42

5 88368 21-999 6.26 $27.276 $170.75 $167.34 6.82 $26.7305 $182.30 $182.30

I 88368 0-20 PATH $64.92 $63.62 1.81 $28.0672 $50.80 $50.80

I 88368 21-999 PATH 1.80 $27.276 $49.10 $48.12 1.81 $26.7305 $48.38 $48.38

I 88368 0-20 1.80 $27.276 $49.10 $48.12 1.81 $28.0672 $50.80 $50.80

I 88368 21-999 1.80 $27.276 $49.10 $48.12 1.81 $26.7305 $48.38 $48.38

5 88384 0-999 $105.12 $103.02 $93.94 $93.94

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 88385 0-20 16.65 $27.276 $454.15 $445.07 $445.07 $445.07

5 88385 21-999 16.65 $27.276 $454.15 $445.07 $445.07 $445.07

5 88386 0-20 15.82 $27.276 $431.51 $422.88 $422.88 $422.88

5 88386 21-999 15.82 $27.276 $431.51 $422.88 $422.88 $422.88

5 88387 0-20 1.19 $28.640 $34.08 $33.40 0.99 $28.0672 $27.79 $27.79

5 88387 21-999 1.19 $27.276 $32.46 $31.81 0.99 $26.7305 $26.46 $26.46

I 88387 0-20 0.93 $28.640 $26.64 $26.11 0.81 $28.0672 $22.73 $22.73

I 88387 21-999 0.93 $27.276 $25.37 $24.86 0.81 $26.7305 $21.65 $21.65

T 88387 0-20 0.26 $28.640 $7.45 $7.30 0.18 $28.0672 $5.05 $5.05

T 88387 21-999 0.26 $27.276 $7.09 $6.95 0.18 $26.7305 $4.81 $4.81

5 88388 0-20 0.69 $28.640 $19.76 $19.36 0.97 $28.0672 $27.23 $27.23

5 88388 21-999 0.69 $27.276 $18.82 $18.44 0.97 $26.7305 $25.93 $25.93

I 88388 0-20 0.56 $28.640 $16.04 $15.72 0.69 $28.0672 $19.37 $19.37

I 88388 21-999 0.56 $27.276 $15.27 $14.96 0.69 $26.7305 $18.44 $18.44

T 88388 0-20 0.13 $28.640 $3.72 $3.65 0.28 $28.0672 $7.86 $7.86

T 88388 21-999 0.13 $27.276 $3.55 $3.48 0.28 $26.7305 $7.48 $7.48


I 88399 0-999 $5.01 $4.91 Manually Priced Manually Priced


5 89049 0-20 NF 1.90 $27.276 $51.82 $50.78 8.05 $28.0672 $225.94 $225.94

5 89049 0-20 F 1.90 $27.276 $51.82 $50.78 1.91 $28.0672 $53.61 $53.61

5 89049 21-999 NF 1.90 $27.276 $51.82 $50.78 8.05 $26.7305 $215.18 $215.18

5 89049 21-999 F 1.90 $27.276 $51.82 $50.78 1.91 $26.7305 $51.06 $51.06

5 89220 0-20 0.45 $27.276 $12.27 $12.02 0.52 $28.0672 $14.59 $14.59

5 89220 21-999 0.45 $27.276 $12.27 $12.02 0.52 $26.7305 $13.90 $13.90

D 89220 0-20 AB/AC 0.45 $27.276 $12.27 $11.41 0.52 $28.0672 $14.59 $13.86

D 89220 21-999 AB/AC 0.45 $27.276 $12.27 $11.41 0.52 $26.7305 $13.90 $13.21

5 89230 0-20 0.07 $27.276 $1.91 $1.87 0.07 $28.0672 $1.96 $1.96

5 89230 21-999 0.07 $27.276 $1.91 $1.87 0.07 $26.7305 $1.87 $1.87


5 92550 0-20 0.61 $28.640 $17.47 $17.12 0.61 $28.0672 $17.12 $17.12

5 92550 21-999 0.61 $27.276 $16.64 $16.31 0.61 $26.7305 $16.31 $16.31

5 92551 0-20 $15.75 $15.44 0.37 $28.0672 $10.38 $10.38

5 92551 21-999 0.32 $27.276 $8.73 $8.56 0.37 $26.7305 $9.89 $9.89

5 92552 0-20 0.82 $27.276 $22.37 $21.92 0.95 $28.0672 $26.66 $26.66

5 92552 21-999 0.82 $27.276 $22.37 $21.92 0.95 $26.7305 $25.39 $25.39

5 92553 0-999 75 0.99 $27.276 $27.00 $26.46 1.15 $26.7305 $30.74 $30.74

5 92553 0-20 0.99 $27.276 $27.00 $26.46 1.15 $28.0672 $32.28 $32.28

5 92553 21-999 0.99 $27.276 $27.00 $26.46 1.15 $26.7305 $30.74 $30.74

5 92555 0-999 75 0.59 $27.276 $16.09 $15.77 0.72 $26.7305 $19.25 $19.25

5 92555 0-20 0.59 $27.276 $16.09 $15.77 0.72 $28.0672 $20.21 $20.21

5 92555 21-999 0.59 $27.276 $16.09 $15.77 0.72 $26.7305 $19.25 $19.25

5 92556 0-999 75 0.93 $27.276 $25.37 $24.86 1.13 $26.7305 $30.21 $30.21

5 92556 0-20 0.93 $27.276 $25.37 $24.86 1.13 $28.0672 $31.72 $31.72

5 92556 21-999 0.93 $27.276 $25.37 $24.86 1.13 $26.7305 $30.21 $30.21

5 92557 0-20 NF $39.52 $38.73 1.10 $28.0672 $30.87 $30.87

5 92557 0-20 F $39.52 $38.73 0.94 $28.0672 $26.38 $26.38

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 92557 21-999 NF $39.52 $38.73 1.10 $26.7305 $29.40 $29.40

5 92557 21-999 F $39.52 $38.73 0.94 $26.7305 $25.13 $25.13

I 92562 0-20 1.13 $27.276 $30.82 $30.20 1.44 $28.0672 $40.42 $40.42

I 92562 21-999 1.13 $27.276 $30.82 $30.20 1.44 $26.7305 $38.49 $38.49

5 92563 0-20 0.81 $28.640 $23.20 $22.74 0.97 $28.0672 $27.23 $27.23

5 92563 21-999 0.81 $27.276 $22.09 $21.65 0.97 $26.7305 $25.93 $25.93

5 92563 21-999 75 0.81 $27.276 $22.09 $21.65 0.97 $26.7305 $25.93 $25.93

5 92564 0-20 0.70 $28.640 $20.05 $19.65 0.88 $28.0672 $24.70 $24.70

5 92564 21-999 0.70 $27.276 $19.09 $18.71 0.88 $26.7305 $23.52 $23.52

5 92565 0-999 75 0.38 $27.276 $10.36 $10.15 0.52 $26.7305 $13.90 $13.90

5 92565 0-20 0.38 $28.640 $10.88 $10.66 0.52 $28.0672 $14.59 $14.59

5 92565 21-999 0.38 $27.276 $10.36 $10.15 0.52 $26.7305 $13.90 $13.90

5 92567 0-20 NF $16.91 $16.57 0.42 $28.0672 $11.79 $11.79

5 92567 0-20 F $16.91 $16.57 0.31 $28.0672 $8.70 $8.70

5 92567 21-999 NF $16.91 $16.57 0.42 $26.7305 $11.23 $11.23

5 92567 21-999 F $16.91 $16.57 0.31 $26.7305 $8.29 $8.29

5 92568 0-20 0.46 $27.276 $12.55 $12.30 0.45 $28.0672 $12.63 $12.63

5 92568 21-999 75 0.46 $27.276 $12.55 $12.30 0.45 $26.7305 $12.03 $12.03

5 92568 21-999 0.46 $27.276 $12.55 $12.30 0.45 $26.7305 $12.03 $12.03

5 92570 0-20 NF 0.94 $28.640 $26.92 $26.38 0.94 $28.0672 $26.38 $26.38

5 92570 0-20 F 0.94 $28.640 $26.92 $26.38 0.87 $28.0672 $24.42 $24.42

5 92570 21-999 NF 0.94 $27.276 $25.64 $25.13 0.94 $26.7305 $25.13 $25.13

5 92570 21-999 F 0.94 $27.276 $25.64 $25.13 0.87 $26.7305 $23.26 $23.26

5 92571 0-20 0.66 $27.276 $18.00 $17.64 0.84 $28.0672 $23.58 $23.58

5 92571 21-999 0.66 $27.276 $18.00 $17.64 0.84 $26.7305 $22.45 $22.45

5 92572 0-20 1.28 $27.276 $34.91 $34.21 1.62 $28.0672 $45.47 $45.47

5 92572 21-999 1.28 $27.276 $34.91 $34.21 1.62 $26.7305 $43.30 $43.30

5 92575 0-20 1.74 $27.276 $47.46 $46.51 2.33 $28.0672 $65.40 $65.40

5 92575 21-999 1.74 $27.276 $47.46 $46.51 2.33 $26.7305 $62.28 $62.28

5 92576 0-20 0.90 $28.640 $25.78 $25.26 1.04 $28.0672 $29.19 $29.19

5 92576 21-999 0.90 $27.276 $24.55 $24.06 1.04 $26.7305 $27.80 $27.80

5 92577 0-999 75 0.45 $27.276 $12.27 $12.02 0.57 $26.7305 $15.24 $15.24

5 92577 0-20 0.45 $28.640 $12.89 $12.63 0.57 $28.0672 $16.00 $16.00

5 92577 21-999 0.45 $27.276 $12.27 $12.02 0.57 $26.7305 $15.24 $15.24

5 92579 0-20 NF 1.29 $27.276 $35.19 $34.49 1.22 $28.0672 $34.24 $34.24

5 92579 0-20 F 1.29 $27.276 $35.19 $34.49 1.08 $28.0672 $30.31 $30.31

5 92579 21-999 NF 1.29 $27.276 $35.19 $34.49 1.22 $26.7305 $32.61 $32.61

5 92579 21-999 F 1.29 $27.276 $35.19 $34.49 1.08 $26.7305 $28.87 $28.87

5 92582 0-20 1.70 $28.640 $48.69 $47.72 2.21 $28.0672 $62.03 $62.03

5 92582 21-999 1.70 $27.276 $46.37 $45.44 2.21 $26.7305 $59.07 $59.07

5 92583 0-20 0.99 $28.640 $28.35 $27.78 1.59 $28.0672 $44.63 $44.63

5 92583 21-999 0.99 $27.276 $27.00 $26.46 1.59 $26.7305 $42.50 $42.50

5 92584 0-20 $78.76 $77.18 2.15 $28.0672 $60.34 $60.34

5 92584 21-999 1.89 $27.276 $51.55 $50.52 2.15 $26.7305 $57.47 $57.47

5 92584 21-999 75 1.89 $27.276 $51.55 $50.52 2.15 $26.7305 $57.47 $57.47

5 92585 0-20 $100.00 $98.00 3.85 $28.0672 $108.06 $108.06

5 92585 21-999 $100.00 $98.00 3.85 $26.7305 $102.91 $102.91

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 92585 0-999 75 $100.00 $98.00 3.85 $26.7305 $102.91 $102.91

I 92585 0-20 0.78 $27.276 $21.28 $20.85 0.76 $28.0672 $21.33 $21.33

I 92585 21-999 0.78 $27.276 $21.28 $20.85 0.76 $26.7305 $20.32 $20.32

T 92585 0-20 2.80 $28.640 $80.19 $78.59 3.09 $28.0672 $86.73 $86.73

T 92585 21-999 2.80 $27.276 $76.37 $74.84 3.09 $26.7305 $82.60 $82.60

5 92586 0-999 75 2.21 $27.276 $60.28 $59.07 2.63 $26.7305 $70.30 $70.30

5 92586 0-20 2.21 $27.276 $60.28 $59.07 2.63 $28.0672 $73.82 $73.82

5 92586 21-999 2.21 $27.276 $60.28 $59.07 2.63 $26.7305 $70.30 $70.30

5 92587 0-20 $46.11 $45.19 0.64 $28.0672 $17.96 $17.96

5 92587 21-999 1.02 $27.276 $27.82 $27.26 0.64 $26.7305 $17.11 $17.11

5 92587 21-999 75 1.02 $27.276 $27.82 $27.26 0.64 $26.7305 $17.11 $17.11

I 92587 0-20 $7.16 $7.02 0.55 $28.0672 $15.44 $15.44

I 92587 21-999 0.21 $27.276 $5.73 $5.62 0.55 $26.7305 $14.70 $14.70

T 92587 0-20 0.81 $28.640 $23.20 $22.74 0.09 $28.0672 $2.53 $2.53

T 92587 21-999 0.81 $27.276 $22.09 $21.65 0.09 $26.7305 $2.41 $2.41

5 92588 0-20 $63.58 $62.31 0.97 $28.0672 $27.23 $27.23

5 92588 21-999 2.00 $27.276 $54.55 $53.46 0.97 $26.7305 $25.93 $25.93

5 92588 21-999 75 2.00 $27.276 $54.55 $53.46 0.97 $26.7305 $25.93 $25.93

I 92588 0-20 $18.03 $17.67 0.85 $28.0672 $23.86 $23.86

I 92588 21-999 0.57 $27.276 $15.55 $15.24 0.85 $26.7305 $22.72 $22.72

T 92588 0-20 1.43 $28.640 $40.96 $40.14 0.12 $28.0672 $3.37 $3.37

T 92588 21-999 1.43 $27.276 $39.00 $38.22 0.12 $26.7305 $3.21 $3.21

5 93000 0-20 0.51 $27.276 $13.91 $13.63 0.54 $28.0672 $15.16 $15.16

5 93000 21-999 0.51 $27.276 $13.91 $13.63 0.54 $26.7305 $14.43 $14.43

T 93005 0-20 0.26 $27.276 $7.09 $6.95 0.30 $28.0672 $8.42 $8.42

T 93005 21-999 0.26 $27.276 $7.09 $6.95 0.30 $26.7305 $8.02 $8.02

I 93010 0-20 0.25 $27.276 $6.82 $6.68 0.24 $28.0672 $6.74 $6.74

I 93010 21-999 0.25 $27.276 $6.82 $6.68 0.24 $26.7305 $6.42 $6.42

5 93561 0-20 $43.54 $42.67 $42.24 $42.24

5 93561 21-999 $43.54 $42.67 $40.22 $40.22

I 93561 0-20 0.74 $27.276 $20.18 $19.78 0.70 $28.0672 $19.65 $19.65

I 93561 21-999 0.74 $27.276 $20.18 $19.78 0.70 $26.7305 $18.71 $18.71

T 93561 0-20 $20.23 $19.83 $22.59 $22.59

T 93561 21-999 $20.23 $19.83 $21.51 $21.51

5 93562 0-20 $20.15 $19.75 $19.55 $19.55

5 93562 21-999 $20.15 $19.75 $18.62 $18.62

I 93562 0-20 0.23 $27.276 $6.27 $6.14 0.22 $28.0672 $6.17 $6.17

I 93562 21-999 0.23 $27.276 $6.27 $6.14 0.22 $26.7305 $5.88 $5.88

T 93562 0-20 $12.59 $12.34 $13.38 $13.38

T 93562 21-999 $12.59 $12.34 $12.74 $12.74

5 93701 0-20 0.66 $27.276 $18.00 $17.64 0.74 $28.0672 $20.77 $20.77

5 93701 21-999 0.66 $27.276 $18.00 $17.64 0.74 $26.7305 $19.78 $19.78

5 93724 0-20 7.73 $27.276 $210.84 $206.62 7.76 $28.0672 $217.80 $217.80

5 93724 21-999 7.73 $27.276 $210.84 $206.62 7.76 $26.7305 $207.43 $207.43

I 93724 0-20 7.00 $27.276 $190.93 $187.11 6.91 $28.0672 $193.94 $193.94

I 93724 21-999 7.00 $27.276 $190.93 $187.11 6.91 $26.7305 $184.71 $184.71

T 93724 0-20 0.73 $27.276 $19.91 $19.51 0.85 $28.0672 $23.86 $23.86

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


T 93724 21-999 0.73 $27.276 $19.91 $19.51 0.85 $26.7305 $22.72 $22.72

5 93740 0-20 0.26 $27.276 $7.09 $6.95 0.25 $28.0672 $7.02 $7.02

5 93740 21-999 0.26 $27.276 $7.09 $6.95 0.25 $26.7305 $6.68 $6.68

I 93740 0-20 $5.78 $5.66 $5.72 $5.72

I 93740 21-999 $5.78 $5.66 $5.45 $5.45

T 93740 0-20 $1.31 $1.28 $1.30 $1.30

T 93740 21-999 $1.31 $1.28 $1.23 $1.23

5 93770 0-20 0.26 $27.276 $7.09 $6.95 0.25 $28.0672 $7.02 $7.02

5 93770 21-999 0.26 $27.276 $7.09 $6.95 0.25 $26.7305 $6.68 $6.68

I 93770 0-20 $6.50 $6.37 $6.44 $6.44

I 93770 21-999 $6.50 $6.37 $6.12 $6.12

T 93770 0-20 $0.59 $0.58 $0.58 $0.58

T 93770 21-999 $0.59 $0.58 $0.56 $0.56

5 93784 0-20 1.53 $27.276 $41.73 $40.90 1.64 $28.0672 $46.03 $46.03

5 93784 21-999 1.53 $27.276 $41.73 $40.90 1.64 $26.7305 $43.84 $43.84

5 93786 0-20 0.83 $27.276 $22.64 $22.19 0.93 $28.0672 $26.10 $26.10

5 93786 21-999 0.83 $27.276 $22.64 $22.19 0.93 $26.7305 $24.86 $24.86

5 93788 0-20 0.15 $27.276 $4.09 $4.01 0.17 $28.0672 $4.77 $4.77

5 93788 21-999 0.15 $27.276 $4.09 $4.01 0.17 $26.7305 $4.54 $4.54

5 93790 0-20 0.55 $27.276 $15.00 $14.70 0.54 $28.0672 $15.16 $15.16

5 93790 21-999 0.55 $27.276 $15.00 $14.70 0.54 $26.7305 $14.43 $14.43

5 93797 0-20 NF 0.49 $27.276 $13.37 $13.10 0.49 $28.0672 $13.75 $13.75

5 93797 0-20 F 0.49 $27.276 $13.37 $13.10 0.26 $28.0672 $7.30 $7.30

5 93797 21-999 NF 0.49 $27.276 $13.37 $13.10 0.49 $26.7305 $13.10 $13.10

5 93797 21-999 F 0.49 $27.276 $13.37 $13.10 0.26 $26.7305 $6.95 $6.95

5 93798 0-20 NF 0.69 $27.276 $18.82 $18.44 0.73 $28.0672 $20.49 $20.49

5 93798 0-20 F 0.69 $27.276 $18.82 $18.44 0.40 $28.0672 $11.23 $11.23

5 93798 21-999 NF 0.69 $27.276 $18.82 $18.44 0.73 $26.7305 $19.51 $19.51

5 93798 21-999 F 0.69 $27.276 $18.82 $18.44 0.40 $26.7305 $10.69 $10.69


I 93799 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

T 93799 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

5 94010 0-20 1.02 $27.276 $27.82 $27.26 1.10 $28.0672 $30.87 $30.87

5 94010 21-999 1.02 $27.276 $27.82 $27.26 1.10 $26.7305 $29.40 $29.40

I 94010 0-20 0.25 $27.276 $6.82 $6.68 0.24 $28.0672 $6.74 $6.74

I 94010 21-999 0.25 $27.276 $6.82 $6.68 0.24 $26.7305 $6.42 $6.42

T 94010 0-20 0.77 $27.276 $21.00 $20.58 0.86 $28.0672 $24.14 $24.14

T 94010 21-999 0.77 $27.276 $21.00 $20.58 0.86 $26.7305 $22.99 $22.99

5 94014 0-20 1.37 $27.276 $37.37 $36.62 1.46 $28.0672 $40.98 $40.98

5 94014 21-999 1.37 $27.276 $37.37 $36.62 1.46 $26.7305 $39.03 $39.03

5 94015 0-20 0.65 $27.276 $17.73 $17.38 0.75 $28.0672 $21.05 $21.05

5 94015 21-999 0.65 $27.276 $17.73 $17.38 0.75 $26.7305 $20.05 $20.05

5 94016 0-999 0.72 $27.276 $19.64 $19.25 0.71 $26.7305 $18.98 $18.98

5 94016 0-999 0.72 $27.276 $19.64 $19.25 0.71 $26.7305 $18.98 $18.98

5 94060 0-999 1.76 $27.276 $48.01 $47.05 1.89 $26.7305 $50.52 $50.52

5 94060 0-999 1.76 $27.276 $48.01 $47.05 1.89 $26.7305 $50.52 $50.52

I 94060 0-20 $14.43 $14.14 0.38 $28.0672 $10.67 $10.67

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 94060 0-20 0.44 $27.276 $12.00 $11.76 0.38 $28.0672 $10.67 $10.67

