1/13/2017 TEXAS MEDICAID FEE SCHEDULE – 1 of 119...
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1/13/2017 TEXAS MEDICAID FEE SCHEDULE – AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 1 of 119 Frm Thru Units 1 2 3 F AMBULATORY SURGICAL CENTER 10022 0 999 Years * 1 6/1/2002 -7.00 1/1/2011 F AMBULATORY SURGICAL CENTER 10030 0 999 Years $70.56 1/1/2014 -7.00 $65.62 1/1/2014 F AMBULATORY SURGICAL CENTER 10061 0 999 Years * 1 2/1/1996 -7.00 1/1/2011 F AMBULATORY SURGICAL CENTER 10081 0 999 Years * 1 2/1/1996 -7.00 1/1/2011 F AMBULATORY SURGICAL CENTER 10120 0 999 Years * 1 2/1/1996 -7.00 1/1/2011 F AMBULATORY SURGICAL CENTER 10121 0 999 Years * 1 2/1/1996 -7.00 1/1/2011 One-character type-of-service (TOS) code assigned to each procedure code for system administration. Field Descriptions TOS Mod 1 Medicaid Fee Group Amount Proc Code TOS Desc A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty. Additional information about rate changes is available on the TMHP website at www.tmhp.com. A percentage reduction has been applied to the allowed fee for this service. This column shows the percent by which the fee was adjusted. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx. The effective date of service for which the fee is payable. The group number that is assigned to the procedure for ASCs/HASCs. Mod 2 Last Pricing Review Date Adjusted Fee for Report Date Client Age Last Pricing Review Date: Note Codes: Medicaid rates are reviewed every two years or as necessary. This column shows the date on which the most recent review was conducted. Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation. Fee Effect Date Adjust % Group No Note Codes 1st Modifier, if required for pricing determination. The payable amounts for ASCs/HASCs are not in this column but are included as a separate file. The Medicaid allowed amount. Medicaid rates are based on the client’s age in days, months or years. The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21- 999 age range, then the client age range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations. The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations. The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System. Description of the TOS. Adjusted Fee for Report Date: Adjust %: Fee Effect Date: Group No: Group Amount: This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the current year’s Texas Medicaid Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin. AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) Texas Medicaid Fee Schedule Information Medicaid Fee: Client Age Units: Thru: Frm: Client Age Mod 2: Mod 1: Proc Code: TOS Desc: TOS: 2nd Modifier, if required for pricing determination. Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Transcript of 1/13/2017 TEXAS MEDICAID FEE SCHEDULE – 1 of 119...
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 1 of 119
Frm Thru Units 1 2 3
F
AMBULATORY
SURGICAL CENTER 10022 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 10030 0 999 Years $70.56 1/1/2014 -7.00 $65.62 1/1/2014
F
AMBULATORY
SURGICAL CENTER 10061 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 10081 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 10120 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 10121 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
One-character type-of-service (TOS) code assigned to each procedure code for system administration.
Field Descriptions
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of
service, client type program, or provider specialty. Additional information about rate changes is available on the TMHP website at www.tmhp.com.
A percentage reduction has been applied to the allowed fee for this service. This column shows the percent by which the fee was adjusted. Additional information about rate changes is available on the TMHP
website at www.tmhp.com/pages/topics/rates.aspx.
The effective date of service for which the fee is payable.
The group number that is assigned to the procedure for ASCs/HASCs.
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age
Last Pricing Review Date:
Note Codes:
Medicaid rates are reviewed every two years or as necessary. This column shows the date on which the most recent review was conducted.
Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation.
Fee Effect
Date
Adjust
%Group No
Note Codes
1st Modifier, if required for pricing determination.
The payable amounts for ASCs/HASCs are not in this column but are included as a separate file.
The Medicaid allowed amount.
Medicaid rates are based on the client’s age in days, months or years.
The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-
999 age range, then the client age range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the
first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations.
The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a
21-999 age range, then the client age range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for
the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations.
The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System.
Description of the TOS.
Adjusted Fee for Report Date:
Adjust %:
Fee Effect Date:
Group No:
Group Amount:
This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and
limitations, providers should refer to the current year’s Texas Medicaid Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC)
Texas Medicaid Fee Schedule Information
Medicaid Fee:
Client Age Units:
Thru:
Frm:
Client Age
Mod 2:
Mod 1:
Proc Code:
TOS Desc:
TOS:
2nd Modifier, if required for pricing determination.
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 2 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 10140 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 10180 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11010 0 999 Years * 2 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11011 0 999 Years * 2 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11012 0 999 Years * 2 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11042 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11043 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11044 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11307 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11310 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11311 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11312 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11313 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11400 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11401 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11402 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11403 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11404 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11406 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11420 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11421 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11422 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11423 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11424 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11426 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11440 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 3 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 11441 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11442 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11443 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11444 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11446 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11450 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11451 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11462 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11463 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11470 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11471 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11600 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11601 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11602 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11603 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11604 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11606 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11620 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11621 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11622 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11623 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11624 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11626 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11640 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11641 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11642 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11643 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 4 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 11644 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11646 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11750 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11755 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11770 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11771 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11772 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11920 18 999 Years $86.50 1/1/2016 0.00 $86.50 1/1/2016
F
AMBULATORY
SURGICAL CENTER 11921 18 999 Years $98.85 1/1/2016 0.00 $98.85 1/1/2016
F
AMBULATORY
SURGICAL CENTER 11960 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11970 18 999 Years * 9 7/1/2012 -7.00 8/1/2011
F
AMBULATORY
SURGICAL CENTER 11971 18 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11976 10 55 Years $150.00 10/1/1992 -7.00 $139.50 1/1/2013
F
AMBULATORY
SURGICAL CENTER 11981 0 999 Years * 1 7/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11982 0 999 Years * 1 7/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 11983 0 999 Years * 1 7/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 12005 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12006 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12007 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12016 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12017 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12018 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12020 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 12021 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 12031 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12032 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12034 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 5 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 12035 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12036 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12037 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12041 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12042 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12044 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12045 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12046 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12047 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12051 0 999 Years * 1 10/1/2009 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12052 0 999 Years * 1 10/1/2009 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12053 0 999 Years * 1 10/1/2009 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12054 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12055 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12056 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 12057 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13100 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13101 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13120 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13121 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13131 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13132 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13151 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13152 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 13160 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 14000 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 14001 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 6 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 14020 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 14021 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 14040 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 14041 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 14060 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 14061 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 14301 0 999 Years * 8 1/1/2010 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 14350 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15002 0 999 Years * 2 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15004 0 999 Years * 2 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15005 0 999 Years * 2 1/1/2007 -7.00 10/1/2016
F
AMBULATORY
SURGICAL CENTER 15040 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15050 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15100 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15110 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15115 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15120 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15130 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15135 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15150 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15155 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15200 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15220 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15240 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15260 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15570 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15572 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 7 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 15574 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15576 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15600 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15610 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15620 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15630 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15650 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15731 0 999 Years * 3 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15732 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15734 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15736 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15738 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15740 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15750 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15760 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15770 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15819 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15820 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15821 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15822 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15823 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15824 0 20 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15825 0 20 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15826 0 20 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15828 0 20 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15829 0 20 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15830 0 999 Years * 6 4/1/2010 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 8 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 15840 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15841 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15842 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15845 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15850 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15851 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 15920 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15922 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15931 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15933 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15934 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15935 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15936 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15937 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15940 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15941 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15944 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15945 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15946 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15950 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15951 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15952 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15953 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15956 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15958 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 15999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 16030 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 9 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 16035 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17004 0 999 Years * 1 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17106 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17107 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17108 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17264 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17266 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17270 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17271 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17273 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17274 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17276 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17281 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17282 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17283 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17284 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17286 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17311 0 999 Years * 2 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 17313 0 999 Years * 2 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19000 0 999 Years $65.23 1/1/2016 0.00 $65.23 1/1/2016
F
AMBULATORY
SURGICAL CENTER 19020 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19081 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 19083 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 19085 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 19100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19101 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19110 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 10 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 19112 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19120 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19125 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19296 0 999 Years * 9 4/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19298 0 999 Years * 1 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19300 0 20 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 19301 0 999 Years * 3 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19302 0 999 Years * 7 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19303 18 999 Years * 4 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19304 18 999 Years * 4 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19316 18 999 Years * 9 6/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19318 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19324 18 999 Years * 9 6/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19325 18 999 Years * 9 6/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19328 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19330 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19340 18 999 Years * 3 9/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19342 18 999 Years * 3 9/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19350 18 999 Years * 3 9/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19355 18 999 Years * 9 6/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19357 18 999 Years * 3 9/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19366 18 999 Years * 5 9/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19370 18 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19371 18 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19380 18 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19396 18 999 Years * 9 6/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 19499 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 11 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 20005 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20103 0 999 Years * 2 7/2/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20150 0 999 Years * 2 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20200 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20205 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20206 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20220 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20225 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20240 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20245 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20250 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20251 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20525 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20526 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20550 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20551 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20552 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20553 0 999 Years * 1 6/1/2002 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 20604 0 999 Years $26.63 1/1/2015 -7.00 $24.77 1/1/2015
F
AMBULATORY
SURGICAL CENTER 20606 0 999 Years $26.63 1/1/2015 -7.00 $24.77 1/1/2015
F
AMBULATORY
SURGICAL CENTER 20611 0 999 Years $26.63 1/1/2015 -7.00 $24.77 1/1/2015
F
AMBULATORY
SURGICAL CENTER 20612 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20650 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20662 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20663 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20665 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 20670 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 12 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 20680 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20690 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20692 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20693 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20694 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20696 0 999 Years * 5 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20697 0 999 Years * 5 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20900 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20902 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20912 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20920 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20922 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20924 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20926 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20972 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20973 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 20982 0 999 Years * 2 5/1/2005 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 20999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21010 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21015 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21016 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21025 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21026 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21029 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21030 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21031 0 999 Years * 1 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21032 0 999 Years * 1 4/1/2010 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 13 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 21034 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21040 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21044 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21046 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21047 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21048 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21050 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21060 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21070 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21073 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21089 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21100 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21110 0 999 Years * 1 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21121 0 999 Years * 7 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21122 0 999 Years * 7 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21123 0 999 Years * 7 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21125 0 999 Years * 8 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21127 0 999 Years * 9 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21137 0 999 Years * 8 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21138 0 999 Years * 9 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21139 0 999 Years * 9 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21181 0 999 Years * 7 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21198 0 999 Years * 9 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21206 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21208 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21209 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21210 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 14 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 21215 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21230 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21235 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21240 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21242 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21243 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21244 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21245 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21246 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21267 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21270 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21275 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21280 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21282 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21295 0 999 Years * 1 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21296 0 999 Years * 1 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21299 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21310 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21315 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21320 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21325 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21330 0 999 Years * 5 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21335 0 999 Years * 7 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21336 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21337 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21338 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21339 0 999 Years * 5 2/1/1996 -7.00 1/1/2013
