fee schedule

FEE SCHEDULE
CODE DESCRIPTION
MEDICATIONS
MED88 ACYCLOVIR/ZOVIRAX 400MG/#60
MED02 ALBUTEROL INHALER
MED06 AMOXICILLIN 250MG/#30
MED07 AMOXICILLIN 500MG/#30
MED85 AMOX-POT-CLAV/AUGMENTIN 875-125/#20
A9150O ANTACID, LIQUID 12OZ
MED08 APAP W/ CODEINE/T-3 #10
MED09 APAP W/ CODEINE/T-3 #15
MED67 AZITHROMYCIN/ZITHROMAX 250MG/#6
MED109 AZITHROMYCIN/ZITHROMAX 500MG/#2
MED98 BENZONATATE/TESSALON 100MG/#20
MED99 BUPROPION-SR/WELLBUTRIN 150MG/#60
MED113 CEFIXIME/SUPRAX TAB 400MG/#1
MED55 CEFTRIAXONE/ROCEPHIN INJ 250MG
MED69 CEFTRIAXONE/ROCEPHIN INJ 500MG
MED100 CEFUROXIME/CEFTIN 500MG/#20
MED121 CEFUROXIME/CEFTIN 250MG/#20
MED96 CELESTONE INJECTABLE
MED91 CEPHALEXIN/KEFLEX 250MG/#40
MED17 CEPHALEXIN/KEFLEX 500MG/#28
MED103 CIPROFLOXACIN 250MG#6
MED78 CIPROFLOXACIN 500MG/#6
MED79 CIPROFLOXACIN 500MG/#14
MED93 CITALOPRAM/CELEXA 20MG/#30
A9150I CLOTRIMAZOLE CR 1%/15G
A9150B CLOTRIMAZOLE-7 CR/45G
MED21 COUGH SYRUP, PROMETH W/ CODEINE
MED114 CYCLOBENZAPRINE/FLEXERIL 10MG/#21
A9150J DIPHENHYDRAMINE AF ELIXIR/4 OZ
A9150M DIPHENHYDRAMINE 25MG/#24
MED26 DOXEPIN 10MG/#30
MED27 DOXYCYCLINE 100MG/#14
MED118 DOXY MONOHYDRATE 100MG/#14
MED28 DOXYCYCLINE 100MG/#20 (1 left)
MED120 DOXY MONOHYDRATE 100MG/#20
MED119 DOXY MONOHYDRATE 100MG/#100
MED31 ERYC OPHTHALMIC OINT 3.5G
MED112 ESCITALOPRAM/LEXAPRO 10MG/#30
A9150K FERROUS SULFATE 325MG/#100
MED77 FLUCONAZOLE/DIFLUCAN 150MG/#1
MED37 FLUOXETINE/PROZAC 20MG/#30
MED101 FLUTICASONE/FLONASE NASAL SPRAY
A9150D HYDROCORTISONE CR 1%/30G
MED38 HYDROXYCHLOROQUINE 200MG/#20
MED39 KETACONAZOLE/NIZORAL CR 2%/15G
MED62 KETOROLAC/TORADOL INJECTABLE
MED110 LEVOFLOXACIN/LEVAQUIN 250MG/#10
MED111 LEVOFLOXACIN/LEVAQUIN 500MG/#10
MED125 LEVOFLOXACIN/LEVAQUIN 750MG/#5
MED70 LIDOCAINE 2%, VISCOUS, 100ML
MED90 LIDOCAINE GARGLE
MED42 LITHIUM CARBONATE 300MG/#100
A9150F LOPERAMIDE #12
A9150N LORATADINE/CLEAR-ATADINE 10MG/#30
MED44 METRONIDAZOLE/FLAGYL 500MG/#14
MED126 MONUROL/FOSFOMYCIN GRANULES 3G/#1
MED45 NAPROXEN/ANAPROX 550MG/#20
MED123 NITROFURANTOIN/MACROBID 100MG/#10
MED43 NITROFURANTOIN/MACROBID 100MG/#14
MED115 ONDANSETRON/ZOFRAN 4MG/#6
MED46 OTIC SUSPENSION