I 94060 21-999 0.44 $27.276 $12.00 $11.76 0.38 $26.7305 $10.16 $10.16

T 94060 0-20 1.32 $27.276 $36.00 $35.28 1.51 $28.0672 $42.38 $42.38

T 94060 21-999 1.32 $27.276 $36.00 $35.28 1.51 $26.7305 $40.36 $40.36

5 94070 0-20 1.74 $27.276 $47.46 $46.51 1.80 $28.0672 $50.52 $50.52

5 94070 21-999 1.74 $27.276 $47.46 $46.51 1.80 $26.7305 $48.11 $48.11

I 94070 0-20 0.86 $27.276 $23.46 $22.99 0.84 $28.0672 $23.58 $23.58

I 94070 21-999 0.86 $27.276 $23.46 $22.99 0.84 $26.7305 $22.45 $22.45

T 94070 0-20 0.88 $27.276 $24.00 $23.52 0.96 $28.0672 $26.94 $26.94

T 94070 21-999 0.88 $27.276 $24.00 $23.52 0.96 $26.7305 $25.66 $25.66

5 94150 0-20 0.70 $27.276 $19.09 $18.71 0.77 $28.0672 $21.61 $21.61

5 94150 21-999 0.70 $27.276 $19.09 $18.71 0.77 $26.7305 $20.58 $20.58

I 94150 0-20 0.11 $27.276 $3.00 $2.94 0.11 $28.0672 $3.09 $3.09

I 94150 21-999 0.11 $27.276 $3.00 $2.94 0.11 $26.7305 $2.94 $2.94

T 94150 0-20 0.59 $27.276 $16.09 $15.77 0.66 $28.0672 $18.52 $18.52

T 94150 21-999 0.59 $27.276 $16.09 $15.77 0.66 $26.7305 $17.64 $17.64

5 94200 0-20 0.70 $27.276 $19.09 $18.71 0.77 $28.0672 $21.61 $21.61

5 94200 21-999 0.70 $27.276 $19.09 $18.71 0.77 $26.7305 $20.58 $20.58

I 94200 0-20 0.16 $27.276 $4.36 $4.27 0.16 $28.0672 $4.49 $4.49

I 94200 21-999 0.16 $27.276 $4.36 $4.27 0.16 $26.7305 $4.28 $4.28

T 94200 0-20 0.54 $27.276 $14.73 $14.44 0.61 $28.0672 $17.12 $17.12

T 94200 21-999 0.54 $27.276 $14.73 $14.44 0.61 $26.7305 $16.31 $16.31

5 94250 0-20 0.70 $27.276 $19.09 $18.71 0.78 $28.0672 $21.89 $21.89

5 94250 21-999 0.70 $27.276 $19.09 $18.71 0.78 $26.7305 $20.85 $20.85

I 94250 0-20 0.16 $27.276 $4.36 $4.27 0.16 $28.0672 $4.49 $4.49

I 94250 21-999 0.16 $27.276 $4.36 $4.27 0.16 $26.7305 $4.28 $4.28

T 94250 0-20 0.54 $27.276 $14.73 $14.44 0.62 $28.0672 $17.40 $17.40

T 94250 21-999 0.54 $27.276 $14.73 $14.44 0.62 $26.7305 $16.57 $16.57

5 94375 0-20 1.11 $27.276 $30.28 $29.67 1.19 $28.0672 $33.40 $33.40

5 94375 21-999 1.11 $27.276 $30.28 $29.67 1.19 $26.7305 $31.81 $31.81

I 94375 0-20 0.44 $27.276 $12.00 $11.76 0.43 $28.0672 $12.07 $12.07

I 94375 21-999 0.44 $27.276 $12.00 $11.76 0.43 $26.7305 $11.49 $11.49

T 94375 0-20 0.67 $27.276 $18.27 $17.90 0.76 $28.0672 $21.33 $21.33

T 94375 21-999 0.67 $27.276 $18.27 $17.90 0.76 $26.7305 $20.32 $20.32

5 94400 0-20 1.55 $27.276 $42.28 $41.43 1.76 $28.0672 $49.40 $49.40

5 94400 21-999 1.55 $27.276 $42.28 $41.43 1.76 $26.7305 $47.05 $47.05

I 94400 0-20 0.55 $27.276 $15.00 $14.70 0.55 $28.0672 $15.44 $15.44

I 94400 21-999 0.55 $27.276 $15.00 $14.70 0.55 $26.7305 $14.70 $14.70

T 94400 0-20 1.00 $27.276 $27.28 $26.73 1.21 $28.0672 $33.96 $33.96

T 94400 21-999 1.00 $27.276 $27.28 $26.73 1.21 $26.7305 $32.34 $32.34

5 94450 0-20 1.89 $27.276 $51.55 $50.52 2.07 $28.0672 $58.10 $58.10

5 94450 21-999 1.89 $27.276 $51.55 $50.52 2.07 $26.7305 $55.33 $55.33

I 94450 0-20 0.58 $27.276 $15.82 $15.50 0.57 $28.0672 $16.00 $16.00

I 94450 21-999 0.58 $27.276 $15.82 $15.50 0.57 $26.7305 $15.24 $15.24

T 94450 0-20 1.31 $27.276 $35.73 $35.02 1.50 $28.0672 $42.10 $42.10

T 94450 21-999 1.31 $27.276 $35.73 $35.02 1.50 $26.7305 $40.10 $40.10

5 94452 0-20 1.62 $28.640 $46.40 $45.47 1.81 $28.0672 $50.80 $50.80

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 94452 21-999 1.62 $27.276 $44.19 $43.31 1.81 $26.7305 $48.38 $48.38

I 94452 0-20 0.43 $28.640 $12.32 $12.07 0.43 $28.0672 $12.07 $12.07

I 94452 21-999 0.43 $27.276 $11.73 $11.50 0.43 $26.7305 $11.49 $11.49

T 94452 0-20 1.19 $28.640 $34.08 $33.40 1.38 $28.0672 $38.73 $38.73

T 94452 21-999 1.19 $27.276 $32.46 $31.81 1.38 $26.7305 $36.89 $36.89

5 94453 0-20 2.19 $28.640 $62.72 $61.47 2.54 $28.0672 $71.29 $71.29

5 94453 21-999 2.19 $27.276 $59.73 $58.54 2.54 $26.7305 $67.90 $67.90

I 94453 0-20 0.55 $28.640 $15.75 $15.44 0.55 $28.0672 $15.44 $15.44

I 94453 21-999 0.55 $27.276 $15.00 $14.70 0.55 $26.7305 $14.70 $14.70

T 94453 0-20 1.64 $28.640 $46.97 $46.03 1.99 $28.0672 $55.85 $55.85

T 94453 21-999 1.64 $27.276 $44.73 $43.84 1.99 $26.7305 $53.19 $53.19

5 94620 0-20 1.56 $27.276 $42.55 $41.70 1.68 $28.0672 $47.15 $47.15

5 94620 21-999 1.56 $27.276 $42.55 $41.70 1.68 $26.7305 $44.91 $44.91

I 94620 0-20 0.90 $27.276 $24.55 $24.06 0.89 $28.0672 $24.98 $24.98

I 94620 21-999 0.90 $27.276 $24.55 $24.06 0.89 $26.7305 $23.79 $23.79

T 94620 0-20 0.66 $27.276 $18.00 $17.64 0.79 $28.0672 $22.17 $22.17

T 94620 21-999 0.66 $27.276 $18.00 $17.64 0.79 $26.7305 $21.12 $21.12

5 94621 0-20 4.59 $27.276 $125.20 $122.70 4.92 $28.0672 $138.09 $138.09

5 94621 21-999 4.59 $27.276 $125.20 $122.70 4.92 $26.7305 $131.51 $131.51

I 94621 0-20 2.00 $27.276 $54.55 $53.46 1.99 $28.0672 $55.85 $55.85

I 94621 21-999 2.00 $27.276 $54.55 $53.46 1.99 $26.7305 $53.19 $53.19

T 94621 0-20 2.59 $27.276 $70.64 $69.23 2.93 $28.0672 $82.24 $82.24

T 94621 21-999 2.59 $27.276 $70.64 $69.23 2.93 $26.7305 $78.32 $78.32

5 94680 0-20 1.63 $27.276 $44.46 $43.57 1.80 $28.0672 $50.52 $50.52

5 94680 21-999 1.63 $27.276 $44.46 $43.57 1.80 $26.7305 $48.11 $48.11

I 94680 0-20 0.38 $27.276 $10.36 $10.15 0.37 $28.0672 $10.38 $10.38

I 94680 21-999 0.38 $27.276 $10.36 $10.15 0.37 $26.7305 $9.89 $9.89

T 94680 0-20 1.25 $27.276 $34.10 $33.42 1.43 $28.0672 $40.14 $40.14

T 94680 21-999 1.25 $27.276 $34.10 $33.42 1.43 $26.7305 $38.22 $38.22

5 94681 0-20 1.42 $27.276 $38.73 $37.96 1.62 $28.0672 $45.47 $45.47

5 94681 21-999 1.42 $27.276 $38.73 $37.96 1.62 $26.7305 $43.30 $43.30

I 94681 0-20 0.29 $27.276 $7.91 $7.75 0.29 $28.0672 $8.14 $8.14

I 94681 21-999 0.29 $27.276 $7.91 $7.75 0.29 $26.7305 $7.75 $7.75

T 94681 0-20 1.13 $27.276 $30.82 $30.20 1.33 $28.0672 $37.33 $37.33

T 94681 21-999 1.13 $27.276 $30.82 $30.20 1.33 $26.7305 $35.55 $35.55

5 94690 0-20 1.40 $27.276 $38.19 $37.43 1.52 $28.0672 $42.66 $42.66

5 94690 21-999 1.40 $27.276 $38.19 $37.43 1.52 $26.7305 $40.63 $40.63

I 94690 0-20 0.11 $27.276 $3.00 $2.94 0.11 $28.0672 $3.09 $3.09

I 94690 21-999 0.11 $27.276 $3.00 $2.94 0.11 $26.7305 $2.94 $2.94

T 94690 0-20 1.29 $27.276 $35.19 $34.49 1.41 $28.0672 $39.57 $39.57

T 94690 21-999 1.29 $27.276 $35.19 $34.49 1.41 $26.7305 $37.69 $37.69

5 94726 0-20 1.58 $28.640 $45.25 $44.35 1.78 $28.0672 $49.96 $49.96

5 94726 21-999 1.58 $27.276 $43.10 $42.24 1.78 $26.7305 $47.58 $47.58

I 94726 0-20 0.36 $28.640 $10.31 $10.10 0.37 $28.0672 $10.38 $10.38

I 94726 21-999 0.36 $27.276 $9.82 $9.62 0.37 $26.7305 $9.89 $9.89

T 94726 0-20 1.22 $28.640 $34.94 $34.24 1.41 $28.0672 $39.57 $39.57

T 94726 21-999 1.22 $27.276 $33.28 $32.61 1.41 $26.7305 $37.69 $37.69

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 94727 0-20 1.24 $28.640 $35.51 $34.80 1.39 $28.0672 $39.01 $39.01

5 94727 21-999 1.24 $27.276 $33.82 $33.14 1.39 $26.7305 $37.16 $37.16

I 94727 0-20 0.36 $28.640 $10.31 $10.10 0.37 $28.0672 $10.38 $10.38

I 94727 21-999 0.36 $27.276 $9.82 $9.62 0.37 $26.7305 $9.89 $9.89

T 94727 0-20 0.88 $28.640 $25.20 $24.70 1.02 $28.0672 $28.63 $28.63

T 94727 21-999 0.88 $27.276 $24.00 $23.52 1.02 $26.7305 $27.27 $27.27

5 94728 0-20 1.24 $28.640 $35.51 $34.80 1.34 $28.0672 $37.61 $37.61

5 94728 21-999 1.24 $27.276 $33.82 $33.14 1.34 $26.7305 $35.82 $35.82

I 94728 0-20 0.36 $28.640 $10.31 $10.10 0.37 $28.0672 $10.38 $10.38

I 94728 21-999 0.36 $27.276 $9.82 $9.62 0.37 $26.7305 $9.89 $9.89

T 94728 0-20 0.88 $28.640 $25.20 $24.70 0.97 $28.0672 $27.23 $27.23

T 94728 21-999 0.88 $27.276 $24.00 $23.52 0.97 $26.7305 $25.93 $25.93

5 94729 0-20 1.57 $28.640 $44.96 $44.06 1.84 $28.0672 $51.64 $51.64

5 94729 21-999 1.57 $27.276 $42.82 $41.96 1.84 $26.7305 $49.18 $49.18

I 94729 0-20 0.24 $28.640 $6.87 $6.73 0.28 $28.0672 $7.86 $7.86

I 94729 21-999 0.24 $27.276 $6.55 $6.42 0.28 $26.7305 $7.48 $7.48

T 94729 0-20 1.33 $28.640 $38.09 $37.33 1.56 $28.0672 $43.78 $43.78

T 94729 21-999 1.33 $27.276 $36.28 $35.55 1.56 $26.7305 $41.70 $41.70

5 94750 0-20 2.29 $27.276 $62.46 $61.21 2.57 $28.0672 $72.13 $72.13

5 94750 21-999 2.29 $27.276 $62.46 $61.21 2.57 $26.7305 $68.70 $68.70

I 94750 0-20 0.33 $27.276 $9.00 $8.82 0.32 $28.0672 $8.98 $8.98

I 94750 21-999 0.33 $27.276 $9.00 $8.82 0.32 $26.7305 $8.55 $8.55

T 94750 0-20 1.96 $27.276 $53.46 $52.39 2.25 $28.0672 $63.15 $63.15

T 94750 21-999 1.96 $27.276 $53.46 $52.39 2.25 $26.7305 $60.14 $60.14

5 94760 0-20 0.09 $27.276 $2.45 $2.40 0.10 $28.0672 $2.81 $2.81

5 94760 21-999 0.09 $27.276 $2.45 $2.40 0.10 $26.7305 $2.67 $2.67

5 94761 0-20 0.13 $27.276 $3.55 $3.48 0.15 $28.0672 $4.21 $4.21

5 94761 21-999 0.13 $27.276 $3.55 $3.48 0.15 $26.7305 $4.01 $4.01

5 94762 0-20 0.27 $28.640 $7.73 $7.58 0.74 $28.0672 $20.77 $20.77

5 94770 0-20 0.25 $27.276 $6.82 $6.68 0.24 $28.0672 $6.74 $6.74

5 94770 21-999 0.25 $27.276 $6.82 $6.68 0.24 $26.7305 $6.42 $6.42

I 94770 0-20 $1.35 $1.32 $1.33 $1.33

I 94770 21-999 $1.35 $1.32 $1.27 $1.27

T 94770 0-20 $5.47 $5.36 $5.41 $5.41

T 94770 21-999 $5.47 $5.36 $5.15 $5.15

5 94772 0-999 $90.22 $88.42 $88.42 $88.42

I 94772 0-999 $24.67 $24.18 $24.18 $24.18

T 94772 0-999 $65.55 $64.24 $64.24 $64.24


5 95803 0-20 4.78 $28.640 $136.90 $134.16 4.48 $28.0672 $125.74 $125.74

5 95803 21-999 4.78 $27.276 $130.38 $127.77 4.48 $26.7305 $119.75 $119.75

I 95803 0-20 1.38 $28.640 $39.52 $38.73 1.29 $28.0672 $36.21 $36.21

I 95803 21-999 1.38 $27.276 $37.64 $36.89 1.29 $26.7305 $34.48 $34.48

T 95803 0-20 3.40 $28.640 $97.38 $95.43 3.19 $28.0672 $89.53 $89.53

T 95803 21-999 3.40 $27.276 $92.74 $90.89 3.19 $26.7305 $85.27 $85.27

5 95805 0-20 11.41 $27.276 $311.22 $305.00 12.62 $28.0672 $354.21 $354.21

5 95805 21-999 11.41 $27.276 $311.22 $305.00 12.62 $26.7305 $337.34 $337.34

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 95805 0-20 1.72 $27.276 $46.91 $45.97 1.69 $28.0672 $47.43 $47.43

