Reimbursement Rates for Some 2014 HCPCS Procedure Codes to Be Implemented for the CSHCN Services Program Information posted May 20, 2014 May 29, 2014, for dates of service on or after January 1, 2014, the Children with Special Health Care Needs (CSHCN) Services Program will implement initial reimbursement rates for some 2014 Healthcare Common Procedure Coding System (HCPCS) procedure codes. The tables on the following pages show the reimbursement rate changes that will be applied to affected procedure codes in the following categories: Ambulatory Surgical Centers Clinical Laboratory (TOS 5) Durable Medical Equipment (Prosthetics, Orthotics and Supplies) Non-Drugs (TOS) Non-Clinical Laboratory (TOS) Physician Administered Drugs Oncology Physician Administered Drugs Surgery Assistant Surgery Services Radiation Therapy (TOS 6, I, T) Claims for any of these procedure codes with dates of service on or after January 1, 2014, which were processed before the implementation date, will be reprocessed. Providers may receive additional payment, which will be reflected on Remittance and Status (R&S) Reports. For more information, call the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.
Ambulatory Surgical Centers (2014 Annual HCPCS) Service (TOS)* Procedure Code Age Range Group Number Max Fee F 10030 0-999 N/A $70.56 F 19081 0-999 1 F 19083 0-999 1 F 19085 0-999 1 F 23333 0-999 1 F 23334 0-999 6 F 37236 0-999 9 F 37238 0-999 9 F 43191 0-999 1 F 43192 0-999 3 F 43193 0-999 3 F 43194 0-999 3 F 43195 0-999 3 F 43196 0-999 3 F 43197 0-999 1 F 43198 0-999 1 F 43211 0-999 1 F 43212 0-999 8 F 43213 0-999 3 F 43214 0-999 3 F 43229 0-999 7 F 43233 0-999 3 F 43253 0-999 3 F 43254 0-999 1 F 43266 0-999 8 F 43270 0-999 3 F 43274 0-999 7 F 43275 0-999 7 F 43276 0-999 7 F 43277 0-999 7 F 43278 0-999 7 F 49407 0-999 1 F 52356 0-999 9 F 64616 0-999 N/A $31.86 F 64617 0-999 N/A $68.54 F 64642 0-999 N/A $41.71 F 64644 0-999 N/A $49.46 F 64646 0-999 N/A $44.44 F 64647 0-999 N/A $50.94 F 66183 0-999 9 F C9735 0-999 9 TOS*: F = Ambulatory Surgical Centers
Service (TOS)* Procedure Code Age Group Clinical Lab Fee Clinical Laboratory 12.5% Adjusted Clinical Lab Fee Sole Community Hospital Fee 12.5% Adjusted Sole Community Fee 5 80155 0-999 $19.30 $16.21 $19.94 $16.75 5 80159 0-999 $25.23 $21.19 $26.07 $21.90 5 80169 0-999 $18.73 $15.73 $19.35 $16.26 5 80171 0-999 $18.09 $15.20 $18.69 $15.70 5 80175 0-999 $18.09 $15.20 $18.69 $15.70 5 80177 0-999 $18.09 $15.20 $18.69 $15.70 5 80180 0-999 $24.63 $20.69 $25.45 $21.38 5 80183 0-999 $18.09 $15.20 $18.69 $15.70 5 80199 0-999 $24.63 $20.69 $25.45 $21.38 5 80203 0-999 $18.09 $15.20 $18.69 $15.70 5 87661 0-999 $47.87 $40.21 $49.47 $41.55 TOS*: 5 = Laboratory