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 15 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 21340 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21345 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21355 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21356 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21360 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21390 0 999 Years * 7 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21400 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21401 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21406 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21407 0 999 Years * 5 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 21421 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21440 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21445 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21450 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21451 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21452 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21453 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21454 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21461 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21462 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21465 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21480 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21485 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21490 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21499 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21501 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21502 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 16 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 21550 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21552 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21554 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21555 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21556 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21558 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21600 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21610 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21685 0 999 Years * 3 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21720 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21725 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21820 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21920 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21925 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21930 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21931 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21932 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21933 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21935 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 21936 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22102 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22310 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 22315 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 22505 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22510 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 17 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 22511 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 22513 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 22514 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 22899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22900 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22901 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22902 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22903 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22904 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22905 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 22999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23000 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23020 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23030 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23031 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23035 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23040 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23044 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23065 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23066 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23071 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23073 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23075 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23076 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23077 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23078 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23100 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 18 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 23101 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23105 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23106 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23107 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23120 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23125 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23130 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23140 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23145 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23146 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23150 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23155 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23156 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23170 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23172 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23174 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23180 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23182 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23184 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23190 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23195 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23330 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23333 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 23334 0 999 Years * 6 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 23395 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23397 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23400 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 19 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 23405 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23406 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23410 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23412 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23415 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23420 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23430 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23440 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23450 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23455 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23460 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23462 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23465 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23466 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23480 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23485 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23490 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23491 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23515 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23520 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23525 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23530 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23532 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23540 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23545 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 20 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 23550 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23552 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23570 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23575 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23585 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23605 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23615 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23616 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23620 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23625 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23630 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23650 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23655 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23660 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23665 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23670 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23675 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23680 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23700 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23800 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23802 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23921 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23929 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23930 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23931 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 23935 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 21 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 24000 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24006 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24065 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24066 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24071 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24073 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24075 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24076 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24077 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24079 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24101 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24102 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24105 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24110 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24115 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24116 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24120 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24125 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24126 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24130 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24134 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24136 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24138 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24140 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24145 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24147 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 22 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 24149 0 999 Years * 3 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24152 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24155 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24160 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24164 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24201 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24301 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24305 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24310 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24320 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24330 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24331 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24332 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24340 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24341 0 999 Years * 3 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24342 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24343 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24344 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24345 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24346 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24357 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24358 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24359 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24360 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24361 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24363 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24365 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 23 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 24366 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24370 0 999 Years * 9 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 24371 0 999 Years * 9 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 24400 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24410 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24420 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24430 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24435 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24470 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24495 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24498 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24515 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24516 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24530 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24535 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24538 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24545 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24560 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24565 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24566 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24575 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24576 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24577 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24579 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24582 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 24 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 24586 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24587 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24605 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24615 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24620 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24635 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24640 0 20 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24650 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24655 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24665 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24666 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24670 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24675 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24685 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24800 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24802 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24925 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 24999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25000 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25001 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25020 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25023 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25024 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25025 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25028 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25031 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 25 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 25035 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25040 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25065 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25066 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25071 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25073 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25075 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25076 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25077 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25078 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25085 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25100 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25101 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25105 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25107 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25109 0 999 Years * 6 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25110 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25111 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25112 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25115 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25116 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25118 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25119 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25120 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25125 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25126 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25130 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 26 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 25135 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25136 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25145 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25150 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25151 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25210 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25215 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25230 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25240 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25248 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25250 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25251 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25259 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25260 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25263 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25265 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25270 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25272 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25274 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25275 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25280 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25290 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25295 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25300 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25301 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25310 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25312 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 27 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 25315 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25316 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25320 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25332 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25335 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25337 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25350 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25355 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25360 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25365 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25370 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25375 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25390 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25391 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25392 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25393 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25394 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25400 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25405 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25415 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25420 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25425 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25426 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25430 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25431 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25440 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25441 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 28 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 25442 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25443 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25444 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25445 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25446 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25447 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25449 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25450 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25455 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25490 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25491 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25492 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25515 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25520 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25525 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25526 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25530 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25535 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25545 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25560 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25565 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25574 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25575 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25605 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 29 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 25606 0 999 Years * 3 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25607 0 999 Years * 5 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25608 0 999 Years * 5 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25609 0 999 Years * 5 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25622 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25624 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25628 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25630 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25635 