I 95805 21-999 1.72 $27.276 $46.91 $45.97 1.69 $26.7305 $45.17 $45.17

T 95805 0-20 9.69 $27.276 $264.30 $259.01 10.93 $28.0672 $306.77 $306.77

T 95805 21-999 9.69 $27.276 $264.30 $259.01 10.93 $26.7305 $292.16 $292.16

5 95807 0-20 12.19 $28.640 $349.12 $342.14 14.69 $28.0672 $412.31 $412.31

5 95807 21-999 12.19 $27.276 $332.49 $325.84 14.69 $26.7305 $392.67 $392.67

I 95807 0-20 1.80 $28.640 $51.55 $50.52 1.79 $28.0672 $50.24 $50.24

I 95807 21-999 1.80 $27.276 $49.10 $48.12 1.79 $26.7305 $47.85 $47.85

5 95808 0-20 18.37 $27.276 $501.06 $491.04 19.23 $28.0672 $539.73 $539.73

5 95808 21-999 18.37 $27.276 $501.06 $491.04 19.23 $26.7305 $514.03 $514.03

I 95808 0-20 2.54 $27.276 $69.28 $67.89 2.49 $28.0672 $69.89 $69.89

I 95808 21-999 2.54 $27.276 $69.28 $67.89 2.49 $26.7305 $66.56 $66.56

T 95808 0-20 15.83 $27.276 $431.78 $423.14 16.74 $28.0672 $469.84 $469.84

T 95808 21-999 15.83 $27.276 $431.78 $423.14 16.74 $26.7305 $447.47 $447.47

5 95810 0-20 17.25 $27.276 $470.51 $461.10 18.99 $28.0672 $533.00 $533.00

5 95810 21-999 17.25 $27.276 $470.51 $461.10 18.99 $26.7305 $507.61 $507.61

I 95810 0-20 3.56 $27.276 $97.10 $95.16 3.52 $28.0672 $98.80 $98.80

I 95810 21-999 3.56 $27.276 $97.10 $95.16 3.52 $26.7305 $94.09 $94.09

T 95810 0-20 13.69 $27.276 $373.41 $365.94 15.47 $28.0672 $434.20 $434.20

T 95810 21-999 13.69 $27.276 $373.41 $365.94 15.47 $26.7305 $413.52 $413.52

5 95811 0-20 18.10 $27.276 $493.70 $483.83 19.92 $28.0672 $559.10 $559.10

5 95811 21-999 18.10 $27.276 $493.70 $483.83 19.92 $26.7305 $532.47 $532.47

I 95811 0-20 3.70 $27.276 $100.92 $98.90 3.66 $28.0672 $102.73 $102.73

I 95811 21-999 3.70 $27.276 $100.92 $98.90 3.66 $26.7305 $97.83 $97.83

T 95811 0-20 14.40 $27.276 $392.77 $384.91 16.26 $28.0672 $456.37 $456.37

T 95811 21-999 14.40 $27.276 $392.77 $384.91 16.26 $26.7305 $434.64 $434.64

5 95812 0-20 10.90 $27.276 $297.31 $291.36 13.32 $28.0672 $373.86 $373.86

5 95812 21-999 10.90 $27.276 $297.31 $291.36 13.32 $26.7305 $356.05 $356.05

I 95812 0-20 1.64 $27.276 $44.73 $43.84 1.64 $28.0672 $46.03 $46.03

I 95812 21-999 1.64 $27.276 $44.73 $43.84 1.64 $26.7305 $43.84 $43.84

T 95812 0-20 9.26 $27.276 $252.58 $247.53 11.68 $28.0672 $327.82 $327.82

T 95812 21-999 9.26 $27.276 $252.58 $247.53 11.68 $26.7305 $312.21 $312.21

5 95813 0-20 11.59 $27.276 $316.13 $309.81 15.31 $28.0672 $429.71 $429.71

5 95813 21-999 11.59 $27.276 $316.13 $309.81 15.31 $26.7305 $409.24 $409.24

I 95813 0-20 2.60 $27.276 $70.92 $69.50 2.63 $28.0672 $73.82 $73.82

I 95813 21-999 2.60 $27.276 $70.92 $69.50 2.63 $26.7305 $70.30 $70.30

T 95813 0-20 8.99 $27.276 $245.21 $240.31 12.68 $28.0672 $355.89 $355.89

T 95813 21-999 8.99 $27.276 $245.21 $240.31 12.68 $26.7305 $338.94 $338.94

5 95816 0-20 10.15 $27.276 $276.85 $271.31 12.22 $28.0672 $342.98 $342.98

5 95816 21-999 10.15 $27.276 $276.85 $271.31 12.22 $26.7305 $326.65 $326.65

I 95816 0-20 1.65 $27.276 $45.01 $44.11 1.66 $28.0672 $46.59 $46.59

I 95816 21-999 1.65 $27.276 $45.01 $44.11 1.66 $26.7305 $44.37 $44.37

T 95816 0-20 8.50 $27.276 $231.85 $227.21 10.56 $28.0672 $296.39 $296.39

T 95816 21-999 8.50 $27.276 $231.85 $227.21 10.56 $26.7305 $282.27 $282.27

5 95819 0-20 11.60 $27.276 $316.40 $310.07 14.04 $28.0672 $394.06 $394.06

5 95819 21-999 11.60 $27.276 $316.40 $310.07 14.04 $26.7305 $375.30 $375.30

I 95819 0-20 1.64 $27.276 $44.73 $43.84 1.65 $28.0672 $46.31 $46.31

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 95819 21-999 1.64 $27.276 $44.73 $43.84 1.65 $26.7305 $44.11 $44.11

T 95819 0-20 9.96 $27.276 $271.67 $266.24 12.39 $28.0672 $347.75 $347.75

T 95819 21-999 9.96 $27.276 $271.67 $266.24 12.39 $26.7305 $331.19 $331.19

5 95822 0-20 10.42 $27.276 $284.22 $278.54 12.55 $28.0672 $352.24 $352.24

5 95822 21-999 10.42 $27.276 $284.22 $278.54 12.55 $26.7305 $335.47 $335.47

I 95822 0-20 1.64 $27.276 $44.73 $43.84 1.65 $28.0672 $46.31 $46.31

I 95822 21-999 1.64 $27.276 $44.73 $43.84 1.65 $26.7305 $44.11 $44.11

T 95822 0-20 8.78 $27.276 $239.48 $234.69 10.90 $28.0672 $305.93 $305.93

T 95822 21-999 8.78 $27.276 $239.48 $234.69 10.90 $26.7305 $291.36 $291.36

I 95824 0-20 1.14 $27.276 $31.09 $30.47 1.15 $28.0672 $32.28 $32.28

I 95824 21-999 1.14 $27.276 $31.09 $30.47 1.15 $26.7305 $30.74 $30.74

5 95827 0-20 20.48 $27.276 $558.61 $547.44 23.88 $28.0672 $670.24 $670.24

5 95827 21-999 20.48 $27.276 $558.61 $547.44 23.88 $26.7305 $638.32 $638.32

I 95827 0-20 1.65 $27.276 $45.01 $44.11 1.65 $28.0672 $46.31 $46.31

I 95827 21-999 1.65 $27.276 $45.01 $44.11 1.65 $26.7305 $44.11 $44.11

T 95827 0-20 18.83 $27.276 $513.61 $503.34 22.23 $28.0672 $623.93 $623.93

T 95827 21-999 18.83 $27.276 $513.61 $503.34 22.23 $26.7305 $594.22 $594.22

5 95829 0-20 48.90 $27.276 $1,333.80 $1,307.12 57.96 $28.0672 $1,626.77 $1,626.77

5 95829 21-999 48.90 $27.276 $1,333.80 $1,307.12 57.96 $26.7305 $1,549.30 $1,549.30

I 95829 0-20 9.36 $27.276 $255.30 $250.19 9.36 $28.0672 $262.71 $262.71

I 95829 21-999 9.36 $27.276 $255.30 $250.19 9.36 $26.7305 $250.20 $250.20

T 95829 0-20 39.54 $27.276 $1,078.49 $1,056.92 48.60 $28.0672 $1,364.07 $1,364.07

T 95829 21-999 39.54 $27.276 $1,078.49 $1,056.92 48.60 $26.7305 $1,299.10 $1,299.10

5 95831 0-20 NF 0.88 $27.276 $24.00 $23.52 0.85 $28.0672 $23.86 $23.86

5 95831 0-20 F 0.88 $27.276 $24.00 $23.52 0.42 $28.0672 $11.79 $11.79

5 95831 21-999 NF 0.88 $27.276 $24.00 $23.52 0.85 $26.7305 $22.72 $22.72

5 95831 21-999 F 0.88 $27.276 $24.00 $23.52 0.42 $26.7305 $11.23 $11.23

I 95831 0-20 $24.00 $23.52 $23.86 $23.86

I 95831 21-999 $24.00 $23.52 $22.72 $22.72

5 95832 0-20 NF 0.89 $27.276 $24.28 $23.79 0.81 $28.0672 $22.73 $22.73

5 95832 0-20 F 0.89 $27.276 $24.28 $23.79 0.44 $28.0672 $12.35 $12.35

5 95832 21-999 NF 0.89 $27.276 $24.28 $23.79 0.81 $26.7305 $21.65 $21.65

5 95832 21-999 F 0.89 $27.276 $24.28 $23.79 0.44 $26.7305 $11.76 $11.76

I 95832 0-20 $24.28 $23.79 0.81 $28.0672 $21.65 $21.65

I 95832 21-999 0.89 $27.276 $24.28 $23.79 0.81 $26.7305 $21.65 $21.65

5 95833 0-20 NF 1.09 $27.276 $29.73 $29.14 1.10 $28.0672 $30.87 $30.87

5 95833 0-20 F 1.09 $27.276 $29.73 $29.14 0.61 $28.0672 $17.12 $17.12

5 95833 21-999 NF 1.09 $27.276 $29.73 $29.14 1.10 $26.7305 $29.40 $29.40

5 95833 21-999 F 1.09 $27.276 $29.73 $29.14 0.61 $26.7305 $16.31 $16.31

I 95833 0-20 NF $29.73 $29.14 0.81 $28.0672 $22.73 $22.73

I 95833 0-20 F $29.73 $29.14 0.44 $28.0672 $12.35 $12.35

I 95833 21-999 NF 0.89 $27.276 $24.28 $23.79 0.81 $26.7305 $21.65 $21.65

I 95833 21-999 F 0.89 $27.276 $24.28 $23.79 0.44 $26.7305 $11.76 $11.76

5 95834 0-20 NF 1.44 $27.276 $39.28 $38.49 1.53 $28.0672 $42.94 $42.94

5 95834 0-20 F 1.44 $27.276 $39.28 $38.49 0.89 $28.0672 $24.98 $24.98

5 95834 21-999 NF 1.44 $27.276 $39.28 $38.49 1.53 $26.7305 $40.90 $40.90

5 95834 21-999 F 1.44 $27.276 $39.28 $38.49 0.89 $26.7305 $23.79 $23.79

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 95834 0-20 $39.28 $38.49 $42.94 $42.94