A9150A OXYMETAZOLINE/AFRIN NASAL SPRAY15ML
MED48 PENICILLIN VK 250MG/#40
A9150H PERMETHRIN CONDITIONER/NIX 1%/60ML
MED49 PERMETHRIN CR 5%/60G
MED87 PHENAZOPYRIDINE/PYRIDIUM 200MG/#9
MED51 PREDNISONE 10MG/#30
COST
$30.00
$42.00
$10.00
$15.00
$40.00
$9.00
$8.00
$12.00
$25.00
$30.00
$10.00
$40.00
$25.00
$15.00
$25.00
$65.00
$15.00
$12.00
$15.00
$15.00
$10.00
$10.00
$15.00
$12.00
$6.00
$10.00
$12.00
$10.00
$5.00
$7.00
$13.00
$50.00
$12.00
$65.00
$15.00
$50.00
$20.00
$12.00
$8.00
$12.00
$12.00
$40.00
$6.00
$15.00
$25.00
$15.00
$10.00
$10.00
$10.00
$6.00
$20.00
$20.00
$5.00
$6.00
$14.00
$65.00
$10.00
$25.00
$35.00
$12.00
$25.00
$2.50
$10.00
$15.00
$65.00
$6.00
$12.00
REV 1/29/15
CODE
DESCRIPTION
COST
MED105
PROMETHAZINE/PHENERGAN 25MG/#5
$10.00
MED54
RANITIDINE/ZANTAC 150MG/#60
$14.00
MED116
RISPERIDONE/RISPERDAL 1MG/#30
$12.00
MED68
SERTRALINE/ZOLOFT 100MG/#30
$12.00
99070H
SPACER, FOR INHALER
$12.00
MED57
SULFA/TRIMETH #6
$8.00
MED58
SULFA/TRIMETH #14
$10.00
MED59
SULFA/TRIMETH #20
$12.00
MED124
SULFA/TRIMETH #28
$15.00
MED104
SUMATRIPTAN/IMITREX 100MG/#9
$25.00
MED122
SUPRAX CAPSULE 400MG/#1
$25.00
MED75
TAMIFLU 75MG/#10
$130.00
MED108
TOBRAMYCIN 0.3%/5ML OPHTH SOLN
$15.00
MED63
TRAZADONE 50MG/#30
$10.00
MED65
TRIAMCINOLONE/KENALOG CR 0.1%/15G
$8.00
MED64
TRIAMCINOLONE/KENALOG INJECTABLE
$15.00
FAMILY PLANNING
J8499W
APRI
$25.00
J8499V
AVIANE
$30.00
J8499X
CRYSELLE
$30.00
96372B
DEPO-PROVERA INJ, ADMIN, PT SUPPLIES MED
$10.00
J1050
DEPO-PROVERA, 150MG/ML PER INJ (150 UNITS)
$95.00
A4266
DIAPHRAGM
$70.00
57170
DIAPHRAGM FITTING
$30.00
J8499AL
ELLA
$30.00
J8499AD
ERRIN
$30.00
J7302
IUD MIRENA
$775.00
J7300
IUD PARAGARD
$750.00
J3490
IUD SKYLA
$650.00
J8499AG
JUNEL FE 1/20
$25.00
J8499Y
JUNEL FE 1.5/30
$25.00
J8499AE
NEXT CHOICE
$20.00
J8499AC
OCELLA
$60.00
J8499U
PORTIA
$30.00
J8499Z
SPRINTEC
$25.00
J8499AA
TRI-SPRINTEC
$25.00
58300
UTERINE SOUNDING/IUD INSERTION
$90.00
EQUIPMENT
29799
ANKLE COMPRESSION WRAP
$12.00
E0100
CANE, WEEKLY RENTAL
$5.00
L0120
CERVICAL COLLAR
$10.00
L3660
CLAVICLE STRAP
$18.00
99070D
COLD/HOT PACK
$3.00
E0116
CRUTCHES, IF NOT RETURNED IN 2 WKS
$50.00
99070I
ELASTIC BANDAGE WRAP 2"
$7.00
99070J