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25645 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25650 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25651 0 999 Years * 2 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25652 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25660 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25670 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25671 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25675 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25676 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25680 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25685 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25690 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25695 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25800 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25805 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25810 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25820 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25825 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 30 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 25830 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25907 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25922 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25929 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 25999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26011 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26020 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26025 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26030 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26034 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26035 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26037 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26040 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26045 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26055 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26060 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26070 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26075 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26080 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26100 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26105 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26110 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26111 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26113 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26115 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26116 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26117 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 31 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 26118 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26121 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26123 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26130 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26135 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26140 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26145 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26160 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26170 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26180 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26185 0 999 Years * 2 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26200 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26205 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26210 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26215 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26230 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26235 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26236 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26250 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26260 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26262 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26320 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26340 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26350 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26352 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26356 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26357 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 32 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 26358 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26370 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26372 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26373 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26390 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26392 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26410 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26412 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26415 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26418 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26420 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26426 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26428 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26432 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26433 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26434 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26437 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26440 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26442 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26445 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26449 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26450 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26455 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26460 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26471 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26474 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26476 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 33 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 26477 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26478 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26479 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26480 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26483 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26485 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26489 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26490 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26492 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26494 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26496 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26497 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26498 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26499 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26500 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26502 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26508 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26510 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26516 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26517 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26518 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26520 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26525 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26530 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26531 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26535 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26536 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 34 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 26540 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26541 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26542 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26545 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26546 0 999 Years * 3 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26548 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26550 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26555 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26560 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26561 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26562 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26565 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26567 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26568 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26580 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26587 0 999 Years * 5 5/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26590 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26591 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26593 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26596 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26605 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26607 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26608 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26615 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26641 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26645 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 35 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 26650 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26665 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26675 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26676 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26685 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26686 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26705 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26706 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26715 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26720 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26725 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26727 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26735 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26742 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26746 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26755 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26756 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26765 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26775 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26776 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26785 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26820 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26841 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26842 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26843 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26844 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26850 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 36 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 26852 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26860 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26862 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26910 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26951 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26952 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26989 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26990 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 26991 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27000 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27001 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27003 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27033 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27035 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27040 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27041 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27043 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27045 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27047 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27048 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27049 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27050 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27052 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27059 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27060 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27062 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27065 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 37 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27066 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27067 0 999 Years * 5 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27080 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27086 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27087 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27097 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27098 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27100 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27105 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27110 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27111 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27200 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27202 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27220 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27230 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27238 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27246 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27250 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27252 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27257 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27265 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27266 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27267 0 999 Years * 1 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27275 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27299 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27301 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27305 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 38 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27306 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27307 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27310 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27323 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27324 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27325 0 999 Years * 2 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27326 0 999 Years * 2 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27327 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27328 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27329 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27330 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27331 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27332 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27333 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27334 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27335 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27337 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27339 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27340 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27345 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27347 0 999 Years * 4 3/1/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27350 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27355 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27356 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27357 0 999 Years * 5 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27360 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27364 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 39 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27372 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27380 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27381 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27385 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27386 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27390 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27391 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27392 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27393 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27394 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27395 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27396 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27397 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27400 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27403 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27405 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27407 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27409 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27415 0 999 Years * 4 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27416 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27418 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27420 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27422 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27424 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27425 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27427 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27428 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 40 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27429 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27430 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27435 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27437 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27438 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27440 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27441 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27442 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27443 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27475 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27479 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27496 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27497 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27498 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27499 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27501 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27502 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27503 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27508 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27509 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27510 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27516 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27517 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27520 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27524 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27530 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 41 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27532 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27538 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27550 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27552 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27560 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27562 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27566 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27570 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27594 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27599 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27600 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27601 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27602 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27603 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27604 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27605 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27606 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27607 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27610 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27612 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27613 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27614 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27615 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27616 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27618 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27619 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27620 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 42 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27625 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27626 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27630 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27632 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27634 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27635 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27637 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27638 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27640 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27641 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27647 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27650 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27652 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27654 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27656 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27658 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27659 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27664 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27665 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27675 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27676 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27680 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27681 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27685 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27686 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27687 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27690 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 43 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27691 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27695 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27696 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27698 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27700 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27704 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27705 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27707 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27709 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27726 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27730 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27732 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27734 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27740 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27742 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27745 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27750 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27752 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27756 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27758 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27759 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27760 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27762 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27766 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27767 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27768 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27769 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 44 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27780 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27781 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27784 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27786 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27788 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27792 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27808 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27810 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27814 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27816 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27818 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27822 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27823 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27824 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27825 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27826 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27827 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27828 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27829 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27830 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27831 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27832 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27840 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27842 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27846 