Durable Medical Equipment, Prosthetics, Orhotics and Supplies Service (TOS)* Procedure Code Age Range Fee Percent Reduction Adjusted Fee (Net of Reductions) 9 T4544 0-999 $1.40 0.0% $1.40 9 L0455 0-999 $246.59 0.0% $246.59 9 L0457 0-999 $463.08-8.0% $426.03 9 L0467 0-999 $283.09 0.0% $283.09 9 L0469 0-999 $327.75 0.0% $327.75 9 L0641 0-999 $55.43 0.0% $55.43 9 L0642 0-999 $292.28 0.0% $292.28 9 L0643 0-999 $115.14 0.0% $115.14 9 L0648 0-999 $729.94 0.0% $729.94 9 L0649 0-999 $203.89 0.0% $203.89 9 L0650 0-999 $400.98-8.0% $368.90 9 L0651 0-999 $648.94-8.0% $597.02 9 L1812 0-999 $72.68-8.0% $66.87 9 L1833 0-999 $359.45-8.0% $330.69 9 L1848 0-999 $435.27-8.0% $400.45 9 L3678 0-999 $381.82-8.0% $351.27 9 L3809 0-999 $161.81 0.0% $161.81 9 L3916 0-999 $343.98 0.0% $343.98 9 L3918 0-999 $68.34 0.0% $68.34 9 L3924 0-999 $56.29 0.0% $56.29 9 L3930 0-999 $64.25-8.0% $59.11 9 L4361 0-999 $162.84-8.0% $149.81 9 L4387 0-999 $112.74 0.0% $112.74 9 L4397 0-999 $124.50-8.0% $114.54 TOS*: 9 = Other Durable Medical Equipment (DME) Purchased Used
Non Drugs (TOS1) Service (TOS)* Procedure Code Age Range POS Fee Percent Reduction Reductions) 1 92521 0-20 N/F $117.18 0.0% $117.18 1 92521 21-999 N/F $117.18 0.0% $117.18 1 92521 0-20 2 $120.00 0.0% $120.00 1 92521 21-999 2 $120.00 0.0% $120.00 1 92522 0-20 N/F $146.48 0.0% $146.48 1 92522 21-999 N/F $146.48 0.0% $146.48 1 92522 0-20 2 $150.00 0.0% $150.00 1 92522 21-999 2 $150.00 0.0% $150.00 1 92523 0-20 N/F $195.30 0.0% $195.30 1 92523 21-999 N/F $195.30 0.0% $195.30 1 92523 0-20 2 $200.00 0.0% $200.00 1 92523 21-999 2 $200.00 0.0% $200.00 1 92524 0-20 N/F $97.65 0.0% $97.65 1 92524 21-999 N/F $97.65 0.0% $97.65 1 92524 0-20 2 $100.00 0.0% $100.00 1 92524 21-999 2 $100.00 0.0% $100.00 TOS*: 1 = Medical
Service (TOS)* Procedure Code Age Range Non-Clinical Laboratory Fee Percent Reduction Adjusted Fee (Net of Reductions) 5 81287 0-20 $88.17 0.0% $88.17 5 81287 21-999 $88.17 0.0% $88.17 TOS*: 5 = Laboratory
Service (TOS)* Physcian Administered Drugs - Oncology Reductions) 1-1-12014 Procedure Code Age Range Fee Percent Reduction 1 J1442 0-999 $0.99 0.00% $0.99 1 J3489 0-999 $105.42 0.00% $105.42 1 J9371 0-999 $2,340.00 0.00% $2,340.00 TOS*: 1 = Medical
