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HomeMy WebLinkAboutC.054.93011_1586 (2)Modifier (if required) CPT CODE SERVICE DESCRIPTION FEES FY 2007-2008 Immunizations/Injections 90471 Admin. single vaccine $10.00 EP 90471EP Admin. single vaccine (Medicaid VFC) $28.00 90472 Admin. 2+ vaccines $5.00 90772 Therapeutic/diag. Admin. Fee $28.00 9038442790 RHO Gam $119.00 FP J1055 Depo-Provera $54.00 90649 Gardasil (HPV) vaccine $122.00 90636 Twinrix - Hep A & B $60.00 90715 Tdap vaccine >7 yr of age $34.00 90716 Adult Varicella $70.00 90707 Adult MMR $45.00 90733 Adult Meningitis $89.00 90734 Menactra $89.00 90736 Zostavax vaccine $155.00 90746 Adult Hepatitis B $64.00 90632 Adult Hepatitis A $67.00 90633 Ped/Adol. Hepatitis A $30.00 90655 Influenza vaccine (preservative free) $15.00 90658 Influenza Vaccine $15.00 90657 Influenza Vaccine (1/2 dose) $15.00 90080 Rotavirus (Rota Teq) $64.00 90732 Pneumonia Vaccine $25.00 86580 PPD (TB Skin Test) $21.00 90669 Prevnar - private stock $72.00 90713 Polio - private stock $28.00 90660 Flumist Intranasal flu vacc $18.00 90473 Imm Administration by intranasal/oral $10.00 CPT CODE SERVICE DESCRIPTION Miscellaneous LU214 Kindergarten physicals $45.00 LU 102 Completion of Record of TB Screen $10.00 LU235 Pill Replacement $7.00 LU115 BC Patches (replacement) $25.00 LU116 NuvaRing BC (replacement) $25.00 T1017" MCC (billable in units) $30.00 T1016" Child Service Coordination $22.00 99501 Postpartum Hoare visit - Mom $60.00 99502 Newborn Assessment - Infant $60.00 T1002" RN services (TB /STD billable in units) $20.00 PAY03 Co -Pay of $3.00 f/NCHC $3.00 PAY05 Co -Pay of $5.00 f/NCHC $5.00 PAY I O Co -Pay of $10.00 FNCHC $10.00 •' 1 unit = 15 minutes CDT CODE SERVICE DESCRIPTION FEES FY 2007-2008 D0120 Recall exam $34.00 D0140 Emergency exam $48.00 D0150 Initial oral exam $60.00 D0210 Complete series x-rays $87.00 D0220 Periapical x-ray $19.00 D0230 Periapical - two or more $16.00 D0240 Occlusal P.A. $29.00 D0270 Bitewings - single film $19.00 D0272 Bitewings - x 2 $31.00 D0273 Bitewings - x 3 $35.00 D0274 Bitewings - x 4 $43.00 D0330 Panorex x-rays $76.00 DI 110 Prophy (adult) 13 & older $63.00 D1120 Prophy (child) age less than 13 $46.00 D1203 Prophy w/fluoride varnish (<13) $26.00 D1204 Floride varnish (13 - 20 yrs) $26.00 D1206 Top fluoride varnish mod/high caries $26.00 D1330 Oral Hyg. Under 3 years $25.00 D1351 Sealants $37.00 D1510 Space Maint. Fixed - Unilateral $224.00 D1515 Space Maim. Fixed - Bilateral $425.00 D1520 Remove Spc Maint. Unilateral $150.00 D1525 Remvl Spc Maint. Bilateral $160.00 D1550 Recement Space Maint. $60.00 D2140 Amalgam I surf. - perm/primary $88.00 D2150 Amalgam 2 surf. - perm/primary $114.00 D2160 Amalgam 3 surf. - perm/primary $140.00 5