I 95834 21-999 $39.28 $38.49 $40.90 $40.90

5 95851 0-20 NF 0.51 $27.276 $13.91 $13.63 0.54 $28.0672 $15.16 $15.16

5 95851 0-20 F 0.51 $27.276 $13.91 $13.63 0.22 $28.0672 $6.17 $6.17

5 95851 21-999 NF 0.51 $27.276 $13.91 $13.63 0.54 $26.7305 $14.43 $14.43

5 95851 21-999 F 0.51 $27.276 $13.91 $13.63 0.22 $26.7305 $5.88 $5.88

I 95851 0-20 $13.91 $13.63 $15.16 $15.16

I 95851 21-999 0.89 $27.276 $24.28 $23.79 $14.43 $14.43

5 95852 0-20 NF 0.46 $27.276 $12.55 $12.30 0.50 $28.0672 $14.03 $14.03

5 95852 0-20 F 0.46 $27.276 $12.55 $12.30 0.17 $28.0672 $4.77 $4.77

5 95852 21-999 NF 0.46 $27.276 $12.55 $12.30 0.50 $26.7305 $13.37 $13.37

5 95852 21-999 F 0.46 $27.276 $12.55 $12.30 0.17 $26.7305 $4.54 $4.54

I 95852 0-20 $12.55 $12.30 $14.03 $14.03

I 95852 21-999 $12.55 $12.30 $13.37 $13.37

5 95857 0-20 NF 0.87 $27.276 $23.73 $23.26 1.58 $28.0672 $44.35 $44.35

5 95857 0-20 F 0.87 $27.276 $23.73 $23.26 0.86 $28.0672 $24.14 $24.14

5 95857 21-999 NF 0.87 $27.276 $23.73 $23.26 1.58 $26.7305 $42.23 $42.23

5 95857 21-999 F 0.87 $27.276 $23.73 $23.26 0.86 $26.7305 $22.99 $22.99

5 95860 0-20 2.84 $27.276 $77.46 $75.91 3.74 $28.0672 $104.97 $104.97

5 95860 21-999 2.84 $27.276 $77.46 $75.91 3.74 $26.7305 $99.97 $99.97

I 95860 0-20 1.49 $27.276 $40.64 $39.83 1.49 $28.0672 $41.82 $41.82

I 95860 21-999 1.49 $27.276 $40.64 $39.83 1.49 $26.7305 $39.83 $39.83

T 95860 0-20 1.35 $27.276 $36.82 $36.08 2.25 $28.0672 $63.15 $63.15

T 95860 21-999 1.35 $27.276 $36.82 $36.08 2.25 $26.7305 $60.14 $60.14

5 95861 0-20 4.18 $27.276 $114.01 $111.73 5.13 $28.0672 $143.98 $143.98

5 95861 21-999 4.18 $27.276 $114.01 $111.73 5.13 $26.7305 $137.13 $137.13

I 95861 0-20 2.38 $27.276 $64.92 $63.62 2.38 $28.0672 $66.80 $66.80

I 95861 21-999 2.38 $27.276 $64.92 $63.62 2.38 $26.7305 $63.62 $63.62

T 95861 0-20 1.80 $27.276 $49.10 $48.12 2.75 $28.0672 $77.18 $77.18

T 95861 21-999 1.80 $27.276 $49.10 $48.12 2.75 $26.7305 $73.51 $73.51

5 95863 0-20 5.11 $27.276 $139.38 $136.59 6.27 $28.0672 $175.98 $175.98

5 95863 21-999 5.11 $27.276 $139.38 $136.59 6.27 $26.7305 $167.60 $167.60

I 95863 0-20 2.88 $27.276 $78.55 $76.98 2.87 $28.0672 $80.55 $80.55

I 95863 21-999 2.88 $27.276 $78.55 $76.98 2.87 $26.7305 $76.72 $76.72

T 95863 0-20 2.23 $27.276 $60.83 $59.61 3.40 $28.0672 $95.43 $95.43

T 95863 21-999 2.23 $27.276 $60.83 $59.61 3.40 $26.7305 $90.88 $90.88

5 95864 0-20 5.41 $27.276 $147.56 $144.61 7.18 $28.0672 $201.52 $201.52

5 95864 21-999 5.41 $27.276 $147.56 $144.61 7.18 $26.7305 $191.92 $191.92

I 95864 0-20 3.06 $27.276 $83.46 $81.79 3.05 $28.0672 $85.60 $85.60

I 95864 21-999 3.06 $27.276 $83.46 $81.79 3.05 $26.7305 $81.53 $81.53

T 95864 0-20 2.35 $27.276 $64.10 $62.82 4.13 $28.0672 $115.92 $115.92

T 95864 21-999 2.35 $27.276 $64.10 $62.82 4.13 $26.7305 $110.40 $110.40

5 95865 0-20 3.68 $27.276 $100.38 $98.37 4.00 $28.0672 $112.27 $112.27

5 95865 21-999 3.68 $27.276 $100.38 $98.37 4.00 $26.7305 $106.92 $106.92

I 95865 0-20 2.45 $27.276 $66.83 $65.49 2.36 $28.0672 $66.24 $66.24

I 95865 21-999 2.45 $27.276 $66.83 $65.49 2.36 $26.7305 $63.08 $63.08

T 95865 0-20 1.23 $27.276 $33.55 $32.88 1.64 $28.0672 $46.03 $46.03

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


T 95865 21-999 1.23 $27.276 $33.55 $32.88 1.64 $26.7305 $43.84 $43.84

5 95866 0-20 3.32 $27.276 $90.56 $88.75 4.09 $28.0672 $114.79 $114.79

5 95866 21-999 3.32 $27.276 $90.56 $88.75 4.09 $26.7305 $109.33 $109.33

I 95866 0-20 1.90 $27.276 $51.82 $50.78 1.93 $28.0672 $54.17 $54.17

I 95866 21-999 1.90 $27.276 $51.82 $50.78 1.93 $26.7305 $51.59 $51.59

T 95866 0-20 1.42 $27.276 $38.73 $37.96 2.16 $28.0672 $60.63 $60.63

T 95866 21-999 1.42 $27.276 $38.73 $37.96 2.16 $26.7305 $57.74 $57.74

5 95867 0-20 2.56 $27.276 $69.83 $68.43 3.39 $28.0672 $95.15 $95.15

5 95867 21-999 2.56 $27.276 $69.83 $68.43 3.39 $26.7305 $90.62 $90.62

I 95867 0-20 1.23 $27.276 $33.55 $32.88 1.21 $28.0672 $33.96 $33.96

I 95867 21-999 1.23 $27.276 $33.55 $32.88 1.21 $26.7305 $32.34 $32.34

T 95867 0-20 1.33 $27.276 $36.28 $35.55 2.18 $28.0672 $61.19 $61.19

T 95867 21-999 1.33 $27.276 $36.28 $35.55 2.18 $26.7305 $58.27 $58.27

5 95868 0-20 3.48 $27.276 $94.92 $93.02 4.25 $28.0672 $119.29 $119.29

5 95868 21-999 3.48 $27.276 $94.92 $93.02 4.25 $26.7305 $113.60 $113.60

I 95868 0-20 1.82 $27.276 $49.64 $48.65 1.80 $28.0672 $50.52 $50.52

I 95868 21-999 1.82 $27.276 $49.64 $48.65 1.80 $26.7305 $48.11 $48.11

T 95868 0-20 1.66 $27.276 $45.28 $44.37 2.45 $28.0672 $68.76 $68.76

T 95868 21-999 1.66 $27.276 $45.28 $44.37 2.45 $26.7305 $65.49 $65.49

5 95869 0-20 2.01 $27.276 $54.82 $53.72 2.56 $28.0672 $71.85 $71.85

5 95869 21-999 2.01 $27.276 $54.82 $53.72 2.56 $26.7305 $68.43 $68.43

I 95869 0-20 0.57 $27.276 $15.55 $15.24 0.56 $28.0672 $15.72 $15.72

I 95869 21-999 0.57 $27.276 $15.55 $15.24 0.56 $26.7305 $14.97 $14.97

T 95869 0-20 1.44 $27.276 $39.28 $38.49 2.00 $28.0672 $56.13 $56.13

T 95869 21-999 1.44 $27.276 $39.28 $38.49 2.00 $26.7305 $53.46 $53.46

5 95870 0-20 1.99 $27.276 $54.28 $53.19 2.69 $28.0672 $75.50 $75.50

5 95870 21-999 1.99 $27.276 $54.28 $53.19 2.69 $26.7305 $71.91 $71.91

I 95870 0-20 0.57 $27.276 $15.55 $15.24 0.57 $28.0672 $16.00 $16.00

I 95870 21-999 0.57 $27.276 $15.55 $15.24 0.57 $26.7305 $15.24 $15.24

T 95870 0-20 1.42 $27.276 $38.73 $37.96 2.12 $28.0672 $59.50 $59.50

T 95870 21-999 1.42 $27.276 $38.73 $37.96 2.12 $26.7305 $56.67 $56.67

5 95872 0-20 5.58 $27.276 $152.20 $149.16 5.96 $28.0672 $167.28 $167.28

5 95872 21-999 5.58 $27.276 $152.20 $149.16 5.96 $26.7305 $159.31 $159.31

I 95872 0-20 4.37 $27.276 $119.20 $116.82 4.41 $28.0672 $123.78 $123.78

I 95872 21-999 4.37 $27.276 $119.20 $116.82 4.41 $26.7305 $117.88 $117.88

T 95872 0-20 1.21 $27.276 $33.00 $32.34 1.55 $28.0672 $43.50 $43.50

T 95872 21-999 1.21 $27.276 $33.00 $32.34 1.55 $26.7305 $41.43 $41.43

5 95875 0-20 3.37 $27.276 $91.92 $90.08 3.77 $28.0672 $105.81 $105.81

5 95875 21-999 3.37 $27.276 $91.92 $90.08 3.77 $26.7305 $100.77 $100.77

I 95875 0-20 1.68 $27.276 $45.82 $44.90 1.69 $28.0672 $47.43 $47.43

I 95875 21-999 1.68 $27.276 $45.82 $44.90 1.69 $26.7305 $45.17 $45.17

T 95875 0-20 1.69 $27.276 $46.10 $45.18 2.08 $28.0672 $58.38 $58.38

T 95875 21-999 1.69 $27.276 $46.10 $45.18 2.08 $26.7305 $55.60 $55.60

5 95885 0-20 1.64 $28.640 $46.97 $46.03 1.80 $28.0672 $50.52 $50.52

5 95885 21-999 1.64 $27.276 $44.73 $43.84 1.80 $26.7305 $48.11 $48.11

I 95885 0-20 0.52 $28.640 $14.89 $14.59 0.54 $28.0672 $15.16 $15.16

I 95885 21-999 0.52 $27.276 $14.18 $13.90 0.54 $26.7305 $14.43 $14.43

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


T 95885 0-20 1.12 $28.640 $32.08 $31.44 1.26 $28.0672 $35.36 $35.36

T 95885 21-999 1.12 $27.276 $30.55 $29.94 1.26 $26.7305 $33.68 $33.68

5 95886 0-20 2.57 $28.640 $73.60 $72.13 2.49 $28.0672 $69.89 $69.89

5 95886 21-999 2.57 $27.276 $70.10 $68.70 2.49 $26.7305 $66.56 $66.56

I 95886 0-20 1.39 $28.640 $39.81 $39.01 1.08 $28.0672 $30.31 $30.31

I 95886 21-999 1.39 $27.276 $37.91 $37.15 1.08 $26.7305 $28.87 $28.87

T 95886 0-20 1.18 $28.640 $33.80 $33.12 1.41 $28.0672 $39.57 $39.57

T 95886 21-999 1.18 $27.276 $32.19 $31.55 1.41 $26.7305 $37.69 $37.69

5 95887 0-20 2.29 $28.640 $65.59 $64.28 2.09 $28.0672 $58.66 $58.66

5 95887 21-999 2.29 $27.276 $62.46 $61.21 2.09 $26.7305 $55.87 $55.87

I 95887 0-20 1.09 $28.640 $31.22 $30.60 0.71 $28.0672 $19.93 $19.93

I 95887 21-999 1.09 $27.276 $29.73 $29.14 0.71 $26.7305 $18.98 $18.98

T 95887 0-20 1.20 $28.640 $34.37 $33.68 1.38 $28.0672 $38.73 $38.73

T 95887 21-999 1.20 $27.276 $32.73 $32.08 1.38 $26.7305 $36.89 $36.89

5 95905 0-20 2.48 $28.640 $71.03 $69.61 2.09 $28.0672 $58.66 $58.66

5 95905 21-999 2.48 $27.276 $67.64 $66.29 2.09 $26.7305 $55.87 $55.87

I 95905 0-20 0.09 $28.640 $2.58 $2.53 0.08 $28.0672 $2.25 $2.25

I 95905 21-999 0.09 $27.276 $2.45 $2.40 0.08 $26.7305 $2.14 $2.14

T 95905 0-20 2.39 $28.640 $68.45 $67.08 2.01 $28.0672 $56.42 $56.42

T 95905 21-999 2.39 $27.276 $65.19 $63.89 2.01 $26.7305 $53.73 $53.73

5 95920 0-20 4.89 $27.276 $133.38 $130.71 $130.71 $130.71

5 95920 21-999 4.89 $27.276 $133.38 $130.71 $130.71 $130.71

I 95920 0-20 3.22 $27.276 $87.83 $86.07 $86.07 $86.07

I 95920 21-999 3.22 $27.276 $87.83 $86.07 $86.07 $86.07

T 95920 0-20 1.67 $27.276 $45.55 $44.64 $44.64 $44.64

T 95920 21-999 1.67 $27.276 $45.55 $44.64 $44.64 $44.64

5 95921 0-20 2.47 $27.276 $67.37 $66.02 2.66 $28.0672 $74.66 $74.66

5 95921 21-999 2.47 $27.276 $67.37 $66.02 2.66 $26.7305 $71.10 $71.10

I 95921 0-20 1.34 $27.276 $36.55 $35.82 1.32 $28.0672 $37.05 $37.05

I 95921 21-999 1.34 $27.276 $36.55 $35.82 1.32 $26.7305 $35.28 $35.28

T 95921 0-20 1.13 $27.276 $30.82 $30.20 1.34 $28.0672 $37.61 $37.61

T 95921 21-999 1.13 $27.276 $30.82 $30.20 1.34 $26.7305 $35.82 $35.82

5 95922 0-20 3.09 $27.276 $84.28 $82.59 3.20 $28.0672 $89.82 $89.82

5 95922 21-999 3.09 $27.276 $84.28 $82.59 3.20 $26.7305 $85.54 $85.54

I 95922 0-20 1.42 $27.276 $38.73 $37.96 1.42 $28.0672 $39.86 $39.86

I 95922 21-999 1.42 $27.276 $38.73 $37.96 1.42 $26.7305 $37.96 $37.96

T 95922 0-20 1.67 $27.276 $45.55 $44.64 1.78 $28.0672 $49.96 $49.96

T 95922 21-999 1.67 $27.276 $45.55 $44.64 1.78 $26.7305 $47.58 $47.58

5 95923 0-20 4.87 $27.276 $132.83 $130.17 7.73 $28.0672 $216.96 $216.96

5 95923 21-999 4.87 $27.276 $132.83 $130.17 7.73 $26.7305 $206.63 $206.63

I 95923 0-20 1.38 $27.276 $37.64 $36.89 1.37 $28.0672 $38.45 $38.45

I 95923 21-999 1.38 $27.276 $37.64 $36.89 1.37 $26.7305 $36.62 $36.62

T 95923 0-20 3.49 $27.276 $95.19 $93.29 6.36 $28.0672 $178.51 $178.51

T 95923 21-999 3.49 $27.276 $95.19 $93.29 6.36 $26.7305 $170.01 $170.01

5 95925 0-20 5.48 $27.276 $149.47 $146.48 5.79 $28.0672 $162.51 $162.51

5 95925 21-999 5.48 $27.276 $149.47 $146.48 5.79 $26.7305 $154.77 $154.77

I 95925 0-20 0.81 $27.276 $22.09 $21.65 0.81 $28.0672 $22.73 $22.73

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 95925 21-999 0.81 $27.276 $22.09 $21.65 0.81 $26.7305 $21.65 $21.65

T 95925 0-20 4.67 $27.276 $127.38 $124.83 4.98 $28.0672 $139.77 $139.77

T 95925 21-999 4.67 $27.276 $127.38 $124.83 4.98 $26.7305 $133.12 $133.12

5 95926 0-20 5.23 $27.276 $142.65 $139.80 5.60 $28.0672 $157.18 $157.18

5 95926 21-999 5.23 $27.276 $142.65 $139.80 5.60 $26.7305 $149.69 $149.69

I 95926 0-20 0.82 $27.276 $22.37 $21.92 0.83 $28.0672 $23.30 $23.30

I 95926 21-999 0.82 $27.276 $22.37 $21.92 0.83 $26.7305 $22.19 $22.19

T 95926 0-20 4.41 $27.276 $120.29 $117.88 4.77 $28.0672 $133.88 $133.88

T 95926 21-999 4.41 $27.276 $120.29 $117.88 4.77 $26.7305 $127.50 $127.50

5 95927 0-20 4.61 $27.276 $125.74 $123.23 5.07 $28.0672 $142.30 $142.30

5 95927 21-999 4.61 $27.276 $125.74 $123.23 5.07 $26.7305 $135.52 $135.52

I 95927 0-20 0.81 $27.276 $22.09 $21.65 0.79 $28.0672 $22.17 $22.17

I 95927 21-999 0.81 $27.276 $22.09 $21.65 0.79 $26.7305 $21.12 $21.12

T 95927 0-20 3.80 $27.276 $103.65 $101.58 4.28 $28.0672 $120.13 $120.13

T 95927 21-999 3.80 $27.276 $103.65 $101.58 4.28 $26.7305 $114.41 $114.41

5 95928 0-20 7.82 $27.276 $213.30 $209.03 8.71 $28.0672 $244.47 $244.47

5 95928 21-999 7.82 $27.276 $213.30 $209.03 8.71 $26.7305 $232.82 $232.82

I 95928 0-20 2.30 $27.276 $62.73 $61.48 2.30 $28.0672 $64.55 $64.55

I 95928 21-999 2.30 $27.276 $62.73 $61.48 2.30 $26.7305 $61.48 $61.48

T 95928 0-20 5.52 $27.276 $150.56 $147.55 6.41 $28.0672 $179.91 $179.91

T 95928 21-999 5.52 $27.276 $150.56 $147.55 6.41 $26.7305 $171.34 $171.34

5 95929 0-20 8.27 $27.276 $225.57 $221.06 8.76 $28.0672 $245.87 $245.87

5 95929 21-999 8.27 $27.276 $225.57 $221.06 8.76 $26.7305 $234.16 $234.16

I 95929 0-20 2.30 $27.276 $62.73 $61.48 2.30 $28.0672 $64.55 $64.55

I 95929 21-999 2.30 $27.276 $62.73 $61.48 2.30 $26.7305 $61.48 $61.48

T 95929 0-20 5.97 $27.276 $162.84 $159.58 6.46 $28.0672 $181.31 $181.31

T 95929 21-999 5.97 $27.276 $162.84 $159.58 6.46 $26.7305 $172.68 $172.68

5 95930 0-20 4.45 $27.276 $121.38 $118.95 4.83 $28.0672 $135.56 $135.56

5 95930 21-999 4.45 $27.276 $121.38 $118.95 4.83 $26.7305 $129.11 $129.11

I 95930 0-20 0.54 $27.276 $14.73 $14.44 0.53 $28.0672 $14.88 $14.88

I 95930 21-999 0.54 $27.276 $14.73 $14.44 0.53 $26.7305 $14.17 $14.17

T 95930 0-20 3.91 $27.276 $106.65 $104.52 4.30 $28.0672 $120.69 $120.69

T 95930 21-999 3.91 $27.276 $106.65 $104.52 4.30 $26.7305 $114.94 $114.94

5 95933 0-20 2.41 $27.276 $65.74 $64.43 2.71 $28.0672 $76.06 $76.06

5 95933 21-999 2.41 $27.276 $65.74 $64.43 2.71 $26.7305 $72.44 $72.44

I 95933 0-20 0.91 $27.276 $24.82 $24.32 0.91 $28.0672 $25.54 $25.54

I 95933 21-999 0.91 $27.276 $24.82 $24.32 0.91 $26.7305 $24.32 $24.32

T 95933 0-20 1.50 $27.276 $40.91 $40.09 1.80 $28.0672 $50.52 $50.52

T 95933 21-999 1.50 $27.276 $40.91 $40.09 1.80 $26.7305 $48.11 $48.11

5 95934 0-20 1.83 $27.276 $49.92 $48.92 $48.92 $48.92

5 95934 21-999 1.83 $27.276 $49.92 $48.92 $48.92 $48.92

I 95934 0-20 0.77 $27.276 $21.00 $20.58 $20.58 $20.58

I 95934 21-999 0.77 $27.276 $21.00 $20.58 $20.58 $20.58

T 95934 0-20 1.06 $27.276 $28.91 $28.33 $28.33 $28.33

T 95934 21-999 1.06 $27.276 $28.91 $28.33 $28.33 $28.33

5 95936 0-20 1.47 $27.276 $40.10 $39.30 $39.30 $39.30

5 95936 21-999 1.47 $27.276 $40.10 $39.30 $39.30 $39.30

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


I 95936 0-20 0.83 $27.276 $22.64 $22.19 $22.19 $22.19

I 95936 21-999 0.83 $27.276 $22.64 $22.19 $22.19 $22.19

T 95936 0-20 0.64 $27.276 $17.46 $17.11 $17.11 $17.11

T 95936 21-999 0.64 $27.276 $17.46 $17.11 $17.11 $17.11

5 95937 0-20 2.09 $27.276 $57.01 $55.87 2.33 $28.0672 $65.40 $65.40

5 95937 21-999 2.09 $27.276 $57.01 $55.87 2.33 $26.7305 $62.28 $62.28

I 95937 0-20 1.00 $27.276 $27.28 $26.73 0.99 $28.0672 $27.79 $27.79

I 95937 21-999 1.00 $27.276 $27.28 $26.73 0.99 $26.7305 $26.46 $26.46

T 95937 0-20 1.09 $27.276 $29.73 $29.14 1.34 $28.0672 $37.61 $37.61

T 95937 21-999 1.09 $27.276 $29.73 $29.14 1.34 $26.7305 $35.82 $35.82

5 95938 0-20 8.69 $28.640 $248.88 $243.90 9.81 $28.0672 $275.34 $275.34

5 95938 21-999 8.69 $27.276 $237.03 $232.29 9.81 $26.7305 $262.23 $262.23

I 95938 0-20 1.28 $28.640 $36.66 $35.93 1.32 $28.0672 $37.05 $37.05

I 95938 21-999 1.28 $27.276 $34.91 $34.21 1.32 $26.7305 $35.28 $35.28

T 95938 0-20 7.41 $28.640 $212.22 $207.98 8.49 $28.0672 $238.29 $238.29

T 95938 21-999 7.41 $27.276 $202.12 $198.08 8.49 $26.7305 $226.94 $226.94

5 95939 0-20 13.60 $28.640 $389.50 $381.71 14.97 $28.0672 $420.17 $420.17

5 95939 21-999 13.60 $27.276 $370.95 $363.53 14.97 $26.7305 $400.16 $400.16

I 95939 0-20 3.37 $28.640 $96.52 $94.59 3.45 $28.0672 $96.83 $96.83

I 95939 21-999 3.37 $27.276 $91.92 $90.08 3.45 $26.7305 $92.22 $92.22

T 95939 0-20 10.23 $28.640 $292.99 $287.13 11.52 $28.0672 $323.33 $323.33

T 95939 21-999 10.23 $27.276 $279.03 $273.45 11.52 $26.7305 $307.94 $307.94

5 95950 0-20 8.72 $27.276 $237.85 $233.09 10.28 $28.0672 $288.53 $288.53

5 95950 21-999 8.72 $27.276 $237.85 $233.09 10.28 $26.7305 $274.79 $274.79

I 95950 0-20 2.31 $27.276 $63.01 $61.75 2.31 $28.0672 $64.84 $64.84

I 95950 21-999 2.31 $27.276 $63.01 $61.75 2.31 $26.7305 $61.75 $61.75

T 95950 0-20 6.41 $27.276 $174.84 $171.34 7.97 $28.0672 $223.70 $223.70

T 95950 21-999 6.41 $27.276 $174.84 $171.34 7.97 $26.7305 $213.04 $213.04

5 95951 0-20 $1,541.91 $1,511.07 $1,586.89 $1,586.89

5 95951 21-999 $1,541.91 $1,511.07 $1,511.31 $1,511.31

I 95951 0-20 9.37 $27.276 $255.58 $250.47 9.40 $28.0672 $263.83 $263.83

I 95951 21-999 9.37 $27.276 $255.58 $250.47 9.40 $26.7305 $251.27 $251.27

T 95951 0-20 $1,286.06 $1,260.34 $1,290.19 $1,290.19

T 95951 21-999 $1,286.06 $1,260.34 $1,228.75 $1,228.75

5 95953 0-20 12.27 $27.276 $334.68 $327.99 13.03 $28.0672 $365.72 $365.72

5 95953 21-999 12.27 $27.276 $334.68 $327.99 13.03 $26.7305 $348.30 $348.30

I 95953 0-20 4.72 $27.276 $128.74 $126.17 4.71 $28.0672 $132.20 $132.20

I 95953 21-999 4.72 $27.276 $128.74 $126.17 4.71 $26.7305 $125.90 $125.90

T 95953 0-20 7.55 $27.276 $205.93 $201.81 8.32 $28.0672 $233.52 $233.52

T 95953 21-999 7.55 $27.276 $205.93 $201.81 8.32 $26.7305 $222.40 $222.40

5 95954 0-20 10.56 $27.276 $288.03 $282.27 14.03 $28.0672 $393.78 $393.78

5 95954 21-999 10.56 $27.276 $288.03 $282.27 14.03 $26.7305 $375.03 $375.03

I 95954 0-20 3.44 $27.276 $93.83 $91.95 3.56 $28.0672 $99.92 $99.92

I 95954 21-999 3.44 $27.276 $93.83 $91.95 3.56 $26.7305 $95.16 $95.16

T 95954 0-20 7.12 $27.276 $194.21 $190.33 10.47 $28.0672 $293.86 $293.86

T 95954 21-999 7.12 $27.276 $194.21 $190.33 10.47 $26.7305 $279.87 $279.87

5 95955 0-20 5.67 $27.276 $154.65 $151.56 7.02 $28.0672 $197.03 $197.03

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 95955 21-999 5.67 $27.276 $154.65 $151.56 7.02 $26.7305 $187.65 $187.65