ELASTIC BANDAGE WRAP 3"
$8.00
99070K
ELASTIC BANDAGE WRAP 4"
$10.00
99070L
ELASTIC BANDAGE WRAP 6"
$11.00
99070F
HEEL CUP
$10.00
99070P
LIGHT BOX 30 DAY DEPOSIT
$100.00
L1820
PATELLA STABILIZER
$50.00
99070G
PEAK FLOW METER
$30.00
L0210
RIB BELT
$13.00
99070B
SHOE, ORTHOPEDIC
$25.00
A4565
SLING
$11.00
A4570A
SPLINT, ANKLE, AIRCAST
$53.00
A4570B
SPLINT, ANKLE, SOFT SIDED
$45.00
A4570F
SPLINT, FINGER, ALL TYPES OF
$7.50
A4570G
SPLINT, KNEE, UNIVERSAL 18"
$35.00
A4570H
SPLINT, KNEE, UNIVERSAL 20"
$37.00
A4570I
SPLINT, KNEE, UNIVERSAL 22"
$40.00
A4570K
SPLINT, RYNOLACER
$35.00
A4570C
SPLINT, SHOULDER IMMOBILIZER
$35.00
A4570L
SPLINT, WALKING BOOT
$85.00
A4570M
SPLINT, WALKING BOOT, MID-CALF
$80.00
A4570E
SPLINT, WRIST FREE HAND
$20.00
A4570D
SPLINT, WRIST LACER
$25.00
FEE SCHEDULE
CODE DESCRIPTION
PROCEDURES
69005A AURICULAR HEMATOMA I&D W/ SUTURE
58100 BIOPSY ENDOMETRIAL
11100 BIOPSY SKIN LESION, PATH FEE NOT INCLUDED
19000 BREAST CYST ASPIRATION
29085 CAST ON, GAUNTLET
29075 CAST ON, SHORT ARM
29700 CAST REMOVAL, APPLIED ELSEWHERE
16020A DEBRIDEMENT, SIMPLE
16020B DEBRIDEMENT, EXTENSIVE
17110 DESTR, SKIN LESION, PER VISIT
11200 DESTR, SKIN TAGS, PER VISIT
99070M DRESSING APP/CHANGE, SIMPLE
99070N DRESSING APP/CHANGE, INTERMEDIATE
69210 EAR LAVAGE, CERUMEN REMOVAL
93000 ELECTROCARDIOGRAM, COMPLETE
114** EXCISION BNGN LESN <0.5 to 2.0 CM
114** EXCISION BNGN LESN 2.1 to >4.0 CM
116** EXCISION MALGN LESN <0.5 to 2.0 CM
116** EXCISION MALGN LESN 2.1 to >4.0 CM
65205A FB REMOVAL, CONJUNCTIVA
65220 FB REMOVAL, CORNEA
69200 FB REMOVAL, EAR
10120 FB REMOVAL, SUBCUT, SIMPLE
10121 FB REMOVAL, SUBCUT, INTERMED
10060 INCISION/DRAINAGE, SIMPLE
10061 INCISION/DRAINAGE, COMPLEX
96372A INJECTION IM, ADMIN, PT SUPPLIES MED
96374 INJECTION IV, ADMIN, PT SUPPLIES MED
96360 IV THERAPY, INITIAL SETUP (NO FLUID)
96361 IV THERAPY, EACH BAG
20600 JOINT ASPIRATION/INJ, SIMPLE
20610 JOINT ASPIRATION/INJ, COMPLEX
11740 NAIL DRILLING
11765 NAIL FOLD WEDGE EXCISION
11730 NAIL PLATE AVULSION
94640 NEBULIZER THERAPY, PER TX
11055 PARING OR CURETTMENT, SKIN
99395A PHYSICAL PREVENTATIVE 18-39YRS
99395G PHYSICAL PREVENTATIVE BRIEF