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27848 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27860 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 45 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 27870 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27871 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27884 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27889 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27892 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27893 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27894 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 27899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28001 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28002 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28003 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28005 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28008 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28010 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28011 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28020 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28022 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28024 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28035 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28041 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28043 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28045 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28046 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28047 0 999 Years * 7 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28050 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28052 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28054 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 46 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 28055 0 999 Years * 4 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28060 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28062 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28070 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28072 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28080 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28086 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28088 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28090 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28092 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28100 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28102 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28103 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28104 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28106 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28107 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28108 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28110 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28111 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28112 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28113 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28114 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28116 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28118 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28119 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28120 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28122 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 47 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 28124 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28126 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28130 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28140 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28150 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28153 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28160 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28171 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28173 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28175 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28192 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28193 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28200 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28202 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28208 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28210 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28220 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28222 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28225 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28226 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28230 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28232 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28234 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28238 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28240 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28250 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28260 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 48 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 28261 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28262 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28264 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28270 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28272 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28280 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28285 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28286 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28288 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28289 0 999 Years * 2 3/1/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28292 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28296 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28297 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28298 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28299 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28300 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28302 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28304 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28305 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28306 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28308 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28309 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28310 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28312 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28313 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28315 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28320 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 49 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 28322 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28400 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28405 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28406 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28415 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28420 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28430 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28435 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28436 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28445 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28446 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28450 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28455 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28465 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28470 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28475 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28476 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28485 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28490 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28495 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28496 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28505 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28515 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28525 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28531 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28545 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28546 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 50 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 28555 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28575 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28576 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28585 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28605 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28606 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28615 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28635 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28636 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28645 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28665 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28666 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28675 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28705 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28715 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28725 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28730 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28735 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28737 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28740 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28750 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28755 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28760 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28810 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28820 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28825 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 28899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 51 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 29000 0 999 Years * 3 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29010 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29015 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29035 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29040 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29044 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29046 0 999 Years * 4 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29049 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29055 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29058 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29065 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29075 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29085 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29086 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29305 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29325 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29345 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29355 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29358 0 999 Years * 2 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29365 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29405 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29425 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29435 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29440 0 999 Years * 1 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29445 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29450 0 999 Years * 2 9/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29581 0 999 Years $42.21 1/1/2010 -7.00 $39.26 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 52 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 29799 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29800 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29804 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29805 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29806 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29807 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29819 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29820 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29821 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29822 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29823 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29824 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29825 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29827 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29828 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29830 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29834 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29835 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29836 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29837 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29838 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29840 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29843 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29844 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29845 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29846 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29847 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 53 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 29848 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29850 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29851 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29855 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29856 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29860 0 999 Years * 4 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29861 0 999 Years * 4 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29862 0 999 Years * 4 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29863 0 999 Years * 4 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29866 0 999 Years * 4 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29870 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29871 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29873 0 999 Years * 4 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29874 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29875 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29876 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29877 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29879 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29880 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29881 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29882 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29883 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29884 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29885 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29886 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29887 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29888 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 54 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 29889 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29891 0 999 Years * 4 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29892 0 999 Years * 4 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29893 0 999 Years * 4 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29894 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29895 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29897 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29898 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29899 0 999 Years * 4 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29900 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29901 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29902 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29904 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29905 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29906 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29907 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29914 0 999 Years * 9 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29915 0 999 Years * 9 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29916 0 999 Years * 9 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 29999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30115 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30117 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30118 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30120 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30124 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30125 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30130 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 55 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 30140 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30150 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30160 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30210 0 999 Years * 3 12/29/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30220 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30310 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30320 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30400 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30410 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30420 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30430 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30435 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30450 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30460 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30462 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30465 0 999 Years * 5 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30520 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30540 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30545 0 999 Years * 5 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30560 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30580 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30600 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30620 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30630 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30801 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30802 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30903 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 56 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 30905 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30906 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30915 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30920 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30930 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 30999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31020 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31030 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31032 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31040 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31050 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31051 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31070 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31075 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31080 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31081 0 999 Years * 4 11/9/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31085 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31086 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31087 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31090 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31200 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31201 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31205 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31231 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31233 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31235 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 57 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 31237 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31238 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31239 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31240 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31254 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31255 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31256 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31267 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31276 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31287 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31288 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31295 0 999 Years * 8 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31296 0 999 Years * 8 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31297 0 999 Years * 8 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31299 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31300 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31320 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31400 0 999 Years * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31420 0 999 Years * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31502 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31510 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31511 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31512 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31513 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31515 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31525 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 58 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 31526 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31527 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31528 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31529 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31530 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31531 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31535 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31536 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31540 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31541 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31545 0 999 Years * 4 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31546 0 999 Years * 5 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31560 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31561 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31570 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31571 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31575 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31576 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31577 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31578 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31580 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31590 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31595 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31599 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31612 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31613 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31614 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 59 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 31615 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31622 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31623 0 999 Years * 1 3/1/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31624 0 999 Years * 1 3/1/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31625 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31626 0 999 Years * 2 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31628 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31629 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31630 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31631 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31634 0 999 Years * 1 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31635 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31636 0 999 Years * 2 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31638 0 999 Years * 2 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31640 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31641 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31643 0 999 Years * 3 3/1/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31645 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31646 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31647 0 999 Years * 5 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 31648 0 999 Years * 5 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 31649 0 999 Years * 1 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 31652 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 31653 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 31717 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31730 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31750 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 60 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 31755 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31820 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31825 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31830 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 31899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 32400 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 32405 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 32550 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 32553 0 999 Years * 3 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 32554 0 999 Years $185.12 1/1/2013 -7.00 $172.16 1/1/2013