Physician Administered Drugs Service TOS* Reductions) Procedure Code Age Range Fee Percent Reduction 1 90673 19-999 $34.37 0.00% $34.37 1 C9133 0-999 $0.74 0.00% $0.74 1 J0151 0-999 $3.45 0.00% $3.45 1 J0401 0-999 $4.01 0.00% $4.01 1 J0717 0-999 $3.86 0.00% $3.86 1 J1602 0-999 $6.18 0.00% $6.18 1 J9306 0-999 $9.90 0.00% $9.90 1 Q3027 0-999 $38.63 0.00% $38.63 1 Q3028 0-999 $18.68 0.00% $18.68 1 Q4137 0-999 $165.04 0.00% $165.04 1 Q4138 0-999 $229.06 0.00% $229.06 1 Q4140 0-999 $146.24 0.00% $146.24 1 Q4142 0-999 $30.53 0.00% $30.53 1 Q4143 0-999 $21.91 0.00% $21.91 1 Q4146 0-999 $153.29 0.00% $153.29 1 Q4147 0-999 $58.91 0.00% $58.91 1 Q4148 0-999 $230.96 0.00% $230.96 1 Q4149 0-999 $43.35 0.00% $43.35 TOS*: 1 = Medical
Surgery and Assistant Surgery Place of Relative Service Procedure Service Age Value Unit Conversion Fee Percent Reductions) (TOS)* Code (POS)** Range (RVU) Factor Reduction 1-1-2014 2 10030 N 0-20 22.07 $28.07 $619.44 0.00% $619.44 2 10030 F 0-20 4.45 $28.07 $124.90 0.00% $124.90 2 10030 N 21-999 22.07 $26.73 $589.94 0.00% $589.94 2 10030 F 21-999 4.45 $26.73 $118.95 0.00% $118.95 2 19081 N 0-20 19.04 $28.07 $534.40 0.00% $534.40 2 19081 F 0-20 5.23 $28.07 $146.79 0.00% $146.79 2 19081 N 21-999 19.04 $26.73 $508.95 0.00% $508.95 2 19081 F 21-999 5.23 $26.73 $139.80 0.00% $139.80 2 19082 N 0-20 15.38 $28.07 $431.67 0.00% $431.67 2 19082 F 0-20 2.49 $28.07 $69.89 0.00% $69.89 2 19082 N 21-999 15.38 $26.73 $411.12 0.00% $411.12 2 19082 F 21-999 2.49 $26.73 $66.56 0.00% $66.56 2 19083 N 0-20 18.91 $28.07 $530.75 0.00% $530.75 2 19083 F 0-20 4.9 $28.07 $137.53 0.00% $137.53 2 19083 N 21-999 18.91 $26.73 $505.47 0.00% $505.47 2 19083 F 21-999 4.9 $26.73 $130.98 0.00% $130.98 2 19084 N 0-20 15.17 $28.07 $425.78 0.00% $425.78 2 19084 F 0-20 2.34 $28.07 $65.68 0.00% $65.68 2 19084 N 21-999 15.17 $26.73 $405.50 0.00% $405.50 2 19084 F 21-999 2.34 $26.73 $62.55 0.00% $62.55 2 19085 N 0-20 28.62 $28.07 $803.28 0.00% $803.28 2 19085 F 0-20 5.72 $28.07 $160.54 0.00% $160.54 2 19085 N 21-999 28.62 $26.73 $765.03 0.00% $765.03 2 19085 F 21-999 5.72 $26.73 $152.90 0.00% $152.90 2 19086 N 0-20 22.81 $28.07 $640.21 0.00% $640.21 2 19086 F 0-20 2.55 $28.07 $71.57 0.00% $71.57 2 19086 N 21-999 22.81 $26.73 $609.72 0.00% $609.72 2 19086 F 21-999 2.55 $26.73 $68.16 0.00% $68.16 2 19281 N 0-20 6.86 $28.07 $192.54 0.00% $192.54 2 19281 F 0-20 2.93 $28.07 $82.24 0.00% $82.24 2 19281 N 21-999 6.86 $26.73 $183.37 0.00% $183.37 2 19281 F 21-999 2.93 $26.73 $78.32 0.00% $78.32 2 19282 N 0-20 4.76 $28.07 $133.60 0.00% $133.60 2 19282 F 0-20 1.4 $28.07 $39.29 0.00% $39.29 2 19282 N 21-999 4.76 $26.73 $127.24 0.00% $127.24 2 19282 F 21-999 1.4 $26.73 $37.42 0.00% $37.42 2 19283 N 0-20 7.79 $28.07 $218.64 0.00% $218.64 2 19283 F 0-20 2.96 $28.07 $83.08 0.00% $83.08 2 19283 N 21-999 7.79 $26.73 $208.23 0.00% $208.23 2 19283 F 21-999 2.96 $26.73 $79.12 0.00% $79.12 2 19284 N 0-20 5.71 $28.07 $160.26 0.00% $160.26 2 19284 F 0-20 1.41 $28.07 $39.57 0.00% $39.57 2 19284 