Reimbursement Rates for Some 2018 HCPCS s Will Implement for the CSHCN Services Program Information posted April 24, 2018 April 17, 2018, the Children with Special Health Care Needs (CSHCN) Services Program reimbursement rates for some 2018 Healthcare Common Coding System (HCPCS) procedure codes will implement for dates of service on or after Jan. 1, 2018. for Dates of Service on or after Jan. 1, 2018 Annual Healthcare Common Coding System: Ambulatory surgical center/hospital ambulatory surgical center Anesthesia services Clinical laboratory services Dental services Diagnostic radiology Durable medical equipment Medical services Nonclinical laboratory services Physician administered drugs (non-oncology) Table 1 Physician administered drugs (oncology) Table 2 Physician administered drugs Quarterly HCPCS s Table 3 Surgery and assistant surgery Claims processed before April 17, 2018, with any of these procedure codes for dates of service on or after Jan. 1, 2018, will be reprocessed. Reprocessing may result in increased or decreased payments, which will be reflected on future Remittance and Status Reports. For more information, call the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.
Ambulatory Surgical Center/Hospital Ambulatory Surgical Center TOS F/Facility Range Group Number F 15730 F 0-999 8 $872.41 F 15733 F 0-999 8 $872.41 F 31253 F 0-999 9 $1,081.33 F 31257 F 0-999 9 $1,081.33 F 31259 F 0-999 9 $1,081.33 F 31298 F 0-999 9 $1,081.33 F 36465 F 0-999 5 $598.96 F 36466 F 0-999 5 $598.96 F 38222 F 0-999 $88.39 F 38573 F 0-999 9 $1,081.33 F 55874 F 0-999 9 $1,081.33 F 64912 F 0-999 9 $1,081.33 *Type of Service (TOS): F = Ambulatory Surgical Centers/Hospital Ambulatory Surgical Centers
Anesthesia Services TOS Non- Facility (N)/Facilit y (F) Range Base Units Base Fee Adjusted Base Fee (Net of s) 7 00731 N/F 0-20 5.00 $25.6000 $0.00 0.0% $0.00 7 00731 N/F 21-999 5.00 $24.3200 $0.00 0.0% $0.00 7 00732 N/F 0-20 6.00 $25.6000 $0.00 0.0% $0.00 7 00732 N/F 21-999 6.00 $24.3200 $0.00 0.0% $0.00 7 00811 N/F 0-20 4.00 $25.6000 $0.00 0.0% $0.00 7 00811 N/F 21-999 4.00 $24.3200 $0.00 0.0% $0.00 7 00812 N/F 0-20 3.00 $25.6000 $0.00 0.0% $0.00 7 00812 N/F 21-999 3.00 $24.3200 $0.00 0.0% $0.00 7 00813 N/F 0-20 5.00 $25.6000 $0.00 0.0% $0.00 7 00813 N/F 21-999 5.00 $24.3200 $0.00 0.0% $0.00 *Type of Service (TOS): 7 = Anesthesia Services
Clinical Laboratory Services Clinical Lab Fee Adjusted Clinical Lab Fee Sole Community Hospital Fee Adjusted Sole Community Hospital Fee TOS* Range 5 81105 0-999 $176.03 $147.87 $181.90 $152.80 5 81106 0-999 $176.03 $147.87 $181.90 $152.80 5 81107 0-999 $176.03 $147.87 $181.90 $152.80 5 81108 0-999 $176.03 $147.87 $181.90 $152.80 5 81109 0-999 $176.03 $147.87 $181.90 $152.80 5 81110 0-999 $176.03 $147.87 $181.90 $152.80 