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Laboratory 82947 Glucose $19.00 $19.00 $21.00 $2.00 82950 1 hour Glucola $25.00 $25.00 $28.00 $3.00 82951 GTT (3 hr) $55.00 $55.00 $61.00 $6.00 82952 GTT Specimen 4 $15.00 $15.00 $16.00 $1.00 85013 Hematocrit $15.00 $15.00 $15.00 $0.00 82270 Occult Blood (pt collected) $5.00 $15.00 $10.00 82272 Occult Blood (from Exam) $23.00 $23.00 $0.00 81002 Urine Dipstick $15.00 $15.00 $15.00 $0.00 81000 Urine with micro $19.00 $19.00 $20.00 $1.00 81025 Pregnancy test (urine) $10.00 $10.00 $10.00 $0.00 87210 Wet Prep (PVT. PAY $0.00) $20.00 $20.00 $21.00 $1.00 87070 GC culture $36.00 $36.00 $36.00 $0.00 82465 Cholesterol $20.00 $20.00 $21.00 $1.00 87205 Gram Stains $21.00 $21.00 $21.00 $0.00 89300 Semen Analysis $40.00 $40.00 $40.00_ $0.00 87164 Darkfield $49.00 - --.__--Discontinued . 36415 Venipuncture/stick $12.00 $12.00 $13.00 $1.00 36416 Finger/heel stick New $12.00 $13.00 $1.00 99000 Handling fee $14.00 $14.00 _$14_00. _._ $0.00 G0001 Medicaid Venipuncture $12.00 (ended 12/31/2004) ------- __-_Office Office Procedure 54050 WartTreatment/Male $134.00 $134.00 $134.00 $0.00 56501 Wart Treatment/Female $134.00 $134.00 $134.00 $0.00 76815 Ultrasound $188.00 $188.00 $203.00 $15.00 59025 Non -Stress test $125.00 $125.00 $133.00 $8.00 59412 Cephalic Version/Extemal $550.00 $550.00 $609.00 $59.00 11976 Norplant Removal $210.00 $210.00 $174.00 ($36.00) 58300 IUD Insertion $86.00 $87.00 $225.00 $138.00 J7300 ParaGard T T380 $344.00 $359.00 $359.00 $0.00 58301 IUD Removal $95.00 $95.00 _________$95.00 _-__$0_00 99070 IUD Supply i _ Discontinued 57170 Diaphragm Fitting $117.00 $117.00 $104.00 ($13.00) .96,111._ Denver Developmental $114.00 $114.00 $172.00 $58.00 92551 Audiometry $23.00 $23.00 $25.00 $2.00 92582 Conditioning Play Audiometry $26.00 $26.00 $72.00 $46.00 69210 Ear Irrigation $67.00 $67.00 $77.00 $10.00 99173 Vision Screening $24.00 $24.00 $19.00 ($5.00) 59430 Postpartum care only $130.00 $130.00 $174.00 $44.00 92588 Diagnostic Otoacoustic @Multiple Levels & Frequencies $54.00 $54.00 $71.00 $17.00 13