I 95955 0-20 1.53 $27.276 $41.73 $40.90 1.55 $28.0672 $43.50 $43.50

I 95955 21-999 1.53 $27.276 $41.73 $40.90 1.55 $26.7305 $41.43 $41.43

T 95955 0-20 4.14 $27.276 $112.92 $110.66 5.47 $28.0672 $153.53 $153.53

T 95955 21-999 4.14 $27.276 $112.92 $110.66 5.47 $26.7305 $146.22 $146.22

5 95956 0-20 35.99 $27.276 $981.66 $962.03 51.17 $28.0672 $1,436.20 $1,436.20

5 95956 21-999 35.99 $27.276 $981.66 $962.03 51.17 $26.7305 $1,367.80 $1,367.80

I 95956 0-20 5.42 $27.276 $147.84 $144.88 5.50 $28.0672 $154.37 $154.37

I 95956 21-999 5.42 $27.276 $147.84 $144.88 5.50 $26.7305 $147.02 $147.02

T 95956 0-20 30.57 $27.276 $833.83 $817.15 45.67 $28.0672 $1,281.83 $1,281.83

T 95956 21-999 30.57 $27.276 $833.83 $817.15 45.67 $26.7305 $1,220.78 $1,220.78

5 95957 0-20 10.13 $28.640 $290.12 $284.32 13.69 $28.0672 $384.24 $384.24

I 95957 0-20 2.82 $28.640 $80.76 $79.14 3.03 $28.0672 $85.04 $85.04

T 95957 0-20 7.31 $28.640 $209.36 $205.17 10.66 $28.0672 $299.20 $299.20

5 95958 0-20 14.93 $27.276 $407.23 $399.09 17.24 $28.0672 $483.88 $483.88

5 95958 21-999 14.93 $27.276 $407.23 $399.09 17.24 $26.7305 $460.83 $460.83

I 95958 0-20 RADS 6.42 $28.640 $183.87 $180.19 6.42 $28.0672 $180.19 $180.19

I 95958 0-20 6.42 $27.276 $175.11 $171.61 6.42 $28.0672 $180.19 $180.19

I 95958 21-999 6.42 $27.276 $175.11 $171.61 6.42 $26.7305 $171.61 $171.61

T 95958 0-20 8.51 $27.276 $232.12 $227.48 10.82 $28.0672 $303.69 $303.69

T 95958 21-999 8.51 $27.276 $232.12 $227.48 10.82 $26.7305 $289.22 $289.22

5 95970 0-20 NF 1.89 $27.276 $51.55 $50.52 2.11 $28.0672 $59.22 $59.22

5 95970 0-20 F 1.89 $27.276 $51.55 $50.52 0.70 $28.0672 $19.65 $19.65

5 95970 21-999 NF 1.89 $27.276 $51.55 $50.52 2.11 $26.7305 $56.40 $56.40

5 95970 21-999 F 1.89 $27.276 $51.55 $50.52 0.70 $26.7305 $18.71 $18.71

5 95971 0-20 NF 1.67 $27.276 $45.55 $44.64 1.77 $28.0672 $49.68 $49.68

5 95971 0-20 F 1.67 $27.276 $45.55 $44.64 1.18 $28.0672 $33.12 $33.12

5 95971 21-999 NF 1.67 $27.276 $45.55 $44.64 1.77 $26.7305 $47.31 $47.31

5 95971 21-999 F 1.67 $27.276 $45.55 $44.64 1.18 $26.7305 $31.54 $31.54

5 95972 0-20 NF 3.19 $27.276 $87.01 $85.27 3.23 $28.0672 $90.66 $90.66

5 95972 0-20 F 3.19 $27.276 $87.01 $85.27 3.23 $28.0672 $90.66 $90.66

5 95972 21-999 NF 3.19 $27.276 $87.01 $85.27 3.23 $26.7305 $86.34 $86.34

5 95972 21-999 F 3.19 $27.276 $87.01 $85.27 3.23 $26.7305 $86.34 $86.34

5 95973 0-20 NF 1.86 $27.276 $50.73 $49.72 1.85 $28.0672 $51.92 $51.92

5 95973 0-20 F 1.86 $27.276 $50.73 $49.72 1.41 $28.0672 $39.57 $39.57

5 95973 21-999 NF 1.86 $27.276 $50.73 $49.72 1.85 $26.7305 $49.45 $49.45

5 95973 21-999 F 1.86 $27.276 $50.73 $49.72 1.41 $26.7305 $37.69 $37.69

5 95974 0-20 NF 4.67 $27.276 $127.38 $124.83 6.04 $28.0672 $169.53 $169.53

5 95974 0-20 F 4.67 $27.276 $127.38 $124.83 4.69 $28.0672 $131.64 $131.64

5 95974 21-999 NF 4.67 $27.276 $127.38 $124.83 6.04 $26.7305 $161.45 $161.45

5 95974 21-999 F 4.67 $27.276 $127.38 $124.83 4.69 $26.7305 $125.37 $125.37

5 95975 0-20 NF 3.10 $27.276 $84.56 $82.87 3.23 $28.0672 $90.66 $90.66

5 95975 0-20 F 3.10 $27.276 $84.56 $82.87 2.65 $28.0672 $74.38 $74.38

5 95975 21-999 NF 3.10 $27.276 $84.56 $82.87 3.23 $26.7305 $86.34 $86.34

5 95975 21-999 F 3.10 $27.276 $84.56 $82.87 2.65 $26.7305 $70.84 $70.84

5 95978 0-20 NF 6.98 $27.276 $190.39 $186.58 7.35 $28.0672 $206.29 $206.29

5 95978 0-20 F 6.98 $27.276 $190.39 $186.58 5.59 $28.0672 $156.90 $156.90

Type of

Service

(TOS)*

Procedure

Code Age Range

Provider

Type

Provider

Specialty

Facility (F)

/Nonfacility

(NF)

Current

Medicaid

RVU

Current

Medicaid

Conversion

Factor

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid

RVU**

4-1-13

Medicaid

Conversion

Factor

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


5 95978 21-999 NF 6.98 $27.276 $190.39 $186.58 7.35 $26.7305 $196.47 $196.47

5 95978 21-999 F 6.98 $27.276 $190.39 $186.58 5.59 $26.7305 $149.42 $149.42

5 95979 0-20 NF 2.59 $27.276 $70.64 $69.23 3.15 $28.0672 $88.41 $88.41

5 95979 0-20 F 2.59 $27.276 $70.64 $69.23 2.58 $28.0672 $72.41 $72.41

5 95979 21-999 NF 2.59 $27.276 $70.64 $69.23 3.15 $26.7305 $84.20 $84.20

5 95979 21-999 F 2.59 $27.276 $70.64 $69.23 2.58 $26.7305 $68.96 $68.96

5 95980 0-20 1.26 $28.640 $36.09 $35.37 1.36 $28.0672 $38.17 $38.17

5 95981 0-20 NF 0.82 $28.640 $23.48 $23.01 0.99 $28.0672 $27.79 $27.79

5 95981 0-20 F 0.82 $28.640 $23.48 $23.01 0.52 $28.0672 $14.59 $14.59

5 95982 0-20 NF 1.38 $28.640 $39.52 $38.73 1.56 $28.0672 $43.78 $43.78

5 95982 0-20 F 1.38 $28.640 $39.52 $38.73 1.05 $28.0672 $29.47 $29.47


5 96105 0-20 2.63 $27.276 $71.74 $70.31 2.76 $28.0672 $77.47 $77.47

5 96105 21-999 2.63 $27.276 $71.74 $70.31 2.76 $26.7305 $73.78 $73.78

S 96110 0-20 $8.49 $8.32 0.27 $28.0672 $7.58 $7.58

5 96110 0-20 0.25 $27.276 $6.82 $6.68 0.27 $28.0672 $7.58 $7.58

5 96111 0-20 NF 3.60 $27.276 $98.19 $96.23 3.73 $28.0672 $104.69 $104.69

5 96111 0-20 F 3.60 $27.276 $98.19 $96.23 3.52 $28.0672 $98.80 $98.80

5 P9012 0-999 $46.90 $45.96 $45.96 $45.96

I P9012 0-999 $46.90 $45.96 $45.96 $45.96

5 Q3031 0-20 $27.50 $26.95 $12.07 $12.07

5 Q3031 21-999 $27.50 $26.95 $11.49 $11.49

5 S3625 0-999 $73.12 $71.66 $73.12 $73.12

5 S3626 0-999 $77.51 $75.96 $77.51 $77.51

5 S3722 0-999 $300.00 $294.00 $294.00 $294.00

5 S3800 0-999 $90.37 $88.56 $90.37 $90.37

5 S3833 0-999 $1,768.61 $1,733.24 $2,009.00 $2,009.00

5 S3834 0-999 $385.00 $377.30 $465.50 $465.50

5 S3840 0-999 $256.80 $251.66 $251.66 $251.66

5 S3841 0-999 $816.00 $799.68 $799.68 $799.68

5 S3842 0-999 $477.00 $467.46 $467.46 $467.46

5 S3844 0-999 $258.00 $252.84 $252.84 $252.84

5 S3846 0-999 $355.25 $348.15 $348.15 $348.15

5 S3849 0-999 $138.00 $135.24 $135.24 $135.24

5 S3850 0-999 $253.75 $248.68 $248.68 $248.68

5 S3853 0-999 $90.37 $88.56 $88.56 $88.56

TOS*: 3 = Consultation, 5 = Laboratory, D = Tuberculosis Clinics, I = Professional Component, S = Texas Health Steps, T = Technical Component

Provider Type; 71 = Family Planning Clinic, 75 = Portable X-Ray Supplier, Radiological Laboratory , AB = Tuberculosis Clinic-Individual, AC = Tuberculosis Clinic-Group

Provider Specialty: PATH = Pathology Specialty Pricing, RAD = Radiology Specialty Pricing

Type of

Service

(TOS)* Procedure Code

Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee

1 90284 0-999 $12.00 $12.00 $12.00 $12.00



1 90291 0-999 $23.27 $23.27 $23.28 $23.28

1 90371 0-999 $112.03 $112.03 $95.21 $95.21

1 90375 0-999 $140.17 $137.37 $155.51 $155.51

1 90376 0-999 $149.33 $149.33 $149.33 $149.33

1 90378 0-999 $24.87 $24.37 $27.17 $27.17

1 90460 0-20 $7.84 $7.84 $7.84 $7.84

S 90460 0-20 $7.84 $7.84 $7.84 $7.84

1 90461 0-20 $3.92 $3.92 $3.92 $3.92

S 90461 0-20 $3.92 $3.92 $3.92 $3.92

1 90471 0-20 $7.84 $7.84 $7.84 $7.84

1 90471 21-999 $7.84 $7.84 $7.84 $7.84

S 90471 0-20 $7.84 $7.84 $7.84 $7.84

1 90472 0-20 $7.84 $7.84 $7.84 $7.84

1 90472 21-999 $7.84 $7.84 $7.84 $7.84

S 90472 0-20 $7.84 $7.84 $7.84 $7.84

1 90473 0-20 $7.84 $7.84 $7.84 $7.84

1 90473 21-999 $7.84 $7.84 $7.84 $7.84

S 90473 0-20 $7.84 $7.84 $7.84 $7.84

1 90474 0-20 $7.84 $7.84 $7.84 $7.84

1 90474 21-999 $7.84 $7.84 $7.84 $7.84

S 90474 0-20 $7.84 $7.84 $7.84 $7.84

1 90585 0-999 $107.28 $107.28 $107.28 $107.28

1 90586 0-999 $111.33 $111.33 $111.33 $111.33

1 90632 19-20 $44.41 $44.41 $44.41 $44.41

1 90632 21-999 $44.41 $44.41 $44.41 $44.41

S 90632 19-20 $44.41 $44.41 $44.41 $44.41

1 90633 19-20 $30.12 $30.12 $30.12 $30.12

S 90633 19-20 $30.12 $30.12 $30.12 $30.12

1 90636 19-20 $94.31 $94.31 $97.10 $97.10

1 90636 21-999 $94.31 $94.31 $97.10 $97.10

S 90636 19-20 $94.31 $94.31 $97.10 $97.10

1 90648 19-20 $23.90 $23.90 $23.90 $23.90

S 90648 19-20 $23.90 $23.90 $23.90 $23.90

1 90649 19-20 $137.27 $137.27 $147.69 $147.69

1 90649 21-26 $137.27 $137.27 $147.69 $147.69

S 90649 19-20 $137.27 $137.27 $147.69 $147.69

1 90650 19-26 $135.38 $135.38 $135.38 $135.38

1 90650 9-18 $135.38 $135.38 $135.38 $135.38

1 90650 9-18 $135.38 $135.38 $135.38 $135.38

S 90650 19-20 $135.38 $135.38 $135.38 $135.38

S 90650 9-18 $135.38 $135.38 $135.38 $135.38

S 90650 9-18 $135.38 $135.38 $135.38 $135.38

1 90654 19-999 $14.15 $13.87 $14.24 $14.24

S 90654 19-999 $14.15 $13.87 $14.24 $14.24

1 90656 0-999 $11.57 $11.57 $11.57 $11.57

1 90656 0-999 $11.57 $11.57 $11.57 $11.57

1 90656 19-20 $11.57 $11.57 $11.57 $11.57

S 90656 19-20 $11.57 $11.57 $11.57 $11.57

1 90658 19-20 $16.22 $16.22 $16.22 $16.22

1 90658 21-999 $16.22 $16.22 $16.22 $16.22

S 90658 19-20 $16.22 $16.22 $16.22 $16.22

1 90660 19-20 $20.60 $20.60 $20.60 $20.60

PHYSICIAN ADMINISTERED DRUGS - NON-ONCOLOGY

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


S 90660 19-20 $20.60 $20.60 $20.60 $20.60

1 90675 0-999 $177.64 $177.64 $177.64 $177.64

1 90680 19-20 $76.01 $76.01 $81.62 $81.62

S 90680 19-20 $76.01 $76.01 $81.62 $81.62

1 90681 0-999 $107.75 $107.75 $107.75 $107.75

1 90681 19-20 $107.75 $107.75 $107.75 $107.75

S 90681 0-999 $107.75 $107.75 $107.75 $107.75

S 90681 19-20 $107.75 $107.75 $107.75 $107.75

1 90696 19-20 $49.99 $49.99 $50.00 $50.00

S 90696 19-20 $49.99 $49.99 $50.00 $50.00

1 90703 19-20 $24.76 $24.26 $26.01 $26.01

1 90703 21-999 $24.76 $24.26 $26.01 $26.01

S 90703 19-20 $24.76 $24.26 $26.01 $26.01

1 90704 19-20 $23.28 $23.28 Not a Benefit Not a Benefit

S 90704 19-20 $23.28 $23.28 Not a Benefit Not a Benefit





1 90707 19-20 $52.44 $52.44 $56.81 $56.81

1 90707 21-999 $52.44 $52.44 $56.81 $56.81

S 90707 19-20 $52.44 $52.44 $56.81 $56.81

1 90710 19-20 $148.93 $145.95 $155.26 $155.26

S 90710 19-20 $148.93 $145.95 $155.26 $155.26

1 90713 19-20 $28.50 $27.93 $27.93 $27.93

S 90713 19-20 $28.50 $27.93 $27.93 $27.93

1 90714 19-20 $18.37 $18.37 $18.37 $18.37

1 90714 21-999 $18.37 $18.37 $18.37 $18.37

S 90714 19-20 $18.37 $18.37 $18.37 $18.37

1 90715 19-20 $33.13 $33.13 $33.13 $33.13

1 90715 21-999 $33.13 $33.13 $33.13 $33.13

S 90715 19-20 $33.13 $33.13 $33.13 $33.13

1 90716 19-20 $97.98 $96.02 $103.30 $103.30

S 90716 19-20 $97.98 $96.02 $103.30 $103.30

1 90718 19-20 $15.26 $14.95 $15.27 $15.27

1 90718 21-999 $15.26 $14.95 $15.27 $15.27

S 90718 19-20 $15.26 $14.95 $15.27 $15.27

1 90721 19-20 $50.64 $49.63 $49.63 $49.63

S 90721 19-20 $50.64 $49.63 $49.63 $49.63

1 90723 19-20 $73.78 $73.78 $73.78 $73.78

S 90723 19-20 $73.78 $73.78 $73.78 $73.78

1 90732 19-20 $50.65 $49.64 $49.64 $49.64

1 90732 21-999 $50.65 $49.64 $49.64 $49.64

S 90732 19-20 $50.65 $49.64 $49.64 $49.64

1 90733 19-20 $101.34 $101.34 $101.34 $101.34

S 90733 19-20 $101.34 $101.34 $101.34 $101.34

1 90734 19-20 $117.64 $115.29 $115.29 $115.29

S 90734 19-20 $117.64 $115.29 $115.29 $115.29

1 90740 19-20 $110.25 $110.25 $110.25 $110.25

1 90740 21-999 $110.25 $110.25 $110.25 $110.25


1 90743 19-20 $22.35 $22.35 $22.35 $22.35

S 90743 19-20 $22.35 $22.35 $22.35 $22.35

1 90744 19-20 $22.36 $22.36 $22.36 $22.36

S 90744 19-20 $22.36 $22.36 $22.36 $22.36

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 90746 19-20 $55.13 $55.13 $55.13 $55.13