5 81111 0-999 $176.03 $147.87 $181.90 $152.80 5 81112 0-999 $176.03 $147.87 $181.90 $152.80 5 81120 0-999 $176.03 $147.87 $181.90 $152.80 5 81121 0-999 $176.03 $147.87 $181.90 $152.80 5 81238 0-999 $152.54 $128.13 $157.62 $132.40 5 81247 0-999 $176.03 $147.87 $181.90 $152.80 5 81248 0-999 $58.72 $49.32 $60.68 $50.97 5 81249 0-999 $152.54 $128.13 $157.62 $132.40 5 81258 0-999 $58.72 $49.32 $60.68 $50.97 5 81259 0-999 $191.72 $161.04 $198.11 $166.41 5 81269 0-999 $166.84 $140.15 $172.40 $144.82 5 81334 0-999 $331.82 $278.73 $342.88 $288.02 5 81361 0-999 $58.72 $49.32 $60.68 $50.97 5 81362 0-999 $58.72 $49.32 $60.68 $50.97 5 81363 0-999 $191.72 $161.04 $198.11 $166.41 5 81364 0-999 $152.54 $128.13 $157.62 $132.40 5 86008 0-999 $6.56 $5.51 $6.78 $5.70 5 86794 0-999 $11.22 $9.42 $11.59 $9.74 5 87634 0-999 $48.14 $40.44 $49.74 $41.78 5 87662 0-999 $48.14 $40.44 $49.74 $41.78 Type of Service (TOS): 5 = Laboratory
TOS* Dental Services (N)/Facility (F) MOD** Range Fee W D5511 N/F 0-999 $69.74 0.0% $69.74 W D5512 N/F 0-999 $69.74 0.0% $69.74 W D5611 N/F 0-999 $69.74 0.0% $69.74 W D5612 N/F 0-999 $69.74 0.0% $69.74 W D9222 N/F 0-999 $60.00 0.0% $60.00 W D9222 N/F UZ 0-999 $83.86 0.0% $83.86 W D9223 N/F 0-999 $45.00 0.0% $45.00 W D9223 N/F UZ 0-999 $62.90 0.0% $62.90 W D9239 N/F 0-999 $58.50 0.0% $58.50 W D9243 N/F 0-999 $43.88 0.0% $43.88 *Type of Service (TOS): W = Texas Health Steps (THSteps) Dental/Orthodontia, **Modifier: UZ = Special pricing for therapeutic dental (eligibility for enhanced rate is determined by provider qualifications)
TOS* Range Facility (N)/ Facility (F) RVU Diagnostic Radiology Fee 4 71045 0-20 N/F 0.56 $28.0672 $15.72 0% $15.72 4 71045 21-999 N/F 0.56 $26.7305 $14.97 0% $14.97 I 71045 0-20 N/F 0.26 $28.0672 $7.30 0% $7.30 I 71045 21-999 N/F 0.26 $26.7305 $6.95 0% $6.95 T 71045 0-20 N 0.30 $28.0672 $8.42 0% $8.42 T 71045 21-999 N 0.30 $26.7305 $8.02 0% $8.02 4 71046 0-20 N/F 0.86 $28.0672 $24.14 0% $24.14 4 71046 21-999 N/F 0.86 $26.7305 $22.99 0% $22.99 I 71046 0-20 N/F 0.31 $28.0672 $8.70 0% $8.70 I 71046 21-999 N/F 0.31 $26.7305 $8.29 0% $8.29 T 71046 0-20 N 0.55 $28.0672 $15.44 0% $15.44 T 71046 21-999 N 0.55 $26.7305 $14.70 0% $14.70 4 71047 0-20 N/F 1.10 $28.0672 $30.87 0% $30.87 4 71047 21-999 N/F 1.10 $26.7305 $29.40 0% $29.40 I 71047 0-20 N/F 0.40 $28.0672 $11.23 0% $11.23 I 71047 21-999 N/F 0.40 $26.7305 $10.69 0% $10.69 T 71047 0-20 N/F 0.70 $28.0672 $19.65 0% $19.65 T 71047 21-999 N/F 0.70 $26.7305 $18.71 0% $18.71 4 71048 0-20 N/F 1.18 $28.0672 $33.12 0% $33.12 4 71048 21-999 N/F 1.18 $26.7305 $31.54 0% $31.54 I 71048 0-20 N/F 0.46 $28.0672 $12.91 0% $12.91 I 71048 21-999 N/F 0.46 $26.7305 $12.30 0% $12.30 T 71048 0-20 N/F 0.72 $28.0672 $20.21 0% $20.21 T 71048 21-999 N/F 0.72 $26.7305 $19.25 0% $19.25 4 74018 