N 21-999 5.71 $26.73 $152.63 0.00% $152.63 2 19284 F 21-999 1.41 $26.73 $37.69 0.00% $37.69 2 19285 N 0-20 13.18 $28.07 $369.93 0.00% $369.93 2 19285 F 0-20 2.51 $28.07 $70.45 0.00% $70.45 2 19285 N 21-999 13.18 $26.73 $352.31 0.00% $352.31 2 19285 F 21-999 2.51 $26.73 $67.09 0.00% $67.09 2 19286 N 0-20 11.05 $28.07 $310.14 0.00% $310.14 2 19286 F 0-20 1.21 $28.07 $33.96 0.00% $33.96 2 19286 N 21-999 11.05 $26.73 $295.37 0.00% $295.37 2 19286 F 21-999 1.21 $26.73 $32.34 0.00% $32.34 2 19287 N 0-20 24.42 $28.07 $685.40 0.00% $685.40 2 19287 F 0-20 4.08 $28.07 $114.51 0.00% $114.51 2 19287 N 21-999 24.42 $26.73 $652.76 0.00% $652.76 2 19287 F 21-999 4.08 $26.73 $109.06 0.00% $109.06 2 19288 N 0-20 19.44 $28.07 $545.63 0.00% $545.63 2 19288 F 0-20 1.81 $28.07 $50.80 0.00% $50.80 2 19288 N 21-999 19.44 $26.73 $519.64 0.00% $519.64 2 19288 F 21-999 1.81 $26.73 $48.38 0.00% $48.38 2 23333 N/F 0-20 13.01 $28.07 $365.15 0.00% $365.15 2 23333 N/F 21-999 13.01 $26.73 $347.76 0.00% $347.76 2 23334 N/F 0-20 30.71 $28.07 $861.94 0.00% $861.94 2 23334 N/F 21-999 30.71 $26.73 $820.89 0.00% $820.89 2 23335 N/F 0-20 36.62 $28.07 $1,027.82 0.00% $1,027.82
Surgery and Assistant Surgery Place of Relative Service Procedure Service Age Value Unit Conversion Fee Percent Reductions) (TOS)* Code (POS)** Range (RVU) Factor Reduction 1-1-2014 2 23335 N/F 21-999 36.62 $26.73 $978.87 0.00% $978.87 2 33366 N/F 0-20 55.69 $28.07 $1,563.06 0.00% $1,563.06 2 33366 N/F 21-999 55.69 $26.73 $1,488.62 0.00% $1,488.62 2 34841 N/F 0-20 $1,088.73 0.00% $1,088.73 2 34841 N/F 21-999 $1,036.88 0.00% $1,036.88 2 34842 N/F 0-20 $1,428.34 0.00% $1,428.34 2 34842 N/F 21-999 $1,360.32 0.00% $1,360.32 2 34843 N/F 0-20 $1,767.95 0.00% $1,767.95 2 34843 N/F 21-999 $1,683.75 0.00% $1,683.75 2 34844 N/F 0-20 $2,107.57 0.00% $2,107.57 2 34844 N/F 21-999 $2,007.19 0.00% $2,007.19 2 34845 N/F 0-20 $1,088.73 0.00% $1,088.73 2 34845 N/F 21-999 $1,036.88 0.00% $1,036.88 2 34846 N/F 0-20 $1,428.34 0.00% $1,428.34 2 34846 N/F 21-999 $1,360.32 0.00% $1,360.32 2 34847 N/F 0-20 $1,767.95 0.00% $1,767.95 2 34847 N/F 21-999 $1,683.75 0.00% $1,683.75 2 34848 N/F 0-20 $2,107.57 0.00% $2,107.57 2 34848 N/F 21-999 $2,007.19 0.00% $2,007.19 2 37217 N/F 0-20 32.5 $28.07 $912.18 0.00% $912.18 2 37217 N/F 21-999 32.5 $26.73 $868.74 0.00% $868.74 2 37236 N 0-20 79.91 $28.07 $2,242.85 0.00% $2,242.85 2 37236 F 0-20 13.46 $28.07 $377.78 0.00% $377.78 2 37236 N 21-999 79.91 $26.73 $2,136.03 0.00% $2,136.03 2 37236 F 21-999 13.46 $26.73 $359.79 0.00% $359.79 2 37237 N 0-20 34.71 $28.07 $974.21 0.00% $974.21 2 37237 F 0-20 6.29 $28.07 $176.54 0.00% $176.54 2 37237 N 21-999 