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Home My WebLink AboutC.054.93011_078387205 Gram Stains $21.00 $21.00 89300 Semen Analysis $40.00 $40.00 87164 Darkfield $49.00 D/C Procedure 36415 Venipuncture/stick $12.00 $12.00 36416 Finger/heelstick New Vaccine $12.00 99000 Handling fee $14.00 $14.00 G0001 Medicaid Venipuncture $12.00 (ended 12/31/2004) Office Procedure $7.00 $7.00 54050 Wart Treatment/Male $134.00 $134.00 56501 Wart Treatment(Female $134.00 $134.00 76815 Ultrasound $188.00 $188.00 59025 Non -Stress test $125.00 $125.00 59412 Cephalic Version/External $550.00 $550.00 11976 Norplant Removal $210.00 $210.00 58300 IUD Insertion $86.00 $87.00 J7300 ParaGard T T380 $344.00 $359.00 58301 IUD Removal $95.00 $95.00 99070 IUD Supply discontinued discontinued 57170 Diaphragm Fitting $117.00 $117.00 96110 Denver Developmental $114.00 $114.00 92551 Audiometry $23.00 $23.00 92582 Conditioning Play Audiometry $26.00 $26.00 69210 Ear Irrigation $67.00 $67.00 99173 Vision Screening $24.00 $24.00 59430 Postpartum care only $130.00$130.00 92588 Diagnostic Otoacoustic Emissions @Multiple Levels & Frequencies Influenza Vaccine $10.00 $12.00 $54.00 $54.00 Modifier CPT CODE SERVICE DESCRIPTION $7.00 $7.00 59445**MOW (billable in units) $17.00 $17.00 FEES FEES $30.00 $30.00 T1016**Child Service Coordination FY 2004-2005 FY 2005-2006 Immunizations/Injections $60.00 $60.00 90782 Therapeutic/diag. Admin. Fee $10.00 $18.00 90471 Admin. single vaccine $8.00 $8.00 EP 90471 EP Admin. single vaccine (Medicaid VFC) $20.00 $20.00 90472 Admin. 2+ vaccines $5.00/each$5.00/each 90788 Admin. antibiotics $23.00 $23.00 90384 RHO Gam $111.00 $111.00 FP J1055 Depo-Provera $45.00 $54.00 90636 Twinrix - Hep A & B 8/14/2004 $60.00 $60.00 90716 Adult Varicella $62.00 $67.00 90707 Adult MMR $40.00 $42.00 90733 Adult Meningitis $73.00 $87.00 90734 Menactn New Vaccine $83.00 90746 Adult Hepatitis B $64.00 $64.00 90632 Adult Hepatitis A $58.00 $67.00 90633 Ped/Adol. Hepatitis A $30.00 $30.00 90658 Influenza Vaccine $10.00 $12.00 90657 Influenza Vaccine (1/2 dose) $10.00 $12.00 90732 Pneumonia Vaccine $19.00 $21.00 86580 PPD (TB Skin Test) $19.00 $19.00 90669 Prevnar - private stock $71.00 $71.00 90713 Polio - private stock $27.00 $27.00 CPT CODE SERVICE DESCRIPTION Miscellaneous C9983 Pill Replacement $7.00 $7.00 59445**MOW (billable in units) $17.00 $17.00 T1017**MCC (billable in units $30.00 $30.00 T1016**Child Service Coordination $21.00 $21.00 99501 Postpartum Home visit -Mom $60.00 $60.00 99502 Newbom Assessment - Infant $60.00 $60.00 T1002**RN services (TB /STD billable in units) $20.00 $20.00 ** 1 utast = 15 minutes Environmental Health Division Fees FY Fees FY Service Detailed Description 2004-2005 2005-2006 Type I or II System $200.00 $200.00 Type III System $330.00 $330.00 Type IV -VI System $575.00 $575.00