F
AMBULATORY
SURGICAL CENTER 32555 0 999 Years $185.12 1/1/2013 -7.00 $172.16 1/1/2013
F
AMBULATORY
SURGICAL CENTER 32556 0 999 Years $185.12 1/1/2013 -7.00 $172.16 1/1/2013
F
AMBULATORY
SURGICAL CENTER 32557 0 999 Years $185.12 1/1/2013 -7.00 $172.16 1/1/2013
F
AMBULATORY
SURGICAL CENTER 32999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33010 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33011 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33206 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33207 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33208 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33210 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33211 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33212 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33213 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33214 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33215 0 999 Years * 1 6/1/2003 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33216 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33217 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 61 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 33218 0 999 Years * 3 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33220 0 999 Years * 3 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33221 0 999 Years * 9 1/1/2012 -7.00 2/1/2012
F
AMBULATORY
SURGICAL CENTER 33222 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33223 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33226 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33227 0 999 Years * 9 1/1/2012 -7.00 2/1/2012
F
AMBULATORY
SURGICAL CENTER 33228 0 999 Years * 9 1/1/2012 -7.00 2/1/2012
F
AMBULATORY
SURGICAL CENTER 33229 0 999 Years * 9 1/1/2012 -7.00 2/1/2012
F
AMBULATORY
SURGICAL CENTER 33230 0 999 Years * 9 1/1/2012 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33231 0 999 Years * 9 1/1/2012 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33233 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33234 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33235 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33240 0 999 Years * 3 8/4/2000 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33241 0 999 Years * 3 8/4/2000 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33249 0 999 Years * 3 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33262 0 999 Years * 9 1/1/2012 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33263 0 999 Years * 9 1/1/2012 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33264 0 999 Years * 9 1/1/2012 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 33282 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33284 0 999 Years * 1 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 33999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 34490 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 35188 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 35207 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 35875 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 62 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 35876 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36002 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36260 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36261 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36262 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36299 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36475 0 999 Years * 5 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36478 0 999 Years * 5 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36511 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36512 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36513 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36514 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36515 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36516 0 999 Years * 3 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36522 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36555 0 4 Years * 1 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36556 5 999 Years * 1 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36557 0 4 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36558 5 999 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36560 0 4 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36561 5 999 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36563 0 999 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36565 0 999 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36566 0 999 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36568 0 4 Years * 1 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36569 5 999 Years * 1 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36570 0 4 Years * 3 7/1/2004 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 63 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 36571 5 999 Years * 3 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36575 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36576 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36578 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36580 0 999 Years * 1 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36581 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36582 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36583 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36584 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36585 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36589 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36590 0 999 Years * 2 7/1/2004 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36595 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36596 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36597 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36598 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36640 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36800 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36810 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36815 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36818 0 999 Years * 3 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36819 0 999 Years * 3 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36820 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36821 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36825 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36830 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36831 0 999 Years * 3 3/1/1999 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 64 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 36832 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36833 0 999 Years * 4 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36835 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36860 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 36861 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37184 0 999 Years * 2 1/1/2006 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 37187 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37188 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37197 0 999 Years * 8 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 37200 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37211 0 999 Years * 1 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 37212 0 999 Years * 1 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 37220 0 999 Years * 9 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37221 0 999 Years * 9 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37236 0 999 Years * 9 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 37238 0 999 Years * 9 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 37500 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37501 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37501 0 999 Years * 6/1/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37607 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37609 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37650 0 999 Years * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37718 0 999 Years * 3 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37722 0 999 Years * 3 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37735 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37760 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 65 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 37761 0 999 Years * 8 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37765 0 999 Years * 3 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37766 0 999 Years * 3 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37780 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37785 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 37799 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38129 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38206 0 999 Years * 4 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38220 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38221 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38230 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38232 0 999 Years * 9 1/1/2012 -7.00 2/1/2012
F
AMBULATORY
SURGICAL CENTER 38241 0 999 Years * 4 2/1/2010 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 38242 0 999 Years * 4 6/1/2003 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 38243 0 999 Years * 3 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 38300 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38305 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38308 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38500 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38510 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38520 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38525 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38530 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38542 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38550 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38555 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 66 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 38570 0 999 Years * 4 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38571 0 999 Years * 2 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38572 0 999 Years * 2 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38589 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38740 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38745 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38760 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 38999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 39499 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 39599 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40500 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40510 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40520 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40525 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40527 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40530 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40650 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40652 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40654 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40700 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40701 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40702 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40720 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40761 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40799 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40801 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 67 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 40805 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40806 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40814 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40816 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40818 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40819 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40820 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40831 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40840 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40842 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40843 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40844 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40845 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 40899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41005 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41006 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41007 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41008 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41009 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41010 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41015 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41016 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41017 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41018 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41105 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 68 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 41110 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41112 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41113 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41114 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41115 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41116 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41120 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41251 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41252 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41510 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41520 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41599 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41805 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41806 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41827 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41870 0 999 Years * 2 12/27/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41872 0 999 Years * 2 12/27/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41874 0 999 Years * 2 12/27/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 41899 EP 0 999 Years $630.00 12/1/2006 -7.00 $585.90 8/1/2011
F
AMBULATORY
SURGICAL CENTER 42000 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42104 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42106 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42107 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42120 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42140 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42145 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 69 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 42160 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42180 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42182 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42200 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42205 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42210 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42215 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42220 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42225 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42226 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42227 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42235 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42260 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42281 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42299 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42300 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42305 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42310 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42320 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42335 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42340 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42405 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42408 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42409 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42410 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42415 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42420 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 70 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 42425 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42440 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42450 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42500 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42505 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42507 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42509 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42510 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42650 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42660 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42699 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42700 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42720 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42725 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42800 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42804 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42806 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42808 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42810 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42815 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42820 0 11 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42821 12 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42825 0 11 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42826 12 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42830 0 11 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42831 12 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 71 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 42835 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42836 12 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42860 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42870 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42890 0 999 Years * 7 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42892 0 999 Years * 7 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42900 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42950 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42955 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42960 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42962 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42972 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 42999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43180 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 43191 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43192 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43193 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43194 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43195 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43196 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43197 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43198 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43200 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43201 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43202 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43204 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43205 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 72 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 43206 0 999 Years * 2 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 43210 0 999 Years * 9 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 43211 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43212 0 999 Years * 8 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43213 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43214 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43215 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 43216 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 43217 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43220 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43226 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43227 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43229 0 999 Years * 7 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43231 0 999 Years * 1 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43232 0 999 Years * 1 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43233 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43235 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43236 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43237 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43238 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43239 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43240 0 999 Years * 2 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43241 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43242 0 999 Years * 2 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43243 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43244 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43245 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 73 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 43246 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43247 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 43248 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43249 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43250 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43251 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43252 0 999 Years * 2 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 43253 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43254 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43255 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43259 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43260 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43261 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43262 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43263 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43264 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43265 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43266 0 999 Years * 8 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43270 0 999 Years * 3 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43274 0 999 Years * 7 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43275 0 999 Years * 7 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43276 0 999 Years * 7 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43277 0 999 Years * 7 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43278 0 999 Years * 7 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 43289 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43450 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43453 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 74 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 43499 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43653 0 999 Years * 2 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43760 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43761 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43870 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43886 13 999 Years * 6 7/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43887 13 999 Years * 6 7/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43888 13 999 Years * 6 7/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 43999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44238 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44312 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44340 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44360 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44361 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44363 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44364 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44365 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44366 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44369 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44370 0 999 Years * 2 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44372 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44373 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44376 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44377 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44378 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44379 0 999 Years * 2 4/1/2001 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 75 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 44380 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44381 0 999 Years * 8 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 44382 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44385 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44386 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44388 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44389 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44390 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44391 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44392 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44394 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44403 0 999 Years * 4 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 44404 0 999 Years * 1 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 44405 0 999 Years * 4 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 44406 0 999 Years * 3 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 44407 0 999 Years * 3 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 44408 0 999 Years * 8 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 44500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44799 0 999 Years * 10/16/2003 -7.00 5 4/1/2014