1 90746 21-999 $55.13 $55.13 $55.13 $55.13

S 90746 19-20 $55.13 $55.13 $55.13 $55.13

1 90747 19-20 $110.25 $110.25 $110.25 $110.25

1 90747 21-999 $110.25 $110.25 $110.25 $110.25


1 90748 19-20 $45.84 $45.84 $45.58 $45.58

S 90748 19-20 $45.84 $45.84 $45.58 $45.58

1 C9250 0-999 $225.30 $220.79 $209.75 $209.75

1 C9254 0-999 $0.22 $0.22 $0.21 $0.21

1 C9257 0-999 $1.69 $1.66 $1.60 $1.60

1 C9275 0-999 $610.81 $610.81 $610.81 $610.81

1 C9279 0-999 $1.92 $1.92 $1.92 $1.92

1 C9286 0-999 $3.96 $3.96 $3.69 $3.69

1 C9287 0-999 $96.66 $96.66 $93.49 $93.49

1 C9288 0-999 $3,644.38 $3,644.38 $3,644.38 $3,644.38

9 C9359 0-999 $94.35 $92.46 $109.33 $109.33

9 C9359 0-999 $94.35 $92.46 $109.33 $109.33

9 C9360 0-999 $11.34 $11.11 $11.11 $11.11

9 C9360 0-999 $11.34 $11.11 $11.11 $11.11

9 C9360 0-999 $11.34 $11.11 $11.11 $11.11

9 C9361 0-999 $295.80 $289.88 $317.17 $317.17

9 C9361 0-999 $295.80 $289.88 $317.17 $317.17

9 C9361 0-999 $295.80 $289.88 $317.17 $317.17

9 C9362 0-999 $94.35 $92.46 $109.33 $109.33

9 C9362 0-999 $94.35 $92.46 $109.33 $109.33

9 C9362 0-999 $94.35 $92.46 $109.33 $109.33

1 C9366 0-999 $403.31 $403.31 $411.71 $411.71

9 C9367 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

1 G9018 0-999 $5.90 $5.90 $5.90 $5.90

1 G9019 0-999 $9.31 $9.12 $10.14 $10.14

1 J0120 0-999 $1.25 $1.25 $1.25 $1.25

1 J0130 0-999 $453.57 $453.57 $453.57 $453.57

1 J0131 0-999 $2.63 $2.63 $0.12 $0.12

1 J0132 0-999 $2.39 $2.39 $2.39 $2.39

1 J0133 0-999 $0.02 $0.02 $0.03 $0.03

1 J0135 0-999 $323.35 $323.35 $342.28 $342.28

1 J0150 0-999 $5.94 $5.94 $5.94 $5.94

1 J0152 0-999 $81.07 $81.07 $82.05 $82.05

1 J0180 0-999 $133.49 $133.49 $133.49 $133.49

1 J0190 0-999 $2.92 $2.92 $2.92 $2.92

1 J0205 0-999 $41.14 $41.14 $41.14 $41.14

1 J0210 0-999 $35.60 $35.60 $35.60 $35.60

1 J0215 0-999 $30.02 $30.02 $31.23 $31.23

1 J0220 0-999 $154.94 $154.94 $154.94 $154.94

1 J0221 0-999 $142.80 $142.80 $142.80 $142.80

1 J0256 0-999 $3.69 $3.69 $3.69 $3.69

1 J0257 0-999 $4.58 $4.58 $3.84 $3.84

1 J0278 0-999 $0.57 $0.57 $0.60 $0.60

D J0278 0-999 $0.57 $0.57 $0.60 $0.60

1 J0280 0-999 $0.37 $0.36 $0.45 $0.45

1 J0282 0-999 $0.28 $0.28 $0.28 $0.28

1 J0285 0-999 $9.49 $9.49 $9.49 $9.49

1 J0287 0-999 $10.23 $10.03 $10.03 $10.03

1 J0288 0-999 $13.72 $13.72 $13.72 $13.72

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 J0289 0-999 $14.58 $14.29 $14.29 $14.29

1 J0290 0-999 $2.13 $2.09 $1.59 $1.59

1 J0295 0-999 $2.29 $2.24 $2.24 $2.24

1 J0300 0-999 $127.55 $125.00 $143.75 $143.75

1 J0330 0-999 $0.17 $0.17 $0.28 $0.28

1 J0348 0-999 $1.04 $1.02 $1.02 $1.02

1 J0360 0-999 $3.81 $3.73 $3.73 $3.73

1 J0364 0-999 $4.31 $4.22 $24.57 $24.57

1 J0380 0-999 $1.20 $1.20 $1.20 $1.20

1 J0390 0-999 $15.55 $15.55 $15.55 $15.55

1 J0395 0-999 $19.76 $19.76 $19.76 $19.76

1 J0400 0-999 $0.32 $0.32 $0.35 $0.35

1 J0456 0-999 $3.90 $3.90 $3.90 $3.90

1 J0470 0-999 $27.01 $27.01 $27.01 $27.01

1 J0475 0-999 $183.42 $179.75 $179.75 $179.75

1 J0476 0-999 $74.72 $74.72 $74.72 $74.72

1 J0480 0-999 $2,183.17 $2,183.17 $2,183.17 $2,183.17

1 J0490 0-999 $38.32 $37.55 $37.55 $37.55

1 J0500 0-999 $22.08 $21.64 $24.00 $24.00

1 J0515 0-999 $25.29 $25.29 $25.29 $25.29

1 J0520 0-999 $4.93 $4.93 $4.93 $4.93

1 J0558 0-999 $3.16 $3.16 $3.16 $3.16

1 J0561 0-999 $3.99 $3.99 $3.99 $3.99

1 J0583 0-999 $2.36 $2.36 $2.36 $2.36

1 J0585 0-999 $5.37 $5.37 $5.37 $5.37

1 J0586 0-999 $7.22 $7.08 $6.81 $6.81

1 J0587 0-999 $10.13 $10.13 $10.13 $10.13

1 J0588 0-999 $4.47 $4.38 $4.38 $4.38

1 J0592 0-999 $0.71 $0.71 $0.71 $0.71

1 J0594 0-999 $14.69 $14.40 $16.43 $16.43

1 J0595 0-999 $0.84 $0.84 $0.84 $0.84

1 J0598 0-999 $40.51 $40.51 $40.51 $40.51

1 J0620 0-999 $12.83 $12.83 $12.83 $12.83

1 J0636 0-999 $0.43 $0.42 $0.39 $0.39

1 J0637 0-999 $11.36 $11.36 $11.36 $11.36

1 J0638 0-999 $87.36 $87.36 $87.36 $87.36

1 J0670 0-999 $3.91 $3.83 $1.19 $1.19

1 J0690 0-999 $0.55 $0.55 $0.56 $0.56

1 J0694 0-999 $4.72 $4.63 $4.63 $4.63

1 J0697 0-999 $2.16 $2.16 $2.85 $2.85

1 J0698 0-999 $1.71 $1.71 $1.71 $1.71

1 J0702 0-999 $5.42 $5.42 $5.42 $5.42

1 J0706 0-999 $0.34 $0.33 $0.36 $0.36

1 J0710 0-999 $1.44 $1.44 $1.44 $1.44

1 J0715 0-999 $5.14 $5.14 $5.14 $5.14

1 J0718 0-999 $3.70 $3.70 $3.70 $3.70

1 J0720 0-999 $17.22 $17.22 $17.22 $17.22

1 J0725 0-999 $9.34 $9.15 $9.57 $9.57

1 J0735 0-999 $21.43 $21.00 $21.00 $21.00

1 J0740 0-999 $739.24 $739.24 $739.24 $739.24

1 J0745 0-999 $1.32 $1.32 $1.32 $1.32

1 J0760 0-999 $6.44 $6.44 $6.44 $6.44

1 J0770 0-999 $12.09 $11.85 $11.35 $11.35

1 J0775 0-999 $36.76 $36.76 $36.76 $36.76

1 J0795 0-999 $4.40 $4.40 $4.40 $4.40

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 J0800 0-999 $2,392.41 $2,392.41 $2,392.41 $2,392.41

1 J0833 0-999 $95.88 $95.88 $95.88 $95.88

1 J0834 0-999 $67.65 $67.65 $67.65 $67.65

1 J0840 0-999 $1,689.12 $1,655.34 $1,655.34 $1,655.34

1 J0850 0-999 $861.25 $861.25 $861.25 $861.25

1 J0878 0-999 $0.42 $0.42 $0.42 $0.42

1 J0882 0-999 $2.82 $2.82 $2.82 $2.82

1 J0886 0-999 $9.25 $9.25 $9.25 $9.25

1 J0945 0-999 $0.83 $0.83 $0.83 $0.83

1 J1020 0-999 $2.44 $2.39 $2.39 $2.39

1 J1060 0-999 $4.06 $4.06 $4.06 $4.06

1 J1070 0-999 $3.26 $3.26 $3.97 $3.97

1 J1094 0-999 $0.24 $0.24 $0.24 $0.24

1 J1110 0-999 $22.08 $22.08 $25.06 $25.06

1 J1160 0-999 $1.68 $1.65 $3.47 $3.47

1 J1162 0-999 $603.28 $591.21 $674.73 $674.73

1 J1165 0-999 $0.31 $0.31 $0.31 $0.31

1 J1205 0-999 $272.32 $272.32 $253.96 $253.96

1 J1212 0-999 $70.70 $70.70 $70.70 $70.70

1 J1230 0-999 $6.97 $6.83 $6.83 $6.83

1 J1240 0-999 $3.42 $3.42 $3.42 $3.42

1 J1245 0-999 $0.81 $0.81 $0.81 $0.81

1 J1250 0-999 $4.38 $4.38 $4.65 $4.65

1 J1265 0-999 $0.46 $0.46 $0.39 $0.39

1 J1265 0-999 $0.46 $0.46 $0.39 $0.39

1 J1265 0-999 $0.46 $0.46 $0.39 $0.39

1 J1267 0-999 $0.51 $0.50 $0.44 $0.44

1 J1270 0-999 $0.67 $0.66 $0.71 $0.71

1 J1324 0-999 $0.51 $0.50 $0.50 $0.50

1 J1325 0-999 $11.67 $11.67 $11.67 $11.67

1 J1327 0-999 $18.62 $18.62 $18.62 $18.62

1 J1330 0-999 $4.87 $4.77 $7.87 $7.87

1 J1335 0-999 $10.49 $10.49 $22.80 $22.80

1 J1364 0-999 $7.92 $7.76 $8.69 $8.69

1 J1380 0-999 $7.35 $7.35 $7.35 $7.35

1 J1430 0-999 $230.95 $226.33 $226.33 $226.33

1 J1435 0-999 $0.25 $0.25 $0.25 $0.25

1 J1436 0-999 $58.77 $58.77 $58.77 $58.77

1 J1438 0-999 $187.73 $187.73 $187.73 $187.73

1 J1450 0-999 $4.34 $4.34 $4.34 $4.34

1 J1451 0-999 $6.75 $6.75 $6.38 $6.38

1 J1455 0-999 $10.17 $10.17 $3.43 $3.43

1 J1457 0-999 $1.99 $1.99 $1.99 $1.99

1 J1458 0-999 $331.62 $331.62 $331.62 $331.62

1 J1460 0-999 $16.61 $16.28 $17.50 $17.50

1 J1557 0-999 $37.29 $36.54 $36.54 $36.54

1 J1559 0-999 $7.13 $7.13 $7.13 $7.13

1 J1560 0-999 $166.10 $162.78 $175.03 $175.03

1 J1570 0-999 $58.27 $57.10 $57.10 $57.10

1 J1571 0-999 $48.16 $47.20 $47.20 $47.20

1 J1573 0-999 $48.16 $47.20 $47.20 $47.20

1 J1580 0-999 $0.96 $0.94 $0.97 $0.97

1 J1590 0-999 $0.78 $0.78 $0.78 $0.78

1 J1595 0-999 $133.08 $130.42 $139.60 $139.60

1 J1599 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 J1600 0-999 $19.28 $18.89 $18.89 $18.89

1 J1610 0-999 $85.29 $83.58 $83.58 $83.58

1 J1620 0-999 $176.69 $176.69 $176.69 $176.69

1 J1631 0-999 $13.62 $13.35 $14.64 $14.64

1 J1640 0-20 $8.28 $8.28 $9.95 $9.95

1 J1655 0-20 $4.46 $4.37 $4.37 $4.37

1 J1670 0-999 $193.75 $189.88 $207.20 $207.20

1 J1680 0-999 $0.09 $0.09 $0.09 $0.09

1 J1700 0-999 $0.30 $0.30 $0.30 $0.30

1 J1710 0-999 $4.90 $4.90 $4.90 $4.90

1 J1725 0-999 $2.82 $2.76 $2.76 $2.76

1 J1730 0-999 $109.61 $109.61 $109.61 $109.61

1 J1742 0-999 $147.60 $144.65 $136.46 $136.46

1 J1743 0-999 $445.93 $445.93 $445.93 $445.93

1 J1786 0-999 $41.15 $41.15 $41.15 $41.15

1 J1800 0-999 $2.53 $2.53 $2.58 $2.58

1 J1826 0-999 $902.70 $884.65 $935.88 $935.88

1 J1830 0-999 $185.23 $181.53 $193.15 $193.15

1 J1840 0-999 $7.54 $7.54 $7.54 $7.54

D J1840 0-999 $7.54 $7.54 $7.54 $7.54

1 J1850 0-999 $1.13 $1.13 $1.13 $1.13

1 J1885 0-999 $0.23 $0.23 $0.23 $0.23

1 J1890 0-999 $9.51 $9.51 $9.51 $9.51

1 J1930 0-999 $28.72 $28.72 $28.72 $28.72

1 J1931 0-999 $25.05 $25.05 $25.05 $25.05

1 J1945 0-999 $305.58 $299.47 $413.82 $413.82

1 J1950 0-999 $505.77 $505.77 $505.77 $505.77

1 J1953 0-999 $0.26 $0.25 $0.25 $0.25

1 J1955 0-20 $6.23 $6.11 $6.11 $6.11

1 J1955 21-999 $6.23 $6.11 $6.11 $6.11

D J1956 0-999 $3.99 $3.91 $3.71 $3.71

1 J1960 0-999 $3.30 $3.30 $3.30 $3.30

1 J1980 0-999 $11.08 $10.86 $11.05 $11.05

1 J1990 0-999 $20.63 $20.63 $20.63 $20.63

1 J2010 0-999 $5.06 $5.06 $5.29 $5.29

D J2020 0-999 $31.93 $31.93 $31.93 $31.93

1 J2180 0-999 $3.71 $3.71 $3.71 $3.71

1 J2185 0-999 $1.72 $1.69 $1.39 $1.39

1 J2210 0-999 $5.27 $5.16 $3.72 $3.72

1 J2248 0-999 $0.96 $0.94 $0.92 $0.92

1 J2260 0-999 $4.50 $4.41 $3.65 $3.65

1 J2271 0-999 $1.43 $1.40 $1.18 $1.18

1 J2278 0-999 $6.28 $6.28 $6.28 $6.28

D J2280 0-999 $2.84 $2.84 $3.06 $3.06

1 J2300 0-999 $0.88 $0.88 $0.88 $0.88

1 J2315 0-999 $2.35 $2.35 $2.35 $2.35

1 J2320 0-999 $3.68 $3.68 $3.68 $3.68

1 J2325 0-999 $37.60 $37.60 $38.86 $38.86

1 J2357 0-999 $19.38 $19.38 $19.38 $19.38

1 J2358 0-999 $2.70 $2.70 $2.70 $2.70

1 J2360 0-999 $6.70 $6.57 $6.35 $6.35

1 J2370 0-999 $0.88 $0.86 $0.41 $0.41

1 J2400 0-999 $12.01 $12.01 $18.24 $18.24

1 J2410 0-999 $2.17 $2.17 $2.17 $2.17

1 J2425 0-999 $11.10 $11.10 $11.10 $11.10

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 J2426 0-999 $6.38 $6.38 $6.38 $6.38

1 J2440 0-999 $0.97 $0.95 $0.95 $0.95

1 J2460 0-999 $0.92 $0.92 $0.92 $0.92

1 J2501 0-999 $1.93 $1.93 $1.71 $1.71

1 J2503 0-999 $1,001.05 $1,001.05 $1,001.05 $1,001.05

1 J2504 0-999 $242.38 $242.38 $242.38 $242.38

1 J2507 0-999 $293.25 $287.39 $287.39 $287.39

1 J2510 0-999 $10.67 $10.67 $10.67 $10.67

1 J2515 0-999 $16.43 $16.43 $19.77 $19.77

1 J2540 0-999 $0.66 $0.66 $0.59 $0.59

1 J2543 0-999 $2.97 $2.97 $2.49 $2.49

1 J2560 0-999 $14.84 $14.84 $14.84 $14.84

1 J2562 0-999 $263.35 $263.35 $263.35 $263.35

1 J2590 0-999 $0.52 $0.52 $0.52 $0.52

1 J2650 0-999 $0.18 $0.18 $0.18 $0.18

1 J2670 0-999 $2.13 $2.13 $2.13 $2.13

1 J2675 0-999 $2.72 $2.72 $1.55 $1.55

1 J2680 0-999 $11.31 $11.08 $11.63 $11.63

1 J2690 0-999 $7.47 $7.32 $9.46 $9.46

1 J2700 0-999 $2.17 $2.13 $2.13 $2.13

1 J2710 0-999 $0.35 $0.34 $0.42 $0.42

1 J2720 0-999 $0.51 $0.50 $0.50 $0.50

1 J2724 0-999 $13.11 $12.85 $12.85 $12.85

1 J2730 0-999 $84.79 $83.09 $83.09 $83.09

1 J2760 0-999 $53.69 $53.69 $53.69 $53.69

1 J2770 0-999 $144.13 $144.13 $144.13 $144.13

1 J2778 0-999 $396.61 $396.61 $396.61 $396.61

1 J2785 0-999 $49.72 $49.72 $49.72 $49.72

1 J2788 0-999 $21.50 $21.50 $21.50 $21.50

1 J2790 0-999 $75.92 $75.92 $75.92 $75.92

1 J2791 0-999 $5.08 $5.08 $5.08 $5.08

1 J2793 0-999 $22.72 $22.72 $22.72 $22.72

1 J2794 0-999 $4.95 $4.95 $4.95 $4.95

1 J2795 0-999 $0.04 $0.04 $0.06 $0.06

1 J2800 0-999 $25.86 $25.86 $27.83 $27.83

1 J2805 0-20 $71.30 $71.30 $65.67 $65.67

1 J2810 0-999 $0.19 $0.19 $0.19 $0.19

1 J2850 0-20 $21.17 $20.75 $20.75 $20.75

1 J2950 0-999 $0.37 $0.37 $0.37 $0.37

1 J2993 0-999 $1,772.46 $1,737.01 $1,737.01 $1,737.01

1 J3000 0-999 $8.26 $8.09 $8.51 $8.51

D J3000 0-999 $8.26 $8.09 $8.51 $8.51

1 J3030 0-999 $57.47 $57.47 $50.85 $50.85

1 J3070 0-999 $10.54 $10.33 $14.71 $14.71

1 J3101 0-999 $51.00 $49.98 $49.98 $49.98

1 J3105 0-999 $4.35 $4.26 $4.26 $4.26

1 J3110 0-999 $18.60 $18.23 $19.87 $19.87

1 J3120 0-999 $3.65 $3.58 $3.58 $3.58

1 J3140 0-999 $0.35 $0.35 $0.35 $0.35

1 J3150 0-999 $0.70 $0.70 $0.70 $0.70

1 J3230 0-999 $8.42 $8.42 $18.81 $18.81

1 J3243 0-999 $1.15 $1.15 $1.15 $1.15

1 J3246 0-999 $7.24 $7.24 $7.24 $7.24

1 J3250 0-999 $4.44 $4.44 $7.83 $7.83

1 J3260 0-999 $2.01 $1.97 $2.07 $2.07

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 J3262 0-999 $3.40 $3.40 $3.40 $3.40

