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Home My WebLink AboutC.054.93010_0522 (2)89300 Semen Analysis $ 40.00 $ 40.00 87166 Darkfield $ 30.00 $ 30.00 86592 Stat RPR $ 20.00 $ 20.00 36415 Ventpunctureistick $ 10.00 $ 10.00 99000 Handling Fee $ 10.00 $ 10.00 Office Procedures 54050 Wart Treatment Male $121.00 $121.00 56501 Wart Treatment/Female $125.00 $125.00 76815 Ultrasound $150.00 $150.00 59025 Non -Stress Test $105.00 $105.00 59412 Cephalic Version/Extemal $350.00 $350.00 11975 Norplant Insertion $505.00 $505.00 11976 Norplant Removal $210.00 $210.00 58300 IUD Insertion $185.00 $185.00 58301 IUD Removal $95.00 $95.00 99070 **IUD Supply $10.00 $10.00 57170 Diaphragm Fining $76.00 $76.00 96110 Denver Developmental $150.00 $150.00 92551 Audiometry $30.00 $30.00 69210 Ear Irrigation $60.00 $60.00 immunization/Injection 90782 Therapeutic/Diagnostic $ 10.00 $ 10.00 Admin. Fee 90471 Admin. Single Vaccine $ 10.00 $5.00 90472 Admin. 2+ Vaccine $ 15.00 $10.00 90788 Admin. Antibiotics $10.00 $10.00 90384 RhoGam $111.00 $111.00 J1055 DepoProvera $45.00 $45.00 90716 *Adult Varicella $55.00 $50.00 90707 * Adult MMR $40.00 $35.00 90733 *Adult Meningitis $65.00 $60.00 90746 *Adult Hepatitis B $60.00 $55.00 90632 *Adult Hepatitis A $50.00 $45.00 90633 *Ped/Adol Hepatitis A $28.00 $23.00 90657 & 90658 *Influenza Vaccine $9.00 $5.00 90732 *Pneumonia Vaccine $16.00 $11.00 86580 *PPD (TB Skin Test) $10.00 $10.00 90699 *Prevnar $67.00 Miscellaneous Adult Health Visit $40.00 $40.00 Pill Replacement Pack $7.00 $7.00 *TRUST $20.00 $20.00 *Chem 23 (co. employee only) $40.00 $40.00 *CBC (co. employee only) $25.00 $25.00 #*Lipid Profile $30.00 $30.00 Fees listed are only those which are new, have codes assigned, or have changed in amounts since January 1, 2000. Sliding Fee Scale applied except as noted *Flat Fee except as prohibited by law, regulation or fee policy (if part of clinic packaged service, will be billed on sliding scale or to third parties regardless of age). **Based on materials used #*Flat Fee and if in conjunction with Allied Health nutritional education, an additional $10.00 will be added to the fee. PREVENTIVE HEALTH DIVISION FY'00-'Ol FY'01-'02 CHILD HEALTH EPSDT Periodic (Medicaid) EPSDT Interperiodic Periodic Screening 100% Interperiodic Screening MATERNAL HEALTH BABY LOVE Medicaid Initial Maternity Care Coordination Subsequent month MCC Home Visit 8 $90.00 $90.00 $90.00 $90.00 $90.00 $90.00 $90.00 $90.00 $110.00 $110.00 55.00 55.00 73.00 73.00