F
AMBULATORY
SURGICAL CENTER 44899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 44979 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45005 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45020 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45108 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45150 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 76 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 45160 0 999 Years * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45171 0 999 Years * 4 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45172 0 999 Years * 8 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45190 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45300 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45303 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45305 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45307 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45308 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45309 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45315 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45317 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45320 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45321 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45327 0 999 Years * 1 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45330 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45331 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45332 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45333 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45334 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45335 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45337 0 999 Years * 1 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45338 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45340 0 999 Years * 1 6/1/2003 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45341 0 999 Years * 1 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45342 0 999 Years * 1 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45346 0 999 Years * 1 1/1/2015 -7.00 1/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 77 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 45347 0 999 Years * 8 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45349 0 999 Years * 3 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45350 0 999 Years * 3 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45378 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45379 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45380 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45381 0 999 Years * 2 6/1/2003 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45382 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45384 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45385 0 999 Years * 2 2/1/1996 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45386 0 999 Years * 2 6/1/2003 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45388 0 999 Years * 1 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45389 0 999 Years * 8 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45390 0 999 Years * 3 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45391 0 999 Years * 2 1/1/2005 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45392 0 999 Years * 2 1/1/2005 -7.00 4/1/2014
F
AMBULATORY
SURGICAL CENTER 45393 0 999 Years * 1 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45398 0 999 Years * 3 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 45499 0 999 Years * 1/1/2006 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45500 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45505 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45560 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45900 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45905 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45910 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45915 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 45990 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 78 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 45999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46020 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46030 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46040 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46045 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46050 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46060 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46070 0 12 Months * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46080 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46200 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46220 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46221 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46230 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46250 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46255 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46257 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46258 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46260 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46261 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46262 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46270 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46275 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46280 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46285 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46288 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46320 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46505 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 79 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 46608 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46610 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46611 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46612 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46615 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46700 21 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46706 0 999 Years * 2 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46707 0 999 Years * 9 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46750 12 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46753 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46754 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46761 12 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46762 12 999 Years * 7 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46917 0 999 Years * 1 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46922 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46924 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46930 0 999 Years * 2 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46945 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46946 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 46999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47379 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47383 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 47399 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47533 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47534 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47535 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 80 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 47536 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47537 0 999 Years $215.99 1/1/2016 -7.00 $200.87 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47538 0 999 Years * 9 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47539 0 999 Years * 9 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47540 0 999 Years * 9 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47541 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 47552 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47553 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47554 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47555 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47556 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47562 0 999 Years * 6 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47563 0 999 Years * 6 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47564 0 999 Years * 6 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47579 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 47999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 48102 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 48999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49180 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49250 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49320 0 999 Years * 3 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49321 0 999 Years * 4 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49322 0 999 Years * 4 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49324 0 999 Years * 1 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49325 0 999 Years * 1 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49329 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49402 0 999 Years * 2 1/1/2007 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 81 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 49407 0 999 Years * 1 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 49418 0 999 Years * 8 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49419 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49421 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49422 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49423 0 999 Years * 1 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49426 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49429 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49436 0 999 Years * 1 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49440 0 999 Years * 2 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49441 0 999 Years * 2 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49446 0 999 Years * 2 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49450 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49451 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49452 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49460 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49495 0 6 Months * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49496 0 6 Months * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49500 0 4 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49501 0 4 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49505 5 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49507 5 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49520 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49521 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49525 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49540 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49550 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 82 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 49553 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49555 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49557 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49560 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49561 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49565 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49566 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49570 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49572 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49580 0 4 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49582 0 4 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49585 5 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49587 5 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49590 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49600 0 12 Months * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49650 0 999 Years * 4 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49651 0 999 Years * 7 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49652 0 999 Years * 6 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49653 0 999 Years * 6 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49654 0 999 Years * 6 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49655 0 999 Years * 6 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49656 0 999 Years * 6 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49657 0 999 Years * 6 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49659 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 49999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50200 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50382 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 83 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 50384 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50385 0 999 Years * 5 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50386 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50387 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50389 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50390 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50391 0 999 Years * 1 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50395 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50396 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50432 0 999 Years * 5 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 50433 0 999 Years * 5 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 50434 0 999 Years $234.62 1/1/2016 -7.00 $218.20 1/1/2016
F
AMBULATORY
SURGICAL CENTER 50435 0 999 Years $234.62 1/1/2016 -7.00 $218.20 1/1/2016
F
AMBULATORY
SURGICAL CENTER 50551 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50553 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50555 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50557 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50561 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50562 0 999 Years * 2 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50570 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50572 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50574 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50575 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50576 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50580 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50590 0 999 Years * 9 7/17/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50592 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 84 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 50686 0 999 Years * 1 11/19/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50688 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50693 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 50694 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 50695 0 999 Years * 8 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 50727 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50947 0 999 Years * 6 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50948 0 999 Years * 5 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50951 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50953 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50955 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50957 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50961 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50970 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50972 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50974 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50976 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 50980 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51020 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51030 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51045 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51050 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51065 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51080 0 999 Years * 1 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51100 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51101 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51102 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 85 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 51500 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51520 0 999 Years * 4 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51710 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51715 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51725 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51726 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51784 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51785 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51880 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51992 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 51999 0 999 Years * 1/1/2006 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52001 0 999 Years * 2 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52005 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52007 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52010 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52204 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52214 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52224 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52234 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52235 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52240 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52250 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52260 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52265 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52270 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52275 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 86 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 52276 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52277 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52281 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52282 0 999 Years * 2 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52283 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52285 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52287 0 999 Years * 3 1/1/2013 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 52290 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52300 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52301 0 999 Years * 2 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52305 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52310 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52315 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52317 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52318 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52320 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52325 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52327 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52330 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52332 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52334 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52341 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52342 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52343 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52344 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52345 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52346 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 87 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 52351 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52352 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52353 0 999 Years * 4 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52354 0 999 Years * 4 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52355 0 999 Years * 2 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52356 0 999 Years * 9 1/1/2014 -7.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 52400 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52450 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52500 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52601 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52630 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52640 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52647 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52648 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 52700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53010 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53020 1 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53040 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53080 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53200 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53210 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53215 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53220 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53230 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53235 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53240 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 88 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 53250 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53260 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53265 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53270 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53275 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53400 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53405 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53410 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53420 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53425 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53430 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53431 0 999 Years * 2 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53440 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53442 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53444 0 999 Years * 5 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53446 0 999 Years * 5 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53447 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53449 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53450 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53460 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53502 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53505 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53510 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53515 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53520 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53601 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 89 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 53605 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53620 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53621 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53660 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53661 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53665 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53850 0 999 Years * 1 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 53899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54000 0 29 Days * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54001 1 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54057 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54060 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54065 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54105 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54110 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54111 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54112 0 999 Years * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54115 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54120 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54150 0 12 Months * 1 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54160 