1 J3265 0-999 $3.80 $3.80 $3.80 $3.80

1 J3280 0-999 $4.96 $4.96 $4.96 $4.96

1 J3285 0-999 $54.77 $54.77 $54.77 $54.77

1 J3300 0-999 $3.16 $3.16 $3.16 $3.16

1 J3301 0-999 $1.52 $1.52 $1.52 $1.52

1 J3302 0-999 $0.27 $0.27 $0.27 $0.27

1 J3303 0-999 $1.32 $1.29 $1.29 $1.29

1 J3305 0-999 $142.16 $142.16 $142.16 $142.16

1 J3310 0-999 $6.05 $6.05 $6.05 $6.05

1 J3320 0-999 $30.95 $30.95 $30.95 $30.95

1 J3350 0-999 $0.83 $0.83 $0.83 $0.83

1 J3357 0-999 $105.28 $105.28 $105.28 $105.28

1 J3364 0-999 $8.97 $8.97 $8.97 $8.97

1 J3385 0-999 $343.58 $343.58 $343.58 $343.58

1 J3396 0-999 $9.31 $9.31 $9.31 $9.31

1 J3400 0-999 $10.94 $10.94 $10.94 $10.94

1 J3410 0-999 $1.07 $1.07 $1.08 $1.08

1 J3411 0-999 $3.07 $3.07 $3.07 $3.07

1 J3415 0-999 $6.21 $6.21 $6.21 $6.21

1 J3465 0-999 $5.70 $5.70 $5.70 $5.70

1 J3471 0-999 $0.17 $0.17 $0.18 $0.18

1 J3472 0-999 $135.36 $135.36 $264.15 $264.15

1 J3473 0-999 $0.59 $0.59 $0.33 $0.33

1 J3485 0-999 $1.28 $1.28 $1.28 $1.28

1 J3486 0-20 $6.29 $6.29 $6.57 $6.57

1 J3486 21-999 $6.29 $6.29 $6.57 $6.57

1 J3490 0-999 $24.50 $24.50 $24.50 $24.50

1 J3520 0-999 $0.96 $0.94 $1.24 $1.24



1 J7030 0-20 $0.86 $0.86 $0.86 $0.86

1 J7120 0-20 $1.02 $1.02 $1.02 $1.02

1 J7180 0-999 $8.38 $8.38 $6.50 $6.50

1 J7183 0-999 $0.88 $0.86 $0.86 $0.86

1 J7185 0-999 $1.05 $1.05 $1.05 $1.05

1 J7186 0-999 $0.89 $0.89 $0.89 $0.89

1 J7189 0-999 $1.33 $1.33 $1.33 $1.33

1 J7191 0-999 $1.09 $1.09 $1.09 $1.09

1 J7193 0-999 $0.88 $0.88 $0.88 $0.88

1 J7194 0-999 $0.85 $0.85 $0.85 $0.85

1 J7197 0-999 $2.26 $2.26 $2.28 $2.28

1 J7198 0-999 $1.52 $1.52 $1.52 $1.52


1 J7308 0-20 $133.69 $133.69 $133.69 $133.69

1 J7311 0-999 $18,958.10 $18,958.10 $18,958.10 $18,958.10

1 J7312 0-999 $185.00 $185.00 $185.00 $185.00

1 J7321 0-999 $88.95 $88.95 $88.95 $88.95

1 J7323 0-999 $111.51 $111.51 $113.32 $113.32

1 J7324 0-999 $165.66 $165.66 $165.66 $165.66

1 J7325 0-999 $11.51 $11.51 $11.51 $11.51

1 J7326 0-999 $153.51 $153.51 $461.18 $461.18

1 J7335 0-999 $25.04 $25.04 $25.04 $25.04

1 J7501 0-999 $94.36 $94.36 $108.47 $108.47

1 J7504 0-999 $478.12 $478.12 $484.58 $484.58

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 J7505 0-999 $1,110.50 $1,110.50 $1,110.50 $1,110.50

1 J7511 0-999 $378.76 $378.76 $378.76 $378.76

1 J7513 0-999 $397.17 $397.17 $397.17 $397.17

1 J7516 0-999 $25.69 $25.69 $25.69 $25.69

1 J7525 0-999 $136.62 $136.62 $136.62 $136.62


1 J7605 0-999 $5.01 $5.01 $5.01 $5.01

1 J7608 0-999 $2.40 $2.40 $2.13 $2.13

1 J7611 0-999 $0.08 $0.08 $0.08 $0.08

1 J7612 0-999 $0.16 $0.16 $0.21 $0.21

1 J7613 0-999 $0.06 $0.06 $0.05 $0.05

1 J7614 0-999 $0.22 $0.22 $0.22 $0.22

1 J7620 0-999 $0.23 $0.23 $0.21 $0.21

1 J7622 0-999 $72.46 $72.46 $112.13 $112.13

1 J7626 0-999 $4.07 $4.07 $4.07 $4.07

1 J7631 0-999 $0.35 $0.35 $0.40 $0.40

1 J7633 0-999 $6.22 $6.22 $7.19 $7.19

1 J7639 0-999 $23.41 $23.41 $23.41 $23.41

1 J7644 0-999 $0.24 $0.24 $0.24 $0.24

1 J7665 0-999 $0.56 $0.56 $0.56 $0.56

1 J7674 0-999 $0.45 $0.45 $0.45 $0.45

1 J7682 0-999 $67.87 $67.87 $69.34 $69.34




1 J9027 0-999 $114.02 $114.02 $114.02 $114.02


1 J9175 0-20 $3.99 $3.99 $3.99 $3.99

1 J9212 0-999 $16.41 $16.08 $16.08 $16.08

1 J9213 0-999 $37.06 $37.06 $37.06 $37.06

1 J9215 0-999 $30.72 $30.11 $30.11 $30.11

1 J9216 0-999 $570.81 $559.39 $395.34 $395.34

1 J9219 0-999 $4,723.42 $4,723.42 $4,723.42 $4,723.42

1 J9225 0-999 $2,859.43 $2,859.43 $2,859.43 $2,859.43

1 J9226 0-999 $14,690.63 $14,690.63 $14,690.63 $14,690.63

1 J9228 0-999 $128.88 $128.88 $122.66 $122.66

1 J9260 0-999 $1.65 $1.65 $1.65 $1.65

1 J9261 0-999 $103.79 $103.79 $103.79 $103.79

1 J9328 0-999 $4.79 $4.79 $4.79 $4.79

1 J9600 0-999 $18,976.03 $18,596.51 $18,596.51 $18,596.51


1 Q0139 0-999 $0.64 $0.63 $0.63 $0.63

1 Q0163 0-20 $0.02 $0.02 $0.02 $0.02

1 Q0164 0-20 $0.06 $0.06 $0.05 $0.05

1 Q0165 0-20 $0.05 $0.05 $0.05 $0.05

1 Q0166 0-20 $0.97 $0.95 $1.23 $1.23

1 Q0167 0-20 $4.89 $4.79 $3.51 $3.51

1 Q0168 0-20 $12.91 $12.91 $7.14 $7.14

1 Q0169 0-20 $0.09 $0.09 $0.08 $0.08

1 Q0170 0-20 $0.06 $0.06 $0.03 $0.03

1 Q0171 0-20 $0.58 $0.58 $0.59 $0.59

1 Q0172 0-20 $0.83 $0.83 $0.83 $0.83

1 Q0173 0-20 $1.87 $1.87 $1.64 $1.64

1 Q0175 0-20 $1.00 $1.00 $1.00 $1.00

1 Q0176 0-20 $1.21 $1.21 $1.21 $1.21

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 Q0177 0-20 $1.59 $1.59 $1.67 $1.67

1 Q0178 0-20 $1.94 $1.94 $2.04 $2.04

1 Q0180 0-20 $65.41 $65.41 $65.41 $65.41

1 Q0181 0-20 Manually Priced Manually Priced Manually Priced Manually Priced

1 Q2009 0-999 $0.45 $0.44 $0.69 $0.69

1 Q2017 0-999 $316.31 $316.31 $316.31 $316.31

1 Q2026 0-999 $16.38 $16.38 $16.39 $16.39

1 Q2027 0-999 $8.00 $8.00 $8.00 $8.00

1 Q2046 0-999 $960.89 $960.89 $960.89 $960.89

1 Q2047 0-999 $11.38 $11.38 $11.38 $11.38

1 Q3025 0-999 $190.05 $190.05 $215.32 $215.32

1 Q3026 0-999 $129.93 $129.93 $138.39 $138.39

1 Q4081 0-999 $0.92 $0.92 $0.92 $0.92

1 Q4081 0-999 $0.92 $0.92 $0.92 $0.92

1 Q4100 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

1 Q4101 0-999 $32.06 $32.06 $32.06 $32.06

1 Q4102 0-999 $5.71 $5.60 $5.83 $5.83

1 Q4103 0-999 $5.71 $5.60 $5.83 $5.83

1 Q4104 0-999 $14.54 $14.54 $15.73 $15.73

1 Q4105 0-999 $9.61 $9.61 $9.61 $9.61

1 Q4106 0-999 $39.30 $39.30 $39.30 $39.30

1 Q4107 0-999 $90.20 $90.20 $90.20 $90.20

1 Q4108 0-999 $20.76 $20.34 $20.34 $20.34

1 Q4110 0-999 $31.49 $30.86 $30.86 $30.86

1 Q4111 0-999 $6.78 $6.78 $6.78 $6.78

1 Q4112 0-999 $163.52 $160.25 $331.65 $331.65

1 Q4113 0-999 $276.34 $270.81 $331.65 $331.65

1 Q4114 0-999 $896.14 $896.14 $896.14 $896.14

1 Q4115 0-999 $13.66 $13.66 $9.99 $9.99

1 Q4116 0-999 $31.08 $31.08 $31.08 $31.08

1 Q4119 0-999 $3.81 $3.81 $3.81 $3.81

1 Q4120 0-999 $3.81 $3.73 $3.81 $3.81

1 Q4121 0-999 $32.87 $32.21 $21.84 $21.84

1 Q4122 0-999 $34.68 $34.68 $33.99 $33.99

1 Q4123 0-999 $8.73 $8.73 $10.03 $10.03

1 Q4124 0-999 $10.74 $10.74 $11.35 $11.35

1 Q4126 0-999 $103.59 $103.59 $105.75 $105.75

1 Q4127 0-999 $10.20 $10.20 $13.53 $13.53

1 Q4128 0-999 $32.86 $32.86 $37.69 $37.69

1 Q4129 0-999 $37.72 $37.72 $37.72 $37.72

1 Q4130 0-999 $32.07 $32.07 $31.43 $31.43

1 Q9956 0-20 $40.08 $40.08 $37.84 $37.84

1 Q9957 0-20 $60.12 $60.12 $56.75 $56.75

1 S0017 0-20 $1.00 $0.98 $0.98 $0.98

1 S0020 0-999 $2.16 $2.12 $2.12 $2.12

1 S0021 0-999 $16.05 $16.05 $16.05 $16.05

1 S0023 0-999 $1.39 $1.36 $1.39 $1.39

1 S0028 0-20 $0.81 $0.79 $0.79 $0.79

1 S0142 0-999 Manually Priced Manually Priced Manually Priced Manually Priced

1 S0145 0-999 $629.23 $616.65 $641.31 $641.31

1 S0148 0-999 $117.26 $114.91 $114.91 $114.91

1 S0164 0-999 $5.10 $5.00 $5.00 $5.00

1 S0166 0-20 $10.42 $10.21 $8.36 $8.36

1 S0189 0-20 $81.81 $80.17 $80.17 $80.17

1 S5010 0-20 $2.08 $2.04 $1.75 $1.75

Type of

Service


Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee


1 S5011 0-20 $1.96 $1.92 $1.75 $1.75

1 S5550 0-20 $0.21 $0.21 $0.35 $0.35

1 S5551 0-20 $0.55 $0.55 $0.69 $0.69

1 S5552 0-20 $0.09 $0.09 $0.04 $0.04

1 S5553 0-20 $0.58 $0.57 $0.68 $0.68

TOS*: 1 = Medical Service, 9 = Durable Medical Equipment, D = TB Clinic, S = THSteps Medical