99395E PHYSICAL PREVENTATIVE COMPREHENSIVE
99385 PHYSICAL PREVENTATIVE, TRAVEL APP
1200* REPAIR SIMPLE WND
1203* REPAIR INTMD WND
131** REPAIR COMPLEX WND
94010 SPIROMETRY
94060 SPIROMETRY W/ NEBULIZER TX
29515 SPLINT, ANKLE, PLASTER/FG
29125A SPLINT, FOREARM/WRIST, PLASTER/FG
29125B SPLINT, GUTTER, PLASTER/FG
29105 SPLINT, LONG ARM, PLASTER/FG
99211 TRAVEL CONSULT, WITH RN
99213 TRAVEL CONSULT, WITH MD, 15-MIN
99214 TRAVEL CONSULT, WITH MD, 30-MIN
20552 TRIGGER POINT INJECTION, ADMIN ONLY
IMMUNIZATIONS/PPD
90715 IMMUNIZATION, ADACEL
90656 IMMUNIZATION, FLU
90649 IMMUNIZATION, GARDASIL
90649A IMMUNIZATION, GARDASIL, <19 YRS
90632 IMMUNIZATION, HEPATITIS A
90633 IMMUNIZATION, HEPATITIS A, <19 YRS
90746 IMMUNIZATION, HEPATITIS B
90744 IMMUNIZATION, HEPATITIS B, <20 YRS
90738 IMMUNIZATION, JAPANESE ENCEPHALITIS
90734B IMMUNIZATION, MENVEO
90734A IMMUNIZATION, MENACTRA, <19 YRS
90707 IMMUNIZATION, MMR
90732 IMMUNIZATION, PNEUMOVAX 23
COST
$80.00
$80.00
$45.00
$32.00
$80.00
$70.00
$30.00
$30.00
$45.00
$12.00
$12.00
$10.00
$20.00
$25.00
$45.00
$65.00
$80.00
$65.00
$80.00
$20.00
$30.00
$30.00
$35.00
$65.00
$40.00
$65.00
$15.00
$15.00
$50.00
$40.00
$40.00
$55.00
$20.00
$80.00
$80.00
$25.00
$25.00
$85.00
$30.00
$120.00
$60.00
$55.00
$70.00
$90.00
$25.00
$45.00
$55.00
$40.00
$40.00
$55.00
$26.00
$55.00
$80.00
$25.00
$49.00
$25.00
$140.00
$20.00
$42.00
$20.00
$53.00
$20.00
$240.00
$100.00
$20.00
$20.00
$80.00
CODE
90713
90670
90675A
90675
90714A
90636
90690
90690A
90691
90716
90716A
90717
86580
LAB TESTS
87147A
87147B
36415
82962
85025
CBCMANDIFF
87491A
87491
87591A
87591
CTGCSPHL
CTGCUPHL
87147C
80100QW
87804QW
87070A
82270
85018QW
86708
86695
86696
HSV1_2
87529
86703
87621
HPV_CT
HPV_CT_GC
80061
83735
85007
86308QW
86735
87077
88175
PAP_CT
PAP_GC
PAP_CT_GC
88141
84132
81025
86765
SCREENPAN1
SCREENPAN2
85652
87186
SCCONFIRM
85660
87880QW
87081
87808
TSH_FT4
81000
82044
87086
82306
REV 1/29/15
COST
$40.00
$160.00
$225.00
$230.00
$30.00
$64.00
$50.00
IMMUNIZATION, TYPHOID, ORAL REPLACEMENT
$22.00
IMMUNIZATION, TYPHOID, TYPHIM-VI
$70.00
IMMUNIZATION, VARIVAX
$104.00
IMMUNIZATION, VARIVAX, <19 YRS
$20.00
IMMUNIZATION, YELLOW FEVER