0 29 Days * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54161 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54162 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54163 0 999 Years * 2 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54164 0 999 Years * 2 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54205 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 90 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 54220 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54300 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54304 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54308 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54312 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54316 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54318 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54322 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54324 0 999 Years * 3 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54326 0 999 Years * 3 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54328 0 999 Years * 3 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54340 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54344 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54348 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54352 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54360 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54380 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54385 0 999 Years * 3 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54406 0 999 Years * 9 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54415 0 999 Years * 9 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54420 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54435 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54437 0 999 Years * 5 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 54440 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54450 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 91 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 54512 0 999 Years * 2 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54520 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54522 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54530 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54550 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54600 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54620 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54640 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54660 0 20 Years * 6 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54670 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54680 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54690 0 999 Years * 4 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54692 0 999 Years * 4 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54699 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54800 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54830 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54840 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54860 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54861 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 54865 0 999 Years * 1 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55040 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55041 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55060 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55110 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55120 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 92 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 55150 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55175 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55180 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55250 21 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55450 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55500 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55520 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55530 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55535 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55540 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55550 0 999 Years * 4 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55559 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55680 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55705 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55706 0 999 Years * 1 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55720 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55725 0 999 Years * 2 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55860 0 999 Years * 5 4/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55875 0 999 Years * 9 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55876 0 999 Years * 9 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 55899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56405 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56420 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56440 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56442 0 999 Years * 1 1/1/2007 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 93 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 56501 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56515 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56605 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56620 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56625 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56700 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56740 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56800 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56805 0 20 Years * 6 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56810 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56820 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 56821 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57010 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57020 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57022 10 55 Years * 2 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57023 0 999 Years * 2 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57061 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57065 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57105 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57130 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57135 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57155 0 999 Years * 2 6/1/2002 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 57180 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57200 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57210 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57220 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 94 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 57230 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57240 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57250 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57260 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57265 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57268 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57287 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57289 0 999 Years * 5 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57291 0 999 Years * 5 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57295 0 999 Years * 2 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57300 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57320 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57400 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57410 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57415 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57420 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57421 0 999 Years * 2 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57426 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57452 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57454 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57455 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57456 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57460 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57461 0 999 Years * 2 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57510 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 95 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 57511 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57513 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57520 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57522 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57530 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57550 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57556 0 999 Years * 5 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57558 0 999 Years * 3 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57720 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 57800 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58100 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58120 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58145 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58260 0 999 Years * 9 10/1/2016 -7.00 10/1/2016
F
AMBULATORY
SURGICAL CENTER 58262 0 999 Years * 9 10/1/2016 -7.00 10/1/2016
F
AMBULATORY
SURGICAL CENTER 58346 0 999 Years * 2 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58353 0 999 Years * 1 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58356 10 55 Years * 9 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58545 0 999 Years * 9 8/10/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58546 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 58550 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58552 0 999 Years * 9 9/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58555 0 999 Years * 1 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58558 0 999 Years * 3 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58559 0 999 Years * 2 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58560 0 999 Years * 1 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58561 0 999 Years * 3 2/1/2000 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 96 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 58562 0 999 Years * 1 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58563 0 999 Years * 4 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58565 21 999 Years * 4 12/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58600 21 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58615 21 55 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58660 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58661 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58662 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58670 21 55 Years * 4 8/4/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58671 21 55 Years * 4 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58672 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58673 0 999 Years * 5 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58679 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58800 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58805 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58820 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58900 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 58999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59150 10 55 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59151 10 55 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59160 10 55 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59320 10 55 Years * 1 5/7/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59412 10 55 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59812 10 55 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59820 10 55 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59821 10 55 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59840 10 55 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 97 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 59841 10 55 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59870 10 55 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59871 10 55 Years * 2 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59897 10 55 Years * 7/1/2004 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59898 10 55 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 59899 10 55 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60000 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60200 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60210 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60212 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60220 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60225 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60280 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60281 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60300 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60659 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 60699 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61020 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61026 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61050 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61055 0 999 Years * 1 2/1/1996 -7.00 7/1/2014
F
AMBULATORY
SURGICAL CENTER 61070 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61215 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61790 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61791 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61880 0 999 Years * 1 4/3/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61885 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 98 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 61886 0 999 Years * 3 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 61888 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62194 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62225 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62230 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62263 0 999 Years * 1 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62264 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62267 0 999 Years * 1 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62268 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62269 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62270 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62272 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62273 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62280 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62281 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62282 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62287 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62350 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62355 0 999 Years * 2 9/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62360 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62361 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62362 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 62365 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63600 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63610 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63650 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63655 0 999 Years * 5 1/1/2008 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 99 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 63661 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63662 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63663 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63664 0 999 Years * 5 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63685 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63688 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63744 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 63746 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64410 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64415 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64416 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64417 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64420 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64421 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64430 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64446 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64448 0 999 Years * 1 6/1/2003 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64449 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64455 0 999 Years * 1 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64461 0 999 Years $66.77 1/1/2016 -7.00 $62.10 1/1/2016
F
AMBULATORY
SURGICAL CENTER 64463 0 999 Years $78.52 1/1/2016 -7.00 $73.02 1/1/2016
F
AMBULATORY
SURGICAL CENTER 64479 0 999 Years * 1 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64483 0 999 Years * 1 2/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64490 0 999 Years * 1 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64493 0 999 Years * 1 1/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64510 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64517 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 100 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 64520 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64530 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64553 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64555 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64561 0 999 Years * 3 1/1/2008 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64565 0 20 Years * 9 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64568 0 999 Years * 9 1/1/2011 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64569 0 999 Years * 9 10/1/2014 10/1/2014
F
AMBULATORY
SURGICAL CENTER 64570 0 999 Years * 9 10/1/2014 10/1/2014
F
AMBULATORY
SURGICAL CENTER 64575 0 999 Years * 9 10/1/2014 10/1/2014
F
AMBULATORY
SURGICAL CENTER 64580 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64581 0 999 Years * 1 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64585 0 999 Years * 1 4/3/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64590 0 999 Years * 2 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64595 0 999 Years * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64600 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64605 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64610 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64612 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64615 0 999 Years $35.60 1/1/2013 -7.00 $33.11 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64616 0 999 Years $31.86 1/1/2014 -7.00 $29.63 1/1/2014
F
AMBULATORY
SURGICAL CENTER 64617 0 999 Years $68.54 1/1/2014 -7.00 $63.74 1/1/2014
F
AMBULATORY
SURGICAL CENTER 64620 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64630 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64632 0 999 Years * 1 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64633 0 999 Years * 1 1/1/2012 -7.00 2/1/2012
F
AMBULATORY
SURGICAL CENTER 64635 0 999 Years * 2 1/1/2012 -7.00 2/1/2012
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 101 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 64640 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64642 0 999 Years $41.71 1/1/2014 -7.00 $38.79 1/1/2014
F
AMBULATORY
SURGICAL CENTER 64644 0 999 Years $49.46 1/1/2014 -7.00 $46.00 1/1/2014
F
AMBULATORY
SURGICAL CENTER 64646 0 999 Years $44.44 1/1/2014 -7.00 $41.33 1/1/2014
F
AMBULATORY
SURGICAL CENTER 64647 0 999 Years $50.94 1/1/2014 -7.00 $47.37 1/1/2014
F
AMBULATORY
SURGICAL CENTER 64650 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64653 0 999 Years * 1 1/1/2006 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64680 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64681 0 999 Years * 1 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64702 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64704 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64708 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64712 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64713 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64714 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64716 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64718 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64719 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64721 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64722 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64726 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64732 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64734 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64736 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64738 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64740 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64742 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 102 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 64744 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64746 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64771 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64772 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64774 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64776 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64782 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64784 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64786 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64788 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64790 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64792 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64795 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64802 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64820 0 999 Years * 4 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64821 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64822 0 999 Years * 3 6/1/2002 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64823 0 999 Years * 3 6/1/2002 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64831 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64834 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64835 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64836 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64840 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64856 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64857 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64858 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64861 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 103 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 64862 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64864 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64865 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64885 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64886 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64890 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64891 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64892 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64893 0 999 Years * 2 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64895 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64896 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64897 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64898 0 999 Years * 3 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 64905 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64907 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64910 0 999 Years * 5 1/1/2007 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 64999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65091 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65093 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65101 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65103 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65105 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65110 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65112 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65114 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65125 0 999 Years 4/1/1994 -7.00 5 6 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65130 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 104 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 65135 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65140 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65150 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65155 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65175 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65235 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65260 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65265 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65270 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65272 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65275 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65280 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65285 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65286 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65290 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65400 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65410 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65420 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65426 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65450 0 999 Years * 2 3/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65710 0 999 Years * 7 2/1/2003 -7.00 8/1/2011
