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Home My WebLink AboutC.054.93011_0782 (2)D7210 Surgical ext. - erupted $136.00 $180.00 $180.00 D7220 Soft tissue impact $97.00 $219.00 $219.00 D7230 Partial bony impact $155.00 $281.00 $281.00 D7240 Bony impact $250.00 $347.00 $347.00 D7241 Bony impact w/complications 300.00 $404.00 $404.00 D7250 Residual roots - unerupted $120.00 $218.00 $218.00 D7270 Tooth Reimplantation 5150.00 $386.00 $386.00 D7510 I & D intra oral $153.00 $158.00 $158.00 D9110 Emergency palliative treatment $35.00 $50.00 $50.00 D9230 Analgesia $45.00 $49.00 $49.00 D9610 Drug injection $48.00 $75.00 $75.00 D9630 Other drug/medication $26.00 $40.00 $40.00 ' Medicaid does not cover effective 10/1/2004 " Medicaid end dated 12/31/2004 Medicaid reimburses for procedure as of 1/1/2005 Modifier CPT CODE SERVICE DESCRIPTION FEES FEES FY 2004-2005 FY 2005-2006 New Patient Preventive Health Visits EP 99381 Age under 1 year $99.00 $99.00 EP 99382 Age 1-4 years $106.00 $106.00 EP/FP 99383 Age 5-11 years $115.00 $115.00 EP/FP 99384 Age 12-17 years $125.00 $125.00 EP/FP 99385 Age 18-39 years $167.00 $167.00 FP 99386 Age 40-64 years $199.00 $199.00 99387 Age 65 years & over $215.00 $215.00 Established Patient Preventive Health Visits EP 99391 Age under I year $90.00 $90.00 EP 99392 Age 1-4 years $90.00 $90.00 EP/FP 99393 Age 5-11 years $95.00 $95.00 EP/FP 99394 Age 12-17 years $105.00 $105.00 EP/FP 99395 Age 18-39 years $142.00 $142.00 FP 99396 Age 40-64 years $158.00 $158.00 99397 Age 65 years & over $175.00 $175.00 New Patient Evaluation and Management Visits FP 99201 Minimal $70.00 $70.00 FP 99202 Limited $90.00 $90.00 FP 99203 Expanded $I28.00 $128.00 FP 99204 Detailed $188.00 $188.00 FP 99205 Comprehensive $236.00 $236.00 Delivery Fee 59409 Vaginal Delivery $1,000.00 $1,000.00 59514 Cesarean Delivery $1,000.00 $1,000.00 Established Patient Evaluation and Management Visits EP/FP/25 99211 Minimal $38.00 $38.00 EP/FP/25 99212 Limited $55.00 $55.00 EP/FP/25 99213 Expanded $76.00 $76.00 EP/FP/25 99214 Detailed $118.00 $118.00 EP/FP/25 99215 Comprehensive $176.00 $176.00 Modifier CPT CODE SERVICE DESCRIPTION FEES FEES QW Laboratory FY 2004-2005 FY 2005-2006 QW 82947 Glucose $19.00 $19.00 QW 82950 1 hour Glucola $25.00 $25.00 QW 82951 GTT (3 hr) $55.00 $55.00 QW 82952 GTT Specimen 4 $15.00 $15.00 85013 Hematocrit $15.00 $15.00 81002 Urine Dipstick $15.00 $15.00 81000 Urine with micro $19.00 $19.00 81025 Pregnancy test (urine) $10.00 $10.00 87210 Wet Prep (PVT. PAY $0.00) $20.00 $20.00 87070 GC culture $36.00 $36.00 QW 82465 Cholesterol $20.00 $20.00