$109.00
$15.00
TB SKIN TEST
DESCRIPTION
IMMUNIZATION, POLIO
IMMUNIZATION, PREVNAR 13
IMMUNIZATION, RABIES IM, IMOVAX
IMMUNIZATION, RABIES IM, RABAVERT
IMMUNIZATION, TENIVAC TD
IMMUNIZATION, TWINRIX
IMMUNIZATION, TYPHOID, ORAL
BETA STREP, FIRST TYPING 68812
BETA STREP, FIRST TYPING 68811
BLOOD [email protected] (OUTSIDE REQ)
BLOOD GLUCOSE BY GLUCOMETER
CBC W/ AUTOMATED DIFFERENTIAL
CBC W/ HAND DIFFERENTIAL COUNT
CT-SWAB PHL
CT-URINE PHL
GC-SWAB PHL
GC-URINE PHL
CT/GC-SWAB PHL
CT/GC-URINE PHL
CULTURE TYPING, AGGLUT
DRUG SCREEN CUP-SHC
FLU TEST, BINAXNOW A/B
GENITAL CULTURE, WITHOUT SENSITIVITY
HEMACULT, SERIES OF 3
HEMOGLOBIN
HEPATITIS A ANTIBODY TOTAL IGG & IGM
HERPES IGG TYPE 1
HERPES IGG TYPE 2
HERPES IGG TYPES 1 & 2
HERPES PCR TYPES 1 & 2
HIV 1&2 ANTIBODIES PHL
HPV DNA AMP PROBE
HPV AND CT FROM NWP
HPV W/ CT AND GC FROM NWP
LIPID PANEL 1 (PHL)
MAGNESIUM
MANUAL DIFFERENTIAL (for cbc, use with SP)
MONO TEST, RAPID
MUMPS TITER
ORGANISM ID, AEROBIC
PAP SMEAR, AUTOCYTE LP
PAP AND CT FROM NWP
PAP AND GC FROM NWP
PAP W/ CT AND GC FROM NWP
PAP SMEAR INTERPRETATION
POTASSIUM
PREGNANCY TEST, RAPID
RUBEOLA TITER
SCREENING PANEL 1, NO LYTES
SCREENING PANEL 2, WITH LYTES
SED RATE
SENSITIVITY (GRAM POS. & NEG.)
SICKLE CELL CONFIRMATION TEST
SICKLE CELL TEST
STREP A TEST, RAPID
THROAT CULTURE, GRP-A STREP ONLY
TRICHOMONAS TEST, RAPID
TSH/FREE T4 PANEL
URINALYSIS INCLUDING MICRO
URINALYSIS MICROALBUMIN
URINE CULTURE, WITHOUT SENSITIVITY
VITAMIN D, 25-HYDROXY
$13.00
$34.00
$15.00
$8.00
$16.00
$21.00
$41.00
$41.00
$41.00
$41.00
$72.00
$72.00
$14.00
$15.00
$25.00
$17.00
$8.00
$8.00
$36.00
$36.00
$36.00
$62.00
$117.00
$24.00
$59.00
$85.00
$105.00
$26.00
$19.00
$11.00
$10.00
$26.00
$26.00
$45.00
$70.00
$70.00
$90.00
$20.00
$12.00
$6.00
$36.00
$77.00
$82.00
$13.00
$19.00
$28.00
$16.00
$20.00
$16.00
$10.00
$44.00
$15.00
$7.00
$16.00
$58.00
FEE SCHEDULE
CODE DESCRIPTION
57500 CERVICAL POLYP REMOVAL (NO COLPO)
57455 COLPOSCOPY W/ BIOPSY
57452 COLPOSCOPY W/OUT BIOPSY
57454 COLPOSCOPY W/ BIOPSY & ECC
57456 COLPOSCOPY W/ ECC (NO BIOPSY)
57505 ECC ONLY (NO COLPO)
REV 7/1/14
COST
$35.00
$170.00
$130.00
$190.00
$170.00
$60.00