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Home My WebLink AboutC.054.93010_0803 (2)FEES FY FEES FY CPT CODE SERVICE DESCRIPTION 2001-2002 99382 Age 1-4 years $90.00 99383 Age 5-11 years $154.00 99384 Age 12-17 years $169.00 99385 Age I8-39 years $167.00 99386 Age 40-64 years $199.00 99387 Age 65 years & over $215.00 Established Patient Preventive Health Visits Pregnancy test (urine) 99391 Age under 1 year $70.00 99392 Age 1-4 years $75.00 99393 Age 5-11 years $126.00 99394 Age 12-17 years $146.00 99395 Age 18-39 years $142.00 99396 Age 40-64 years $158.00 99397 Age 65 years & over $175.00 New Patient Evaluation and Management Visits WartTreatment/Mate 99201 Minimal $60.00 99202 Limited $90.00 99203 Expanded $128.00 99204 Detailed $188.00 99205 Comprehensive $236.00 Established Patient Evaluation and Management Visits 99211 Minimal $35.00 99212 Limited $55.00 99213 Expanded $76.00 99214 Detailed $118.00 99215 Comprehensive $176.00 Antepartum Care Admin. Antibiotics 59425 4-6 Visits 375.00 59426 7 or more visits 1,000.00 Laboratory 82947 Glucose 82950 1 hour Glucola 82951 GTT (3 hr) 82952 GTT Specimen 4 85013 Hematocrit 81002 Urine Dipstick 81000 Urine with micro 87086 Urine colony count 81025 Pregnancy test (urine) 87210 Wet Prep 87070 GC culture 82465 Cholesterol 87205 Gram Stains 89300 Semen Analysis 87164 Darkfield 86592 Stat RPR 36415 Venipuncture/stick 99000 Handling fee G0001 Medicaid Venipuncture Office Procedure 54050 WartTreatment/Mate 56501 Wart Treatment/Female 76815 Ultrasound 59025 Non -Stress test 59412 Cephalic Version/External 11975 Norplant Insertion 11976 Norplant Removal 58300 IUD Insertion 58301 IUD Removal 99070 IUD Supply 57170 Diaphragm Fitting 96110 Denver Developmental 92551 Audiometry 69210 Ear Irrigation Immunizations/Injections 90782 Therapeutic/diag. Admin. Fee 90471 Admin. single vaccine 90472 Admin. 2+ vaccines 90788 Admin. Antibiotics 90384 RHO Gain 11055 Depo-Provera 90716 Adult Varicella 90707 Adult MMR 2002-2003 $94.00 $154.00 $169.00 $167.00 $199.00 $215.00 15.00 25.00 40.00 New 7/1/2002 15.00 12.00 18.00 25.00 10.00 20.00 30.00 20.00 15.00 40.00 30.00 20.00 10.00 10.00 10.00 134.00 134.00 150.00 105.00 350.00 505.00 210.00 185.00 97.00 10.00 79.00 150.00 30.00 60.00 10.00 5.00 10.00 10.00 1IIko 45.00 50.00 35.00 $72.00 $76.00 $126.00 $146.00 $142.00 $158.00 $175.00 $66.00 $90.00 $128.00 $188.00 $236.00 $35.00 $55.00 $76.00 $118.00 $176.00 New Code New Code 19.00 25.00 55.00 15.00 15.00 15.00 19.00 Discontinued 10.00 18.00 36.00 18.00 19.00 40.00 44.00 Discontinued 12.00 13.00 12.00 134.00 134.00 170.00 125.00 510.00 Discontinued 210.00 212.00 97.00 10.00 92.00 114.00 22.00 62.00 10.00 5.00 10.00 23.00 111.00 45.00 60.00 40.00