0-20 N/F 0.77 $28.0672 $21.61 0% $21.61 4 74018 21-999 N/F 0.77 $26.7305 $20.58 0% $20.58 I 74018 0-20 N/F 0.26 $28.0672 $7.30 0% $7.30 I 74018 21-999 N/F 0.26 $26.7305 $6.95 0% $6.95 T 74018 0-20 N/F 0.51 $28.0672 $14.31 0% $14.31 T 74018 21-999 N/F 0.51 $26.7305 $13.63 0% $13.63 4 74019 0-20 N/F 0.94 $28.0672 $26.38 0% $26.38 4 74019 21-999 N/F 0.94 $26.7305 $25.13 0% $25.13 I 74019 0-20 N/F 0.33 $28.0672 $9.26 0% $9.26 I 74019 21-999 N/F 0.33 $26.7305 $8.82 0% $8.82
TOS* Range Facility (N)/ Facility (F) RVU Diagnostic Radiology Fee T 74019 0-20 N/F 0.61 $28.0672 $17.12 0% $17.12 T 74019 21-999 N/F 0.61 $26.7305 $16.31 0% $16.31 4 74021 0-20 N/F 1.10 $28.0672 $30.87 0% $30.87 4 74021 21-999 N/F 1.10 $26.7305 $29.40 0% $29.40 I 74021 0-20 N/F 0.39 $28.0672 $10.95 0% $10.95 I 74021 21-999 N/F 0.39 $26.7305 $10.42 0% $10.42 T 74021 0-20 N/F 0.71 $28.0672 $19.93 0% $19.93 T 74021 21-999 N/F 0.71 $26.7305 $18.98 0% $18.98 *Type of Service (TOS): 4= Radiology, I = Interpretation Component, T = Technical Component
TOS* Durable Medical Equipment Fee (N)/Facility (F) PT** Range J E0953 N/F 0-999 $110.63 0.0% $110.63 J E0954 N/F 0-999 $201.32 0.0% $201.32 9 L3761 N/F 0-999 $329.44 0.0% $329.44 9 L7700 N/F 0-999 $92.88 0.0% $92.88 9 L8625 F PT- 51 / 52 0-999 $1,251.03 0.0% $1,251.03 J L8625 N/F 0-999 $1,251.03 0.0% $1,251.03 9 L8694 F PT- 51 / 52 0-999 $1,933.91 0.0% $1,933.91 J L8694 N/F 0-999 $1,933.91 0.0% $1,933.91 *Type of Service (TOS): 9 = Other Medical Items or Service, J = DME Purchase-New **Proviter Type (PT): 51 = Ambulatory Surgical Center - Freestanding/Independent, 52 = Ambulatory Surgical Center - Hospital Based
TOS* Non- Facility (N)/Facil ity (F) Provider Type (PT) /Provider Specialty (PS)** MOD*** Medical Services Range RVU Fee 1 96573 N/F 0-20 5.37 $28.0672 $150.72 0.0% $150.72 1 96573 N/F 21-999 5.37 $26.7305 $143.54 0.0% $143.54 1 96574 N/F 0-20 6.92 $28.0672 $194.23 0.0% $194.23 1 96574 N/F 21-999 6.92 $26.7305 $184.98 0.0% $184.98 1 97763 N/F 44 UB 0-20 $30.31 0.0% $30.31 1 97763 N/F 44 U5 0-20 $35.66 0.0% $35.66 1 97763 N/F 44 UB 21-999 $30.31 0.0% $30.31 1 97763 N/F 44 U5 21-999 $35.66 0.0% $35.66 1 97763 N/F 65/25 UB 0-20 $30.31 0.0% $30.31 1 97763 N/F 65/25 U5 0-20 $35.66 0.0% $35.66 1 97763 N/F 65/25 U5 21-999 $35.66 0.0% $35.66 1 97763 N/F 65/25 UB 21-999 $30.31 0.0% $30.31 1 97763 N/F U5 0-20 $35.66 0.0% $35.66 1 97763 N/F UB 0-20 $30.31 0.0% $30.31 1 97763 N/F U5 21-999 $35.66 0.0% $35.66 1 97763 N/F UB 21-999 $30.31 0.0% $30.31 *Type of Service (TOS): 1 = Medical Services **Provider Type (PT) /Provider Specialty (PS): 65/25 = Comprehensive Outpatient Rehabilitation Facility/Outpatient Rehabilitation Facility, 44 = Home Health ncy, ***Modifier: U5 = Services provided by licensed therapist, UB = Services provided by therapy assistant