Type of

Service

(TOS)*

Procedure

Code

Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid Fee

4-1-13

Adjusted Fee

1 C9289 0-999 $381.84 $381.84 $381.84 $381.84

1 J0129 0-999 $21.68 $21.68 $22.19 $22.19

1 J0171 0-999 $0.07 $0.07 $0.07 $0.07

1 J0207 0-999 $323.69 $323.69 $323.69 $323.69

1 J0461 0-999 $0.02 $0.02 $0.03 $0.03

1 J0600 0-999 $191.85 $191.85 $201.40 $201.40

1 J0610 0-999 $0.66 $0.66 $0.66 $0.66

1 J0640 0-999 $2.09 $2.09 $2.56 $2.56

1 J0641 0-999 $1.71 $1.71 $1.91 $1.91

1 J0692 0-999 $3.28 $3.28 $3.28 $3.28

1 J0696 0-999 $0.89 $0.89 $0.89 $0.89

1 J0713 0-999 $2.43 $2.43 $2.62 $2.62

1 J0743 0-999 $11.51 $11.51 $11.51 $11.51

1 J0744 0-999 $1.11 $1.11 $1.11 $1.11

1 J0780 0-999 $2.12 $2.12 $2.12 $2.12

1 J0881 0-999 $3.21 $3.21 $3.32 $3.32

1 J0885 0-999 $9.76 $9.76 $9.87 $9.87

1 J0894 0-999 $33.23 $33.23 $33.40 $33.40

1 J0895 0-999 $16.45 $16.45 $16.45 $16.45

1 J0897 0-999 $14.43 $14.43 $14.43 $14.43

1 J1030 0-999 $3.35 $3.35 $4.03 $4.03

1 J1040 0-999 $7.09 $7.09 $7.09 $7.09

1 J1080 0-999 $6.42 $6.42 $6.42 $6.42

1 J1100 0-999 $0.12 $0.12 $0.12 $0.12

1 J1120 0-999 $30.60 $30.60 $30.60 $30.60

1 J1170 0-999 $1.57 $1.57 $1.66 $1.66

1 J1190 0-999 $218.04 $218.04 $218.04 $218.04

1 J1200 0-999 $0.74 $0.74 $0.90 $0.90

1 J1260 0-999 $5.35 $5.35 $5.35 $5.35

1 J1300 0-999 $195.46 $195.46 $195.46 $195.46

1 J1410 0-999 $115.05 $115.05 $125.45 $125.45

1 J1440 0-999 $260.34 $260.34 $268.91 $268.91

1 J1441 0-999 $414.07 $414.07 $426.87 $426.87

1 J1453 0-999 $1.72 $1.72 $1.72 $1.72

1 J1459 0-999 $35.07 $35.07 $35.14 $35.14

1 J1561 0-999 $37.62 $37.62 $38.28 $38.28

1 J1566 0-999 $31.51 $31.51 $32.21 $32.21

1 J1568 0-999 $56.87 $56.87 $56.87 $56.87

1 J1569 0-999 $40.21 $40.21 $40.21 $40.21

1 J1572 0-999 $35.08 $35.08 $35.08 $35.08

1 J1626 0-999 $1.31 $1.31 $1.31 $1.31

1 J1630 0-999 $3.17 $3.17 $3.17 $3.17

1 J1642 0-999 $0.16 $0.16 $0.17 $0.17

1 J1644 0-999 $0.30 $0.30 $0.30 $0.30

1 J1645 0-999 $11.09 $11.09 $11.09 $11.09

1 J1650 0-999 $6.26 $6.26 $6.26 $6.26

1 J1652 0-999 $6.16 $6.16 $6.16 $6.16

1 J1720 0-999 $4.11 $4.11 $4.28 $4.28

1 J1740 0-999 $151.89 $151.89 $151.89 $151.89

1 J1745 0-999 $63.53 $63.53 $65.18 $65.18

1 J1750 0-999 $12.10 $12.10 $12.10 $12.10

1 J1756 0-999 $0.35 $0.35 $0.35 $0.35

1 J1756 0-999 $0.35 $0.35 $0.35 $0.35

1 J1790 0-999 $3.23 $3.23 $3.32 $3.32

1 J1940 0-999 $0.99 $0.99 $0.99 $0.99

1 J1956 0-999 $5.25 $5.25 $5.25 $5.25

PHYSICIAN ADMINISTERED DRUGS - ONCOLOGY

Type of

Service

(TOS)*

Procedure

Code

Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid Fee

4-1-13

Adjusted Fee


1 J2060 0-999 $0.79 $0.79 $1.34 $1.34

1 J2150 0-999 $1.20 $1.20 $1.47 $1.47

1 J2175 0-999 $0.59 $0.59 $2.16 $2.16

1 J2250 0-20 $0.14 $0.14 $0.16 $0.16

1 J2270 0-999 $0.75 $0.75 $3.39 $3.39

1 J2275 0-999 $4.62 $4.62 $4.62 $4.62

1 J2310 0-999 $10.44 $10.44 $10.44 $10.44

1 J2323 0-999 $11.11 $11.11 $11.59 $11.59

1 J2353 0-999 $123.10 $123.10 $127.00 $127.00

1 J2354 0-999 $1.65 $1.65 $1.65 $1.65

1 J2355 0-999 $244.32 $244.32 $244.32 $244.32

1 J2405 0-999 $0.13 $0.13 $0.22 $0.22

1 J2430 0-999 $12.65 $12.65 $12.65 $12.65

1 J2469 0-999 $18.47 $18.47 $19.02 $19.02

1 J2505 0-999 $2,798.77 $2,798.77 $2,838.89 $2,838.89

1 J2545 0-999 $55.11 $55.11 $60.78 $60.78

1 J2550 0-999 $1.74 $1.74 $1.90 $1.90

1 J2597 0-999 $5.73 $5.73 $6.12 $6.12

1 J2765 0-999 $1.59 $1.59 $1.59 $1.59

1 J2780 0-999 $0.87 $0.87 $1.34 $1.34

1 J2792 0-999 $18.18 $18.18 $18.43 $18.43

1 J2796 0-999 $47.75 $47.75 $48.18 $48.18

1 J2820 0-999 $24.83 $24.83 $31.59 $31.59

1 J2916 0-999 $4.74 $4.74 $4.74 $4.74

1 J2920 0-999 $1.94 $1.94 $2.07 $2.07

1 J2930 0-999 $2.87 $2.87 $2.87 $2.87

1 J2997 0-999 $46.36 $46.36 $49.22 $49.22

1 J3010 0-999 $0.74 $0.74 $0.80 $0.80

1 J3130 0-999 $9.48 $9.48 $9.48 $9.48

1 J3240 0-999 $1,053.30 $1,053.30 $1,053.79 $1,053.79

1 J3315 0-999 $193.77 $193.77 $193.77 $193.77

1 J3360 0-999 $1.02 $1.02 $1.42 $1.42

1 J3365 0-999 $457.73 $457.73 $457.73 $457.73

1 J3370 0-999 $2.94 $2.94 $2.94 $2.94

1 J3420 0-999 $0.66 $0.66 $0.66 $0.66

1 J3430 0-999 $1.49 $1.49 $1.49 $1.49

1 J3470 0-999 $21.20 $21.20 $21.20 $21.20

1 J3475 0-999 $0.10 $0.10 $0.12 $0.12

1 J3480 0-999 $0.02 $0.02 $0.02 $0.02

1 J3487 0-999 $226.83 $226.83 $226.83 $226.83

1 J3488 0-999 $222.64 $222.64 $224.75 $224.75

1 J3490 0-999 $5.01 $5.01 $5.01 $5.01

1 J7040 0-20 $0.57 $0.57 $0.57 $0.57

1 J7042 0-20 $0.36 $0.36 $0.36 $0.36

1 J7050 0-20 $0.29 $0.29 $0.29 $0.29

1 J7060 0-20 $1.09 $1.09 $1.09 $1.09

1 J7070 0-20 $2.18 $2.18 $2.18 $2.18

1 J7187 0-999 $0.89 $0.89 $0.90 $0.90

1 J7190 0-999 $0.90 $0.90 $0.90 $0.90

1 J7192 0-999 $1.11 $1.11 $1.11 $1.11

1 J7195 0-999 $1.19 $1.19 $1.24 $1.24

1 J9000 0-999 $3.88 $3.88 $3.88 $3.88

1 J9001 0-999 $414.19 $414.19 $414.19 $414.19

1 J9010 0-999 $589.08 $589.08 $589.08 $589.08

1 J9015 0-999 $1,097.99 $1,097.99 $1,246.98 $1,246.98

1 J9017 0-20 $40.84 $40.84 $44.99 $44.99

Type of

Service

(TOS)*

Procedure

Code

Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid Fee

4-1-13

Adjusted Fee


1 J9020 0-999 $63.27 $63.27 $63.27 $63.27

1 J9025 0-999 $5.39 $5.39 $5.52 $5.52

1 J9031 0-999 $119.88 $119.88 $119.88 $119.88

1 J9033 0-999 $18.81 $18.81 $20.61 $20.61

1 J9035 0-999 $61.09 $61.09 $62.32 $62.32

1 J9040 0-999 $304.60 $304.60 $304.60 $304.60

1 J9041 0-999 $42.46 $42.46 $43.47 $43.47

1 J9043 0-999 $138.50 $138.50 $138.50 $138.50

1 J9045 0-999 $4.21 $4.21 $4.21 $4.21

1 J9050 0-999 $175.80 $175.80 $175.80 $175.80

1 J9055 0-999 $50.46 $50.46 $51.09 $51.09

1 J9060 0-999 $1.80 $1.80 $1.90 $1.90

1 J9065 0-999 $64.97 $64.97 $64.97 $64.97

1 J9070 0-999 $14.96 $14.96 $23.48 $23.48

1 J9098 0-20 $513.17 $513.17 $523.87 $523.87

1 J9100 0-999 $8.62 $8.62 $8.62 $8.62

1 J9120 0-999 $578.75 $578.75 $578.93 $578.93

1 J9130 0-999 $3.61 $3.61 $3.61 $3.61

1 J9150 0-999 $17.64 $17.64 $19.19 $19.19

1 J9151 0-999 $57.66 $57.66 $65.28 $65.28

1 J9155 0-999 $2.96 $2.96 $2.99 $2.99

1 J9160 0-999 $1,646.18 $1,646.18 $1,646.18 $1,646.18

1 J9171 0-999 $17.27 $17.27 $17.27 $17.27

1 J9178 0-999 $1.73 $1.73 $1.73 $1.73

1 J9179 0-999 $91.04 $91.04 $92.81 $92.81

1 J9181 0-999 $0.80 $0.80 $0.80 $0.80

1 J9185 0-999 $95.24 $95.24 $95.24 $95.24

1 J9190 0-999 $2.18 $2.18 $2.34 $2.34

1 J9200 0-999 $144.00 $144.00 $144.00 $144.00

1 J9201 0-999 $111.28 $111.28 $111.28 $111.28

1 J9202 0-999 $191.33 $191.33 $191.33 $191.33

1 J9206 0-999 $4.90 $4.90 $4.90 $4.90

1 J9207 0-999 $65.59 $65.59 $66.49 $66.49

1 J9208 0-999 $158.29 $158.29 $158.29 $158.29

1 J9209 0-999 $4.49 $4.49 $4.49 $4.49

1 J9211 0-999 $116.51 $116.51 $116.51 $116.51

1 J9214 0-999 $17.76 $17.76 $19.06 $19.06

1 J9217 0-999 $215.04 $215.04 $217.02 $217.02

1 J9218 0-999 $5.17 $5.17 $5.98 $5.98

1 J9230 0-999 $157.86 $157.86 $157.86 $157.86

1 J9245 0-999 $1,352.09 $1,352.09 $1,352.09 $1,352.09

1 J9250 0-999 $0.20 $0.20 $0.20 $0.20

1 J9263 0-999 $10.26 $10.26 $10.26 $10.26

1 J9264 0-999 $9.63 $9.63 $9.63 $9.63

1 J9265 0-999 $7.55 $7.55 $7.55 $7.55

1 J9266 0-999 $5,890.00 $5,890.00 $5,890.00 $5,890.00

1 J9268 0-999 $1,088.96 $1,088.96 $1,088.96 $1,088.96

1 J9280 0-999 $134.11 $134.11 $134.11 $134.11

1 J9293 0-999 $39.57 $39.57 $39.57 $39.57

1 J9300 0-999 $2,742.59 $2,742.59 $2,742.59 $2,742.59

1 J9302 0-999 $45.42 $45.42 $45.44 $45.44

1 J9303 0-999 $87.22 $87.22 $89.02 $89.02

1 J9305 0-999 $55.06 $55.06 $56.51 $56.51

1 J9307 0-999 $165.63 $165.63 $173.94 $173.94

1 J9310 0-999 $641.96 $641.96 $659.72 $659.72

1 J9315 0-999 $226.03 $226.03 $233.16 $233.16

Type of

Service

(TOS)*

Procedure

Code

Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4-1-13

Medicaid Fee

4-1-13

Adjusted Fee


1 J9320 0-999 $269.20 $269.20 $274.16 $274.16

1 J9330 0-999 $52.33 $52.33 $53.51 $53.51

1 J9340 0-999 $143.01 $143.01 $175.30 $175.30

1 J9351 0-999 $19.28 $19.28 $19.28 $19.28

1 J9355 0-999 $72.45 $72.45 $76.40 $76.40

1 J9357 0-999 $991.66 $991.66 $1,006.27 $1,006.27

1 J9360 0-999 $4.32 $4.32 $4.32 $4.32

1 J9370 0-999 $35.77 $35.77 $35.77 $35.77

1 J9390 0-999 $11.59 $11.59 $11.59 $11.59

1 J9395 0-999 $86.25 $86.25 $87.04 $87.04

1 Q0138 0-999 $0.69 $0.69 $0.69 $0.69

TOS*: 1 = Medical Services

Type of

Service

(TOS)*

Procedure

Code

Age

Range POS**

Current

Medicaid Fee

Current Adjusted

Fee

4-1-13 Medicaid

Fee

4-1-13 Adjusted

Fee

1 S0620 0-20 N $68.00 $66.64 $68.48 $68.48

1 S0620 0-20 F $68.00 $66.64 $39.86 $39.86

1 S0620 21-999 N $68.00 $66.64 $65.22 $65.22

1 S0620 21-999 F $68.00 $66.64 $37.96 $37.96

1 S0621 0-20 N $72.00 $70.56 $72.13 $72.13

1 S0621 0-20 F $72.00 $70.56 $43.78 $43.78

1 S0621 21-999 N $72.00 $70.56 $68.70 $68.70

1 S0621 21-999 F $72.00 $70.56 $41.70 $41.70

2 S2053 0-999 F $7,042.00 $6,901.16 $7,000.39 $7,000.39

8 S2053 0-999 F $1,126.72 $1,104.19 $1,120.06 $1,120.06

2 S2068 0-999 F $15,582.67 $15,271.02 $16,687.05 $16,687.05

8 S2068 0-999 F $2,493.23 $2,443.37 $2,669.93 $2,669.93

2 S2079 0-20 F $950.85 $931.83 $1,021.65 $1,021.65

2 S2079 21-999 F $950.85 $931.83 $972.99 $972.99

2 S2095 0-20 F $445.92 $437.00 $636.84 $636.84

2 S2095 21-999 F $445.92 $437.00 $606.52 $606.52

2 S2118 0-20 F $1,239.25 $1,214.47 $1,199.87 $1,199.87

2 S2118 21-999 F $1,180.23 $1,156.63 $1,142.73 $1,142.73

2 S2142 0-20 F $91.65 $89.82 $136.41 $136.41

2 S2142 21-999 F $91.65 $89.82 $129.91 $129.91

2 S2225 0-20 F $86.78 $85.04 $114.79 $114.79

2 S2225 21-999 F $86.78 $85.04 $109.33 $109.33

2 S2235 0-20 F $827.98 $811.42 $797.11 $797.11

2 S2235 21-999 F $827.98 $811.42 $759.15 $759.15

2 S2325 0-20 F $667.31 $653.96 $765.39 $765.39

2 S2325 21-999 F $667.31 $653.96 $728.94 $728.94

8 S2325 0-20 F $106.77 $104.63 $122.46 $122.46

8 S2325 21-999 F $106.77 $104.63 $116.63 $116.63

2 S2401 0-20 F $1,143.88 $1,121.00 $1,195.10 $1,195.10

8 S2401 0-20 F $183.02 $179.36 $191.22 $191.22

2 S2402 0-20 F $1,172.52 $1,149.07 $1,231.31 $1,231.31

8 S2402 0-20 F $187.60 $183.85 $197.01 $197.01

2 S2403 0-20 F $1,452.33 $1,423.28 $1,519.28 $1,519.28

8 S2403 0-20 F $232.37 $227.72 $243.08 $243.08

2 S2405 0-20 F $1,985.32 $1,945.61 $1,463.14 $1,463.14

8 S2405 0-20 F $317.65 $311.30 $234.10 $234.10

2 S2409 0-20 F Manually Priced Manually Priced Manually Priced Manually Priced

8 S2409 0-20 F Manually Priced Manually Priced Manually Priced Manually Priced

2 S2411 0-20 F $543.59 $532.72 $575.94 $575.94

8 S2411 0-20 F $86.97 $85.23 $92.15 $92.15

2 S8030 0-20 F $1,091.47 $1,069.64 $1,275.65 $1,275.65

2 S8030 21-999 F $1,091.47 $1,069.64 $1,275.65 $1,275.65

1 S9470 0-20 N $90.00 $88.20 $58.38 $58.38

1 S9470 0-20 F $90.00 $88.20 $58.38 $58.38

"S CODES" (Medical Services, Surgery and Assistant Surgery )

TOS*: 1 = Medical Services, 2 = Surgery, 8 = Assistant Surgery

**Place of Service (POS): NF = Non-Facility, F = Facility

Type of

Service

(TOS)*

Procedure CodeAge

Range

Current Medicaid

Fee

Current Adjusted

Fee Medicaid Fee Eff. 4-1-

2013

Medicaid Adjusted Fee

Eff. 4-1-2013

1 C9292 0-999 Not a Benefit Not a Benefit $98.98 $98.98

TOS*: 1 = Medical

HCPCS 3rd Quarter 2012 Update for Physician-Administered Drugs

1 of 1

Type of

Service

(TOS)*

Procedure

Code

Age

Range

Current

Medicaid Fee

Current

Adjusted Fee

4/1/2013

Medicaid

RVU**

4/1/2013

Medicaid

Conversion

Factor

4/1/2013

Medicaid

Fee

4/1/2013

Adjusted

Fee

5 95012 0-20 Not a Benefit Not a Benefit 0.61 $28.0672 $17.12 $17.12

5 95012 21-999 Not a Benefit Not a Benefit 0.61 $26.7305 $16.31 $16.31

Aerosol Treatments

TOS*: 5 = Laboratory

**RVU = Relative Value Unit

Type of Service

(TOS)*

Procedure

Code

Age

Range

Current

Medicaid

Fee

Current

Adjusted

Fee

4/1/2013

Medicaid

RVU

4/1/2013

Medicaid

Conversion

Factor

4/1/2013

Medicaid

Fee

4/1/2013

Adjusted

Fee

5 95873 0-20

Not a

Benefit

Not a

Benefit 2.12 $28.0672 $59.50 $59.50

5 95873 21-999

Not a

Benefit

Not a

Benefit 2.12 $26.7305 $56.67 $56.67

I 95873 0-20

Not a

Benefit

Not a

Benefit 0.58 $28.0672 $16.28 $16.28

I 95873 21-999

Not a

Benefit

Not a

Benefit 0.58 $26.7305 $15.50 $15.50

T 95873 0-20

Not a

Benefit

Not a

Benefit 1.54 $28.0672 $43.22 $43.22

T 95873 21-999

Not a

Benefit

Not a

Benefit 1.54 $26.7305 $41.16 $41.16

5 95874 0-20

Not a

Benefit

Not a

Benefit 2.02 $28.0672 $56.70 $56.70

5 95874 21-999

Not a

Benefit

Not a

Benefit 2.02 $26.7305 $54.00 $54.00

I 95874 0-20

Not a

Benefit

Not a

Benefit 0.56 $28.0672 $15.72 $15.72

I 95874 21-999

Not a

Benefit

Not a

Benefit 0.56 $26.7305 $14.97 $14.97

T 95874 0-20

Not a

Benefit

Not a

Benefit 1.46 $28.0672 $40.98 $40.98

T 95874 21-999

Not a

Benefit

Not a

Benefit 1.46 $26.7305 $39.03 $39.03

4 96000 0-20

Not a

Benefit

Not a

Benefit 2.89 $28.0672 $81.11 $81.11

4 96001 0-20

Not a

Benefit

Not a

Benefit 2.87 $28.0672 $80.55 $80.55

4 96002 0-20

Not a

Benefit

Not a

Benefit 0.62 $28.0672 $17.40 $17.40

4 96003 0-20

Not a

Benefit

Not a

Benefit 0.56 $28.0672 $15.72 $15.72

EVOKED RESPONSE TESTS AND NEUROMUSCULAR PROCEDURES

TOS*: 4 = Radiology Services, 5 = Laboratory Services, I = Professional Component, T = Technical Component

**RVU= Relative Value Unit

Type of

Service

(TOS)*

Procedure

Code Modifier**

Place of

Service

Provider

Type

Age

Range

Current

Medicaid

RVU***

Current

Medicaid

Conversion

Factor

Current

Medicaid

Fee

Current

Adjusted

Fee

4/1/2013

Medicaid

RVU***

4/1/2013

Medicaid

Conversion

Factor

4/1/2013

Medicaid

Fee

4/1/2013

Adjusted

Fee

3 G0406 GT F, NF 0-20

Not a

Benefit

Not a

Benefit 1.12 $28.0672 $31.44 $31.44

3 G0406 GT F, NF 21-999

Not a

Benefit

Not a

Benefit 1.12 $26.7305 $29.94 $29.94

3 G0407 GT F, NF 0-20

Not a

Benefit

Not a

Benefit 2.06 $28.0672 $57.82 $57.82

3 G0407 GT F, NF 21-999

Not a

Benefit

Not a

Benefit 2.06 $26.7305 $55.06 $55.06

3 G0408 GT F, NF 0-20

Not a

Benefit

Not a

Benefit 2.97 $28.0672 $83.36 $83.36

3 G0408 GT F, NF 21-999

Not a

Benefit

Not a

Benefit 2.97 $26.7305 $79.39 $79.39

TELEMEDICINE AND TELEHEALTH SERVICES

TOS*: 3 = Cunsultation

**Modifier: GT = Telemedicine / Telehealth Service

***RVU = Relative Value Unit

Place of Service: F = Facility (example: hospital or clinic), NF = Nonfacility (example: office)

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

4-1-2013

Medicaid Fee

4-1-2013

Adjusted Fee

W D2410 0-999 $75.00 $73.50 Not a Benefit Not a Benefit









W D6010 0-999 $1,125.00 $1,102.50 Not a Benefit Not a Benefit

W D6040 0-999 $2,000.00 $1,960.00 Not a Benefit Not a Benefit

W D6050 0-999 Manually Priced Manually Priced Not a Benefit Not a Benefit










W D6199 0-999 Manually Priced Manually Priced Not a Benefit Not a Benefit

TEXAS HEALTH STEPS THERAPEUTIC DENTAL SERVICES

TOS*: W = Dental Services

Type of

Service


Age

Range

Current Medicaid

Fee

Current Adjusted

Fee

Medicaid Fee Eff. 4-1-

2013

Medicaid Adjusted Fee

Eff. 4-1-2013

1 90662 60-999 Not a Benefit Not a Benefit $26.97 $26.97

TOS*: 1 = Medical

Vaccines and Toxoids

Date Printed: 4/2/2013 @ 3:14 PM 1 of 1

initial reimbursement rates and reimbursement rate changes … initial... · 2013-04-08 ·...

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