34.71 $26.73 $927.82 0.00% $927.82 2 37237 F 21-999 6.29 $26.73 $168.13 0.00% $168.13 2 37238 N 0-20 116.85 $28.07 $3,279.65 0.00% $3,279.65 2 37238 F 0-20 9.43 $28.07 $264.67 0.00% $264.67 2 37238 N 21-999 116.85 $26.73 $3,123.46 0.00% $3,123.46 2 37238 F 21-999 9.43 $26.73 $252.07 0.00% $252.07 2 37239 N 0-20 58.08 $28.07 $1,630.14 0.00% $1,630.14 2 37239 F 0-20 4.39 $28.07 $123.22 0.00% $123.22 2 37239 N 21-999 58.08 $26.73 $1,552.51 0.00% $1,552.51 2 37239 F 21-999 4.39 $26.73 $117.35 0.00% $117.35 2 37241 N 0-20 129.36 $28.07 $3,630.77 0.00% $3,630.77 2 37241 F 0-20 12.95 $28.07 $363.47 0.00% $363.47 2 37241 N 21-999 129.36 $26.73 $3,457.86 0.00% $3,457.86 2 37241 F 21-999 12.95 $26.73 $346.16 0.00% $346.16 2 37242 N 0-20 217.89 $28.07 $6,115.56 0.00% $6,115.56 2 37242 F 0-20 14.46 $28.07 $405.85 0.00% $405.85 2 37242 N 21-999 217.89 $26.73 $5,824.31 0.00% $5,824.31 2 37242 F 21-999 14.46 $26.73 $386.52 0.00% $386.52 2 37243 N 0-20 275.06 $28.07 $7,720.16 0.00% $7,720.16 2 37243 F 0-20 17.24 $28.07 $483.88 0.00% $483.88 2 37243 N 21-999 275.06 $26.73 $7,352.49 0.00% $7,352.49 2 37243 F 21-999 17.24 $26.73 $460.83 0.00% $460.83 2 37244 N 0-20 192.59 $28.07 $5,405.46 0.00% $5,405.46 2 37244 F 0-20 20.11 $28.07 $564.43 0.00% $564.43 2 37244 N 21-999 192.59 $26.73 $5,148.03 0.00% $5,148.03 2 43191 N/F 21-999 3.64 $26.73 $97.30 0.00% $97.30 2 43192 N/F 0-20 4.34 $28.0672 $121.81 0.00% $121.81 2 43192 N/F 21-999 4.34 $26.7305 $116.01 0.00% $116.01 2 43193 N/F 0-20 5.17 $28.07 $145.11 0.00% $145.11 2 43193 N/F 21-999 5.17 $26.73 $138.20 0.00% $138.20 2 43194 N/F 0-20 4.69 $28.07 $131.64 0.00% $131.64 2 43194 N/F 21-999 4.69 $26.73 $125.37 0.00% $125.37 2 43195 N/F 0-20 5.18 $28.07 $145.39 0.00% $145.39 2 43195 N/F 21-999 5.18 $26.73 $138.46 0.00% $138.46 2 43196 N/F 0-20 5.68 $28.07 $159.42 0.00% $159.42 2 43196 N/F 21-999 5.68 $26.73 $151.83 0.00% $151.83 2 43197 N 0-20 5.24 $28.07 $147.07 0.00% $147.07 2 43197 F 0-20 2.31 $28.07 $64.84 0.00% $64.84
Surgery and Assistant Surgery Place of Relative Service Procedure Service Age Value Unit Conversion Fee Percent Reductions) (TOS)* Code (POS)** Range (RVU) Factor Reduction 1-1-2014 2 43197 N 21-999 5.24 $26.73 $140.07 0.00% $140.07 2 43197 F 21-999 2.31 $26.73 $61.75 0.00% $61.75 2 43198 N 0-20 5.85 $28.07 $164.19 0.00% $164.19 2 43198 F 0-20 2.75 $28.07 $77.18 0.00% $77.18 2 43198 N 21-999 5.85 $26.73 $156.37 0.00% $156.37 2 43198 F 21-999 2.75 $26.73 $73.51 0.00% $73.51 2 43211 N/F 0-20 7.06 $28.07 $198.15 0.00% $198.15 2 43211 N/F 21-999 7.06 $26.73 $188.72 0.00% $188.72 2 43212 N/F 0-20 5.57 $28.07 $156.33 0.00% $156.33 2 43212 N/F 21-999 5.57 $26.73 $148.89 0.00% $148.89 2 43213 N 0-20 34.97 $28.07 $981.51 0.00% $981.51 2 43213 F 21-999 7.85 $26.73 $209.83 0.00% $209.83 2 43213 N 0-20 34.97 $28.07 $981.51 0.00% $981.51 2 43213 F 21-999 7.85 $26.73 $209.83 0.00% $209.83 2 43214 N/F 0-20 5.68 $28.07 $159.42 0.00% $159.42 2 43214 N/F 21-999 5.68 $26.73 $151.83 0.00% $151.83 2 43229 N 0-20 20.62 $28.07 $578.75 0.00% $578.75 2 43229 F 0-20 6 $28.07 $168.40 0.00% $168.40 2 43229 N 21-999 20.62 $26.73 $551.18 0.00% $551.18 2 43229 F 21-999 6 $26.73 $160.38 0.00% $160.38 2 43233 N/F 0-20 6.74 $28.07 $189.17 0.00% $189.17 2 43233 N/F 21-999 6.74 $26.73 $180.16 0.00% $180.16 2 43253 N/F 0-20 7.82 $28.07 $219.49 0.00% $219.49 2 43253 N/F 21-999 7.82 $26.73 $209.03 0.00% $209.03 2 43254 N/F 0-20 8.12 $28.07 $227.91 0.00% $227.91 2 43254 N/F 21-999 8.12 $26.73 $217.05 0.00% $217.05 2 43266 N/F 0-20 6.72 $28.07 $188.61 0.00% $188.61 2 43266 N/F 21-999 6.72 $26.73 $179.63 0.00% $179.63 2 43270 N 0-20 20.56 $28.07 $577.06 0.00% $577.06 2 43270 F 0-20 7.06 $28.07 $198.15 0.00% $198.15 2 43270 N 21-999 20.56 $26.73 $549.58 0.00% $549.58 2 43270 F 21-999 7.06 $26.73 $188.72 0.00% $188.72 2 43274 N/F 0-20 13.91 $28.07 $390.41 0.00% $390.41 2 43274 N/F 21-999 13.91 $26.73 $371.82 0.00% $371.82 2 43275 N/F 0-20 11.47 $28.07 $321.93 0.00% $321.93 2 43275 N/F 21-999 11.47 $26.73 $306.60 0.00% $306.60 2 43276 N/F 0-20 14.47 $28.07 $406.13 0.00% $406.13 2 43276 N/F 21-999 14.47 $26.73 $386.79 0.00% $386.79 2 43277 N/F 0-20 11.54 $28.07 $323.90 0.00% $323.90 2 43277 N/F 21-999 11.54 $26.73 $308.47 0.00% $308.47 2 43278 N/F 0-20 13.12 $28.07 $368.24 0.00% $368.24 2 43278 N/F 21-999 13.12 $26.73 $350.70 0.00% $350.70 2 49405 N 0-20 24.74 $28.07 $694.38 0.00% $694.38 2 49405 F 0-20 6.15 $28.07 $172.61 0.00% $172.61 2 49405 N 21-999 24.74 $26.73 $661.31 0.00% $661.31 2 49405 F 21-999 6.15 $26.73 $164.39 0.00% $164.39 2 49406 N 0-20 24.73 $28.07 $694.10 0.00% $694.10 2 49406 F 0-20 6.16 $28.07 $172.89 0.00% $172.89 2 49406 N 21-999 24.73 $26.73 $661.05 0.00% $661.05 2 49406 F 21-999 6.16 $26.73 $164.66 0.00% $164.66 2 49407 N 0-20 20.9 $28.07 $586.60 0.00% $586.60 2 49407 F 0-20 6.56 $28.07 $184.12 0.00% $184.12 2 49407 N 21-999 20.9 $26.73 $558.67 0.00% $558.67 2 49407 F 21-999 6.56 $26.73 $175.35 0.00% $175.35 2 52356 N/F 0-20 11.83 $28.07 $332.03 0.00% $332.03 2 52356 N/F 21-999 11.83 $26.73 $316.22 0.00% $316.22 2 64616 N 0-20 3.48 $28.07 $97.67 0.00% $97.67 2 64616 F 0-20 3.07 $28.07 $86.17 0.00% $86.17 2 64616 N 21-999 3.48 $26.73 $93.02 0.00% $93.02 2 64616 F 21-999 3.07 $26.73 $82.06 0.00% $82.06 2 64617 N 0-20 5.4 $28.07 $151.56 0.00% $151.56 2 64617 F 0-20 3.26 $28.07 $91.50 0.00% $91.50 2 64617 N 21-999 5.4 $26.73 $144.34 0.00% $144.34 2 64617 F 21-999 3.26 $26.73 $87.14 0.00% $87.14 2 64642 N 0-20 3.95 $28.07 $110.87 0.00% $110.87