(N)/Facility (F) Nonclinical Laboratory Services TOS Range RVU Fee 5 94617 N/F 0-20 2.70 $28.0672 $75.78 0.0% $75.78 5 94617 N/F 21-999 2.70 $26.7305 $72.17 0.0% $72.17 I 94617 N/F 0-20 0.95 $28.0672 $26.66 0.0% $26.66 I 94617 N/F 21-999 0.95 $26.7305 $25.39 0.0% $25.39 T 94617 N/F 0-20 1.75 $28.0672 $49.12 0.0% $49.12 T 94617 N/F 21-999 1.75 $26.7305 $46.78 0.0% $46.78 5 94618 N/F 0-20 0.97 $28.0672 $27.23 0.0% $27.23 5 94618 N/F 21-999 0.97 $26.7305 $25.93 0.0% $25.93 I 94618 N/F 0-20 0.65 $28.0672 $18.24 0.0% $18.24 I 94618 N/F 21-999 0.65 $26.7305 $17.37 0.0% $17.37 T 94618 N/F 0-20 0.32 $28.0672 $8.98 0.0% $8.98 T 94618 N/F 21-999 0.32 $26.7305 $8.55 0.0% $8.55 *Type of Service (TOS): 5 = Laboratory Services, I = Interpretation Component, T = Technical Component
Physician administered drugs (Non Oncology) Table 1 TOS (N)/Facility (F) Modifier Range Fee Effecive Effecive 1 C9015 N/F 0-999 $10.10 0.0% $10.10 1 C9029 N/F 0-999 $104.01 0.0% $104.01 1 J1555 N/F 0-999 $11.72 0.0% $11.72 1 J7211 N/F 0-999 $1.83 0.0% $1.83 1 90756 N/F 0-18 Informational only Informational only 1 90756 N/F U4 0-18 $20.40 0.0% $20.40 1 90756 N/F 19-999 $20.40 0.0% $20.40 *Type of Service (TOS): 1 = Medical Services
TOS Physician administered drugs (Oncology) Table 2 (N)/Facility (F) Range Fee Effecive Effecive 1 C9016 N/F 0-999 $2,864.00 0.0% $2,864.00 1 C9024 N/F 0-999 $211.36 0.0% $211.36 1 C9028 N/F 0-999 $1,870.00 0.0% $1,870.00 1 J9203 N/F 0-999 $193.16 0.0% $193.16 *Type of Service (TOS): 1 = Medical Services
Physician Administered Drugs Quarterly HCPCS s Table 3 TOS (N)/Facility (F) Range Fee Effecive Effecive 1 C9492 N/F 0-999 $83.49 0.0% $83.49 1 J0565 N/F 0-999 $36.34 0.0% $36.34 1 J2350 N/F 0-999 $51.09 0.0% $51.09 1 J3358 N/F 0-999 $12.55 0.0% $12.55 1 J9285 N/F 0-999 $56.64 0.0% $56.64 1 J1627 N/F 0-999 $5.94 0.0% $5.94 1 J9023 N/F 0-999 $79.37 0.0% $79.37 *Type of Service (TOS): 1 = Medical Services
TOS (N)/Facility (F) Surgery and Assistant Surgery Range RVU Fee 2 15730 F 0-20 26.42 $28.0672 $741.54 0.0% $741.54 2 15730 F 21-999 26.42 $26.7305 $706.22 0.0% $706.22 2 15733 N/F 0-20 30.17 $28.0672 $846.79 0.0% $846.79 2 15733 N/F 21-999 30.17 $26.7305 $806.46 0.0% $806.46 2 19294 F 0-20 4.72 $28.0672 $132.48 0.0% $132.48 2 19294 F 21-999 4.72 $26.7305 $126.17 0.0% $126.17 2 20939 F 0-20 1.94 $28.0672 $54.45 0.0% $54.45 2 20939 F 21-999 1.94 $26.7305 $51.86 0.0% $51.86 2 31241 N/F 0-20 12.83 $28.0672 $360.10 0.0% $360.10 2 31241 N/F 21-999 12.83 $26.7305 $342.95 0.0% $342.95 2 31253 N/F 0-20 14.38 $28.0672 $403.61 0.0% $403.61 2 31253 N/F 21-999 14.38 $26.7305 $384.38 0.0% $384.38 2 31257 F 0-20 12.80 $28.0672 $359.26 0.0% $359.26 2 31257 F 21-999 12.80 $26.7305 $342.15 0.0% $342.15 2 31259 N/F 0-20 13.57 $28.0672 $380.87 0.0% $380.87 