F
AMBULATORY
SURGICAL CENTER 65730 0 999 Years * 7 2/1/2003 -7.00 8/1/2011
F
AMBULATORY
SURGICAL CENTER 65750 0 999 Years * 7 2/1/2003 -7.00 8/1/2011
F
AMBULATORY
SURGICAL CENTER 65755 0 999 Years * 7 2/1/2003 -7.00 8/1/2011
F
AMBULATORY
SURGICAL CENTER 65756 0 999 Years * 8 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65772 0 999 Years * 4 3/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65775 0 999 Years * 4 3/1/2008 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 105 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 65780 0 999 Years * 9 4/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65785 21 999 Years * 9 1/1/2016 -7.00 1/1/2016
F
AMBULATORY
SURGICAL CENTER 65800 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 65810 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65815 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65820 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65850 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65855 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65860 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65865 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65870 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65875 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65880 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65900 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65920 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 65930 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66020 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66030 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66130 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66150 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66155 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66160 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66170 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66172 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66179 0 999 Years * 9 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 66180 0 999 Years * 2 2/1/1996 -7.00 7/1/2014
F
AMBULATORY
SURGICAL CENTER 66183 0 999 Years * 9 1/1/2014 -7.00 1/1/2014
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 106 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 66184 0 999 Years * 6 1/1/2015 -7.00 1/1/2015
F
AMBULATORY
SURGICAL CENTER 66185 0 999 Years * 2 2/1/1996 -7.00 7/1/2014
F
AMBULATORY
SURGICAL CENTER 66220 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66225 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66250 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66500 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66505 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66600 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66605 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66625 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66630 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66635 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66680 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66682 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66710 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66711 0 999 Years * 2 1/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66720 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66740 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66761 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66762 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66770 0 999 Years * 3 3/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66820 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66821 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66825 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66830 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66840 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 107 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 66850 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66852 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66920 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66930 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66940 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66982 0 999 Years * 8 7/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66983 0 999 Years * 8 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66984 0 999 Years * 8 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66985 0 999 Years * 6 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66986 0 999 Years * 6 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 66999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67005 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67010 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67015 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67025 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67027 0 999 Years * 1 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67028 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67030 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67031 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67036 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67039 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67040 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67041 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67042 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67043 0 999 Years * 9 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67101 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67105 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 108 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 67107 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67108 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67110 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67113 0 999 Years * 9 1/1/2009 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67115 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67120 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67121 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67141 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67145 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67208 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67210 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67218 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67220 0 999 Years * 3 9/1/2000 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67221 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67227 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67228 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67229 0 365 Days * 1 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67250 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67255 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67299 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67311 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67312 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67314 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67316 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67318 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67343 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67346 0 999 Years * 1 1/1/2007 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 109 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 67399 0 999 Years * 10/16/2003 -7.00 5 7/1/2014
F
AMBULATORY
SURGICAL CENTER 67400 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67405 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67412 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67413 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67414 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67415 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67420 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67430 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67440 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67445 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67450 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67550 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67560 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67570 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67599 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67715 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67800 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67801 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67805 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67808 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67810 0 999 Years * 1 2/1/1996 -7.00 1/1/2013
F
AMBULATORY
SURGICAL CENTER 67825 0 999 Years * 1 5/7/1999 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67830 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67835 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67840 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67850 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 110 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 67875 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67880 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67882 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67900 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67901 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67902 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67903 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67904 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67906 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67908 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67909 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67911 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67912 0 999 Years * 3 5/1/2005 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67914 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67915 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67916 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67917 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67921 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67922 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67923 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67924 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67935 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67938 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67950 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67961 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67966 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67971 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 111 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 67973 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67974 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67975 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 67999 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68110 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68115 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68130 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68320 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68325 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68326 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68328 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68330 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68335 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68340 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68360 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68362 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68399 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68500 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68505 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68510 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68520 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68525 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68540 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68550 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68700 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68705 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68720 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 112 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 68745 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68750 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68760 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68761 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68770 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68810 0 999 Years * 1 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68811 0 999 Years * 1 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68815 0 999 Years * 1 2/1/1997 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68816 0 999 Years * 2 1/1/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68840 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 68899 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69105 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69110 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69120 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69140 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69145 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69150 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69205 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69222 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69300 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69310 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69320 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69399 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69420 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69421 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69424 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69433 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 113 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 69436 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69440 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69450 0 999 Years * 1 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69501 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69502 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69505 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69511 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69530 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69550 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69552 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69601 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69602 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69603 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69604 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69605 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69620 0 999 Years * 2 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69631 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69632 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69633 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69635 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69636 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69637 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69641 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69642 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69643 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69644 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69645 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 114 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 69646 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69650 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69660 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69661 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69662 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69666 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69667 0 999 Years * 4 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69670 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69676 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69700 0 999 Years * 3 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69711 0 999 Years * 9 10/1/2012 -7.00 10/1/2012
F
AMBULATORY
SURGICAL CENTER 69714 5 999 Years * 9 12/2/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69715 5 999 Years * 9 12/2/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69717 5 999 Years * 9 12/2/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69718 5 999 Years * 9 12/2/2008 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69720 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69740 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69745 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69799 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69801 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69805 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69806 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69820 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69840 0 999 Years * 5 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69905 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69910 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69915 0 999 Years * 7 2/1/1996 -7.00 1/1/2011
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 115 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
F
AMBULATORY
SURGICAL CENTER 69930 1 999 Years * 7 4/1/2005 -7.00 8/24/2012
F
AMBULATORY
SURGICAL CENTER 69949 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
F
AMBULATORY
SURGICAL CENTER 69979 0 999 Years * 10/16/2003 -7.00 5 1/1/2011
9
OTHER MEDICAL
ITEMS OR A4264 21 999 Years $1,560.00 1/1/2015 0.00 $1,560.00 1/1/2016
9
OTHER MEDICAL
ITEMS OR A4264 21 999 Years $1,560.00 9/1/2013 0.00 $1,560.00 1/1/2016
9
OTHER MEDICAL
ITEMS OR A4290 0 999 Years $377.20 1/1/2015 0.00 $377.20 1/1/2015
9
OTHER MEDICAL
ITEMS OR A4648 0 20 Years * 1/1/2011 5 1/1/2015
9
OTHER MEDICAL
ITEMS OR C1883 0 999 Years $733.90 7/1/2015 0.00 $733.90 7/1/2015
9
OTHER MEDICAL
ITEMS OR C1897 0 999 Years $1,336.60 7/1/2015 0.00 $1,336.60 7/1/2015
9
OTHER MEDICAL
ITEMS OR C9359 0 999 Years $131.07 4/1/2015 0.00 $131.07 4/1/2016
9
OTHER MEDICAL
ITEMS OR C9360 0 999 Years $17.52 10/1/2016 0.00 $17.52 4/1/2016
9
OTHER MEDICAL
ITEMS OR C9361 0 999 Years $373.52 4/1/2016 0.00 $373.52 4/1/2016
9
OTHER MEDICAL
ITEMS OR C9362 0 999 Years $131.07 4/1/2015 0.00 $131.07 4/1/2016
9
OTHER MEDICAL
ITEMS OR E0616 0 20 Years $3,033.59 4/1/2013 0.00 $3,033.59 6 4/1/2015
9
OTHER MEDICAL
ITEMS OR E0749 0 999 Years $2,786.83 4/1/2013 0.00 $2,786.83 4/1/2015
9
OTHER MEDICAL
ITEMS OR E0782 0 999 Years $3,753.51 4/1/2013 0.00 $3,753.51 4/1/2015
9
OTHER MEDICAL
ITEMS OR E0783 0 999 Years $7,480.40 4/1/2013 0.00 $7,480.40 4/1/2015
F
AMBULATORY
SURGICAL CENTER G0104 0 999 Years * 1 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER G0105 0 999 Years * 2 3/1/1998 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER G0121 0 999 Years * 1 7/1/2010 -7.00 1/1/2011
F
AMBULATORY
SURGICAL CENTER G0186 0 999 Years * 3 4/1/2001 -7.00 1/1/2011
1
MEDICAL
SERVICES J1265 0 999 Years $0.49 11/1/2015 0.00 $0.49 4/1/2016
1
MEDICAL
SERVICES J7312 0 999 Years $190.43 4/1/2014 0.00 $190.43 4/1/2016
9
OTHER MEDICAL
ITEMS OR L8614 1 999 Years $23,380.00 4/1/2015 0.00 $23,380.00 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8630 0 20 Years $227.68 10/1/2014 0.00 $227.68 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8631 0 20 Years $1,453.84 10/1/2016 0.00 $1,453.84 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8641 0 20 Years $236.57 10/1/2014 0.00 $236.57 10/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 116 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
9
OTHER MEDICAL
ITEMS OR L8642 0 20 Years $196.72 10/1/2014 0.00 $196.72 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8658 0 20 Years $206.26 10/1/2014 0.00 $206.26 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8659 0 20 Years $1,292.31 10/1/2016 0.00 $1,292.31 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8680 0 999 Years $272.16 10/1/2014 0.00 $272.16 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8680 TG 0 999 Years $4,646.94 10/1/2011 0.00 $4,646.94 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8681 0 999 Years $926.72 1/1/2008 0.00 $926.72 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8682 0 999 Years $5,178.47 1/1/2008 0.00 $5,178.47 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8683 0 999 Years $4,558.23 1/1/2008 0.00 $4,558.23 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8684 0 999 Years $670.64 1/1/2008 0.00 $670.64 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8685 0 999 Years $11,358.87 1/1/2008 0.00 $11,358.87 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8686 0 999 Years $6,885.47 10/1/2016 0.00 $6,885.47 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8686 TG 0 999 Years $15,756.30 10/1/2011 0.00 $15,756.30 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8687 0 999 Years $14,043.32 10/1/2016 0.00 $14,043.32 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8688 0 999 Years $8,960.75 10/1/2016 0.00 $8,960.75 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8689 0 999 Years $1,498.34 1/1/2008 0.00 $1,498.34 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8690 5 999 Years $4,338.80 7/1/2010 0.00 $4,338.80 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8691 5 999 Years $2,432.05 7/1/2010 0.00 $2,432.05 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8692 5 999 Years $3,321.00 10/1/2012 0.00 $3,321.00 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8693 5 999 Years $1,414.77 10/1/2012 0.00 $1,414.77 10/1/2016
9
OTHER MEDICAL
ITEMS OR L8695 0 999 Years $11.86 10/1/2014 0.00 $11.86 10/1/2016
0 BLOOD P9010 0 999 Years $124.83 11/1/2015 0.00 $124.83 11/1/2015
0 BLOOD P9011 0 999 Years $61.20 11/1/2015 0.00 $61.20 11/1/2015
0 BLOOD P9031 0 999 Years $67.85 11/1/2015 0.00 $67.85 11/1/2015
0 BLOOD P9032 0 999 Years $69.63 11/1/2015 0.00 $69.63 11/1/2015
0 BLOOD P9033 0 999 Years $121.14 11/1/2015 0.00 $121.14 11/1/2015
0 BLOOD P9034 0 999 Years $343.82 11/1/2015 0.00 $343.82 11/1/2015
0 BLOOD P9035 0 999 Years $362.50 11/1/2015 0.00 $362.50 11/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 117 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
0 BLOOD P9036 0 999 Years $262.17 11/1/2015 0.00 $262.17 11/1/2015
0 BLOOD P9037 0 999 Years $566.59 11/1/2015 0.00 $566.59 11/1/2015
0 BLOOD P9038 0 999 Years $93.30 11/1/2015 0.00 $93.30 11/1/2015
0 BLOOD P9039 0 999 Years $233.22 11/1/2015 0.00 $233.22 11/1/2015
0 BLOOD P9040 0 999 Years $153.00 11/1/2015 0.00 $153.00 11/1/2015
0 BLOOD P9041 0 999 Years $9.27 11/1/2015 0.00 $9.27 11/1/2015
0 BLOOD P9043 0 999 Years $22.52 11/1/2015 0.00 $22.52 11/1/2015
0 BLOOD P9044 0 999 Years $48.30 11/1/2015 0.00 $48.30 11/1/2015
0 BLOOD P9045 0 999 Years $46.36 11/1/2015 0.00 $46.36 11/1/2015
0 BLOOD P9046 0 999 Years $19.11 11/1/2015 0.00 $19.11 11/1/2015
0 BLOOD P9047 0 999 Years $45.42 11/1/2015 0.00 $45.42 11/1/2015
0 BLOOD P9048 0 999 Years $41.98 11/1/2015 0.00 $41.98 11/1/2015
0 BLOOD P9050 0 999 Years $1,093.88 11/1/2015 0.00 $1,093.88 11/1/2015
0 BLOOD P9051 0 999 Years $75.00 11/1/2015 0.00 $75.00 11/1/2015
0 BLOOD P9052 0 999 Years $446.25 11/1/2015 0.00 $446.25 11/1/2015
0 BLOOD P9053 0 999 Years $437.98 11/1/2015 0.00 $437.98 11/1/2015
0 BLOOD P9054 0 999 Years $68.00 11/1/2015 0.00 $68.00 11/1/2015
0 BLOOD P9055 0 999 Years $374.09 11/1/2015 0.00 $374.09 11/1/2015
0 BLOOD P9056 0 999 Years $143.49 11/1/2015 0.00 $143.49 11/1/2015
0 BLOOD P9057 0 999 Years $250.01 11/1/2015 0.00 $250.01 11/1/2015
0 BLOOD P9058 0 999 Years $214.72 11/1/2015 0.00 $214.72 11/1/2015
0 BLOOD P9059 0 999 Years $51.00 11/1/2015 0.00 $51.00 11/1/2015
0 BLOOD P9060 0 999 Years $51.00 11/1/2015 0.00 $51.00 11/1/2015
9
OTHER MEDICAL
ITEMS OR Q0507 0 999 Years * 7/1/2013 5 1/1/2016
9
OTHER MEDICAL
ITEMS OR Q0508 0 999 Years * 7/1/2013 -2.00 5 1/1/2016
1
MEDICAL
SERVICES Q4112 0 999 Years $223.73 4/1/2016 0.00 $223.73 4/1/2016
1
MEDICAL
SERVICES Q4113 0 999 Years $223.73 4/1/2016 0.00 $223.73 4/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 118 of 119
Frm Thru Units 1 2 3
TOSMod
1
Medicaid
Fee
Group
Amount
Proc
CodeTOS Desc
Mod
2
Last Pricing
Review Date
Adjusted Fee
for Report
Date
Client Age Fee Effect
Date
Adjust
%Group No
Note Codes
1
MEDICAL
SERVICES Q4114 0 999 Years $1,333.53 10/1/2016 0.00 $1,333.53 4/1/2016
9
OTHER MEDICAL
ITEMS OR V2790 0 999 Years $735.00 7/1/2014 0.00 $735.00 7/1/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
1/13/2017 TEXAS MEDICAID FEE SCHEDULE –
AMBULATORY SURGICAL CENTER (ASC) / HOSPITAL - BASED AMBULATORY SURGICAL CENTER (HASC) 119 of 119
Note Code(s): 5 - This procedure is manually reviewed to determine pricing.
6 - This procedure is payable only through the CCP program.
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