Surgery and Assistant Surgery Place of Relative Service Procedure Service Age Value Unit Conversion Fee Percent Reductions) (TOS)* Code (POS)** Range (RVU) Factor Reduction 1-1-2014 2 64642 F 0-20 3.06 $28.07 $85.89 0.00% $85.89 2 64642 N 21-999 3.95 $26.73 $105.59 0.00% $105.59 2 64642 F 21-999 3.06 $26.73 $81.80 0.00% $81.80 2 64643 N 0-20 2.6 $28.07 $72.97 0.00% $72.97 2 64643 F 0-20 2.05 $28.07 $57.54 0.00% $57.54 2 64643 N 21-999 2.6 $26.73 $69.50 0.00% $69.50 2 64643 F 21-999 2.05 $26.73 $54.80 0.00% $54.80 2 64644 N 0-20 4.51 $28.07 $126.58 0.00% $126.58 2 64644 F 0-20 3.34 $28.07 $93.74 0.00% $93.74 2 64644 N 21-999 4.51 $26.73 $120.55 0.00% $120.55 2 64644 F 21-999 3.34 $26.73 $89.28 0.00% $89.28 2 64645 N 0-20 3.18 $28.07 $89.25 0.00% $89.25 2 64645 F 0-20 2.35 $28.07 $65.96 0.00% $65.96 2 64645 N 21-999 3.18 $26.73 $85.00 0.00% $85.00 2 64645 F 21-999 2.35 $26.73 $62.82 0.00% $62.82 2 64646 N 0-20 4.25 $28.07 $119.29 0.00% $119.29 2 64646 F 0-20 3.31 $28.07 $92.90 0.00% $92.90 2 64646 N 21-999 4.25 $26.73 $113.60 0.00% $113.60 2 64646 F 21-999 3.31 $26.73 $88.48 0.00% $88.48 2 64647 N 0-20 4.92 $28.07 $138.09 0.00% $138.09 2 64647 F 0-20 3.82 $28.07 $107.22 0.00% $107.22 2 64647 N 21-999 4.92 $26.73 $131.51 0.00% $131.51 2 64647 F 21-999 3.82 $26.73 $102.11 0.00% $102.11 2 66183 N/F 0-20 30.42 $28.07 $853.80 0.00% $853.80 2 66183 N/F 21-999 30.42 $26.73 $813.14 0.00% $813.14 8 66183 N/F 0-20 4.87 $28.07 $136.69 0.00% $136.69 8 66183 N/F 21-999 4.87 $26.73 $130.18 0.00% $130.18 2 93582 N/F 0-20 19.47 $28.07 $546.47 0.00% $546.47 2 93582 N/F 21-999 19.47 $26.73 $520.44 0.00% $520.44 2 93583 N/F 0-20 21.67 $28.07 $608.22 0.00% $608.22 2 93583 N/F 21-999 21.67 $26.73 $579.25 0.00% $579.25 TOS*: 2 = Surgery, 8 = Assistant Surgery POS*: N = Non-Facility, F = Facility
Service (TOS)* Procedure Code Radiation Therapy Services, Professional Component and Technical Component Age Range Place of Service (POS)** Relative Value Unit (RVU) Conversion Factor Fee Percent Reduction Adjusted Fee (Net of Reductions) 6 77293 0-20 N/F 12.07 $28.0672 $338.77 0.0% $338.77 6 77293 21-999 N/F 12.07 $26.7305 $322.64 0.0% $322.64 I 77293 0-20 N/F 2.9 $28.0672 $81.39 0.0% $81.39 I 77293 21-999 N/F 2.9 $26.7305 $77.52 0.0% $77.52 T 77293 0-20 N/F 9.17 $28.0672 $257.38 0.0% $257.38 T 77293 21-999 N/F 9.17 $26.7305 $245.12 0.0% $245.12 TOS*: 6 = Radiation Therapy, I = Professional Component, T = Technical Component POS**: N= Non-Facility, F = Facility