2 31259 N/F 21-999 13.57 $26.7305 $362.73 0.0% $362.73 2 31298 N 0-20 109.84 $28.0672 $3,082.90 0.0% $3,082.90 2 31298 F 0-20 7.33 $28.0672 $205.73 0.0% $205.73 2 31298 N 21-999 109.84 $26.7305 $2,936.08 0.0% $2,936.08 2 31298 F 21-999 7.33 $26.7305 $195.93 0.0% $195.93 2 34701 F 0-20 35.72 $28.0672 $1,002.56 0.0% $1,002.56 2 34701 F 21-999 35.72 $26.7305 $954.81 0.0% $954.81 8 34701 F 0-20 $160.41 0.0% $160.41 8 34701 F 21-999 $152.77 0.0% $152.77 2 34702 F 0-20 53.36 $28.0672 $1,497.67 0.0% $1,497.67 2 34702 F 21-999 53.36 $26.7305 $1,426.34 0.0% $1,426.34 8 34702 F 0-20 $239.63 0.0% $239.63 8 34702 F 21-999 $228.21 0.0% $228.21 2 34703 F 0-20 40.25 $28.0672 $1,129.70 0.0% $1,129.70 2 34703 F 21-999 40.25 $26.7305 $1,075.90 0.0% $1,075.90 8 34703 F 0-20 $180.75 0.0% $180.75 8 34703 F 21-999 $172.14 0.0% $172.14 2 34704 F 0-20 66.95 $28.0672 $1,879.10 0.0% $1,879.10 2 34704 F 21-999 66.95 $26.7305 $1,789.61 0.0% $1,789.61 8 34704 F 0-20 $300.66 0.0% $300.66 8 34704 F 21-999 $286.34 0.0% $286.34
Surgery and Assistant Surgery TOS (N)/Facility (F) Range RVU Fee 2 34705 F 0-20 44.34 $28.0672 $1,244.50 0.0% $1,244.50 2 34705 F 21-999 44.34 $26.7305 $1,185.23 0.0% $1,185.23 8 34705 F 0-20 $199.12 0.0% $199.12 8 34705 F 21-999 $189.64 0.0% $189.64 2 34706 F 0-20 66.74 $28.0672 $1,873.20 0.0% $1,873.20 2 34706 F 21-999 66.74 $26.7305 $1,783.99 0.0% $1,783.99 8 34706 F 0-20 $299.71 0.0% $299.71 8 34706 F 21-999 $285.44 0.0% $285.44 2 34707 F 0-20 33.31 $28.0672 $934.92 0.0% $934.92 2 34707 F 21-999 33.31 $26.7305 $890.39 0.0% $890.39 8 34707 F 0-20 $149.59 0.0% $149.59 8 34707 F 21-999 $142.46 0.0% $142.46 2 34708 F 0-20 53.61 $28.0672 $1,504.68 0.0% $1,504.68 2 34708 F 21-999 53.61 $26.7305 $1,433.02 0.0% $1,433.02 8 34708 F 0-20 $240.75 0.0% $240.75 8 34708 F 21-999 $229.28 0.0% $229.28 2 34709 F 0-20 9.38 $28.0672 $263.27 0.0% $263.27 2 34709 F 21-999 9.38 $26.7305 $250.73 0.0% $250.73 8 34709 F 0-20 $42.12 0.0% $42.12 8 34709 F 21-999 $40.12 0.0% $40.12 2 34710 F 0-20 23.25 $28.0672 $652.56 0.0% $652.56 2 34710 F 21-999 23.25 $26.7305 $621.48 0.0% $621.48 8 34710 F 0-20 $104.41 0.0% $104.41 8 34710 F 21-999 $99.44 0.0% $99.44 2 34711 F 0-20 8.66 $28.0672 $243.06 0.0% $243.06 2 34711 F 21-999 8.66 $26.7305 $231.49 0.0% $231.49 8 34711 F 0-20 $38.89 0.0% $38.89 8 34711 F 21-999 $37.04 0.0% $37.04 2 34712 F 0-20 19.87 $28.0672 $557.70 0.0% $557.70 2 34712 F 21-999 19.87 $26.7305 $531.14 0.0% $531.14 8 34712 F 0-999 $84.98 0.0% $84.98 2 34713 F 0-20 3.74 $28.0672 $104.97 0.0% $104.97 2 34713 F 21-999 3.74 $26.7305 $99.97 0.0% $99.97 8 34713 F 0-999 $16.00 0.0% $16.00 2 34714 F 0-20 7.85 $28.0672 $220.33 0.0% $220.33 2 34714 F 21-999 7.85 $26.7305 $209.83 0.0% $209.83
