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Home My WebLink AboutC.054.93011_1585 (2)Established Patient Preventive Health Visits EP 99391 Age under 1 year $92.00 EP 99392 Age 14 years $97.00 EP/FP 99393 Age 5-11 years $106.00 EP/FP 99394 Age 12-17 years $115.00 EP/FP 99395 Age I8-39 years $155.00 FP 99396 Age 40-64 years $169.00 99387 Age 65 years & over $192.00 New Patient Evaluation and Management Visits FP 99201 Minimal $79.00 FP 99202 Limited $98.00 FP 99203 Expanded $133.00 FP 99204 Detailed $195.00 FP 99205 Comprehensive $246.00 Delivery Fee 59409/DELIV Vaginal Delivery $1,000.00 59514/DELIV Cesarean Delivery $1,000.00 Established Patient Evaluation and Management Visits EP/FP/25 99211 Minimal $42.00 EP/FP/25 99212 Limited $60.00 EP/FP/25 99213 Expanded $79.00 EP/FP/25 99214 Detailed $123.00 EP/FP/25 99215 Comprehensive $183.00 Modifier (if required)CPT CODE SERVICE DESCRIPTION FEES FY 2007-2008 Laboratory QW 82947 Glucose $21.00 QW 82950 1 hour Glucola $28.00 QW 82951 GTT (3 hr) $61.00 QW 82952 GTT Specimen 4 $16.00 FP 85013 Hematocrit $15.00 FP 82270 Fecal occult (3 cards) $15.00 FP 82272 Fecal occult w/digital exm $23.00 FP 81002 Urine Dipstick $15.00 FP 81000 Urine with micro $20.00 FP 81025 Pregnancy test (urine) $10.00 FP 87210 Wet Prep (PVT. PAY $0.00) $21.00 87070 GC culture $36.00 QW 82465 Cholesterol $21.00 87205 Gram Stains $21.00 89300 Semen Analysis $40.00 FP 36415 Vempuncture/stick $13.00 FP 36416 Finger/heelstick $13.00 99000 Handling fee $14.00 Office Procedure 54050 Wart Treatment/Male $134.()0 FP 56501 Wart Treatment/Female $134.00 76815 Ultrasound $203.00 59025 Non -Stress test $133.00 59412 Cephalic Version/Extemal $609.00 J7300 ParaGard T T380 $359.00 J3490 Hydroxyprogesterone Caproate $14.00 FP 11976 Norplant Removal $174.00 FP 58300 IUD Insertion $225.00 FP 58301 IUD Removal $95.00 FP 57170 Diaphragm Fitting $104.00 EP 96110 Denver Developmental $114.00 96111 Developmental $172.00 92551 Audiometry $25.00 92582 Conditioning Play Audiometry $72.00 69210 Ear Irrigation $77.00 99173 Vision Screening $19.00 59430 Postpartum care only $174.00 92587 Evoked Otoacoustic emissions $54.00 92588 Diagnostic Otoacoustic Emissions @Multiple Levels & Frequencies $71.00 4