Surgery and Assistant Surgery TOS (N)/Facility (F) Range RVU Fee 8 34714 F 0-20 $35.25 0.0% $35.25 8 34714 F 21-999 $33.57 0.0% $33.57 2 34715 F 0-20 8.77 $28.0672 $246.15 0.0% $246.15 2 34715 F 21-999 8.77 $26.7305 $234.43 0.0% $234.43 8 34715 F 0-20 $39.38 0.0% $39.38 8 34715 F 21-999 $37.51 0.0% $37.51 2 34716 F 0-20 10.89 $28.0672 $305.65 0.0% $305.65 2 34716 F 21-999 10.89 $26.7305 $291.10 0.0% $291.10 8 34716 F 0-20 $48.90 0.0% $48.90 8 34716 F 21-999 $46.58 0.0% $46.58 2 36465 N 0-20 45.12 $28.0672 $1,266.39 0.0% $1,266.39 2 36465 F 0-20 3.46 $28.0672 $97.11 0.0% $97.11 2 36465 N 21-999 45.12 $26.7305 $1,206.08 0.0% $1,206.08 2 36465 F 21-999 3.46 $26.7305 $92.49 0.0% $92.49 2 36466 N 0-20 47.14 $28.0672 $1,323.09 0.0% $1,323.09 2 36466 F 0-20 4.40 $28.0672 $123.50 0.0% $123.50 2 36466 N 21-999 47.14 $26.7305 $1,260.08 0.0% $1,260.08 2 36466 F 21-999 4.40 $26.7305 $117.61 0.0% $117.61 2 38222 N 0-20 4.84 $28.0672 $135.85 0.0% $135.85 2 38222 F 0-20 2.24 $28.0672 $62.87 0.0% $62.87 2 38222 N 21-999 4.84 $26.7305 $129.38 0.0% $129.38 2 38222 F 21-999 2.24 $26.7305 $59.88 0.0% $59.88 2 38573 F 0-20 33.59 $28.0672 $942.78 0.0% $942.78 2 38573 F 21-999 33.59 $26.7305 $897.88 0.0% $897.88 8 38573 F 0-20 $150.84 0.0% $150.84 8 38573 F 21-999 $143.66 0.0% $143.66 2 43286 F 0-20 91.06 $28.0672 $2,555.80 0.0% $2,555.80 2 43286 F 21-999 91.06 $26.7305 $2,434.08 0.0% $2,434.08 8 43286 F 0-20 $408.93 0.0% $408.93 8 43286 F 21-999 $389.45 0.0% $389.45 2 43287 F 0-20 104.00 $28.0672 $2,918.99 0.0% $2,918.99 2 43287 F 21-999 104.00 $26.7305 $2,779.97 0.0% $2,779.97 8 43287 F 0-20 $467.04 0.0% $467.04 8 43287 F 21-999 $444.80 0.0% $444.80 2 43288 F 0-20 108.51 $28.0672 $3,045.57 0.0% $3,045.57 2 43288 F 21-999 108.51 $26.7305 $2,900.53 0.0% $2,900.53
Surgery and Assistant Surgery TOS (N)/Facility (F) Range RVU Fee 8 43288 F 0-20 $487.29 0.0% $487.29 8 43288 F 21-999 $464.08 0.0% $464.08 2 55874 N 0-20 105.48 $28.0672 $2,960.53 0.0% $2,960.53 2 55874 F 0-20 4.81 $28.0672 $135.00 0.0% $135.00 2 55874 N 21-999 105.48 $26.7305 $2,819.53 0.0% $2,819.53 2 55874 F 21-999 4.81 $26.7305 $128.57 0.0% $128.57 2 58575 F 0-20 53.62 $28.0672 $1,504.96 0.0% $1,504.96 2 58575 F 21-999 53.62 $26.7305 $1,433.29 0.0% $1,433.29 2 64912 F 0-20 22.39 $28.0672 $628.42 0.0% $628.42 2 64912 F 21-999 22.39 $26.7305 $598.50 0.0% $598.50 8 64912 F 0-20 $100.55 0.0% $100.55 8 64912 F 21-999 $95.76 0.0% $95.76 2 64913 F 0-20 4.54 $28.0672 $127.43 0.0% $127.43 2 64913 F 21-999 4.54 $26.7305 $121.36 0.0% $121.36 8 64913 F 0-20 $20.39 0.0% $20.39 8 64913 F 21-999 $19.42 0.0% $19.42 2 C9738 N 0-20 $132.76 0.0% $132.76 2 C9738 F 0-20 $66.80 0.0% $66.80 2 C9738 N 21-999 $126.44 0.0% $126.44 2 C9738 F 21-999 $63.62 0.0% $63.62 2 C9748 F 0-20 $493.70 0.0% $493.70 2 C9748 F 21-999 $470.19 0.0% $470.19 *Type of Service (TOS): 2 = Surgery, 8 = Assistant Surgery