FEE SCHEDULE CODE DESCRIPTION MEDICATIONS MED88 ACYCLOVIR/ZOVIRAX 400MG/#60 MED02 ALBUTEROL INHALER MED06 AMOXICILLIN 250MG/#30 MED07 AMOXICILLIN 500MG/#30 MED85 AMOX-POT-CLAV/AUGMENTIN 875-125/#20 A9150O ANTACID, LIQUID 12OZ MED08 APAP W/ CODEINE/T-3 #10 MED09 APAP W/ CODEINE/T-3 #15 MED67 AZITHROMYCIN/ZITHROMAX 250MG/#6 MED109 AZITHROMYCIN/ZITHROMAX 500MG/#2 MED98 BENZONATATE/TESSALON 100MG/#20 MED99 BUPROPION-SR/WELLBUTRIN 150MG/#60 MED113 CEFIXIME/SUPRAX TAB 400MG/#1 MED55 CEFTRIAXONE/ROCEPHIN INJ 250MG MED69 CEFTRIAXONE/ROCEPHIN INJ 500MG MED100 CEFUROXIME/CEFTIN 500MG/#20 MED121 CEFUROXIME/CEFTIN 250MG/#20 MED96 CELESTONE INJECTABLE MED91 CEPHALEXIN/KEFLEX 250MG/#40 MED17 CEPHALEXIN/KEFLEX 500MG/#28 MED103 CIPROFLOXACIN 250MG#6 MED78 CIPROFLOXACIN 500MG/#6 MED79 CIPROFLOXACIN 500MG/#14 MED93 CITALOPRAM/CELEXA 20MG/#30 A9150I CLOTRIMAZOLE CR 1%/15G A9150B CLOTRIMAZOLE-7 CR/45G MED21 COUGH SYRUP, PROMETH W/ CODEINE MED114 CYCLOBENZAPRINE/FLEXERIL 10MG/#21 A9150J DIPHENHYDRAMINE AF ELIXIR/4 OZ A9150M DIPHENHYDRAMINE 25MG/#24 MED26 DOXEPIN 10MG/#30 MED27 DOXYCYCLINE 100MG/#14 MED118 DOXY MONOHYDRATE 100MG/#14 MED28 DOXYCYCLINE 100MG/#20 (1 left) MED120 DOXY MONOHYDRATE 100MG/#20 MED119 DOXY MONOHYDRATE 100MG/#100 MED31 ERYC OPHTHALMIC OINT 3.5G MED112 ESCITALOPRAM/LEXAPRO 10MG/#30 A9150K FERROUS SULFATE 325MG/#100 MED77 FLUCONAZOLE/DIFLUCAN 150MG/#1 MED37 FLUOXETINE/PROZAC 20MG/#30 MED101 FLUTICASONE/FLONASE NASAL SPRAY A9150D HYDROCORTISONE CR 1%/30G MED38 HYDROXYCHLOROQUINE 200MG/#20 MED39 KETACONAZOLE/NIZORAL CR 2%/15G MED62 KETOROLAC/TORADOL INJECTABLE MED110 LEVOFLOXACIN/LEVAQUIN 250MG/#10 MED111 LEVOFLOXACIN/LEVAQUIN 500MG/#10 MED125 LEVOFLOXACIN/LEVAQUIN 750MG/#5 MED70 LIDOCAINE 2%, VISCOUS, 100ML MED90 LIDOCAINE GARGLE MED42 LITHIUM CARBONATE 300MG/#100 A9150F LOPERAMIDE #12 A9150N LORATADINE/CLEAR-ATADINE 10MG/#30 MED44 METRONIDAZOLE/FLAGYL 500MG/#14 MED126 MONUROL/FOSFOMYCIN GRANULES 3G/#1 MED45 NAPROXEN/ANAPROX 550MG/#20 MED123 NITROFURANTOIN/MACROBID 100MG/#10 MED43 NITROFURANTOIN/MACROBID 100MG/#14 MED115 ONDANSETRON/ZOFRAN 4MG/#6 MED46 OTIC SUSPENSION A9150A OXYMETAZOLINE/AFRIN NASAL SPRAY15ML MED48 PENICILLIN VK 250MG/#40 A9150H PERMETHRIN CONDITIONER/NIX 1%/60ML MED49 PERMETHRIN CR 5%/60G MED87 PHENAZOPYRIDINE/PYRIDIUM 200MG/#9 MED51 PREDNISONE 10MG/#30 COST $30.00 $42.00 $10.00 $15.00 $40.00 $9.00 $8.00 $12.00 $25.00 $30.00 $10.00 $40.00 $25.00 $15.00 $25.00 $65.00 $15.00 $12.00 $15.00 $15.00 $10.00 $10.00 $15.00 $12.00 $6.00 $10.00 $12.00 $10.00 $5.00 $7.00 $13.00 $50.00 $12.00 $65.00 $15.00 $50.00 $20.00 $12.00 $8.00 $12.00 $12.00 $40.00 $6.00 $15.00 $25.00 $15.00 $10.00 $10.00 $10.00 $6.00 $20.00 $20.00 $5.00 $6.00 $14.00 $65.00 $10.00 $25.00 $35.00 $12.00 $25.00 $2.50 $10.00 $15.00 $65.00 $6.00 $12.00 REV 1/29/15 CODE DESCRIPTION COST MED105 PROMETHAZINE/PHENERGAN 25MG/#5 $10.00 MED54 RANITIDINE/ZANTAC 150MG/#60 $14.00 MED116 RISPERIDONE/RISPERDAL 1MG/#30 $12.00 MED68 SERTRALINE/ZOLOFT 100MG/#30 $12.00 99070H SPACER, FOR INHALER $12.00 MED57 SULFA/TRIMETH #6 $8.00 MED58 SULFA/TRIMETH #14 $10.00 MED59 SULFA/TRIMETH #20 $12.00 MED124 SULFA/TRIMETH #28 $15.00 MED104 SUMATRIPTAN/IMITREX 100MG/#9 $25.00 MED122 SUPRAX CAPSULE 400MG/#1 $25.00 MED75 TAMIFLU 75MG/#10 $130.00 MED108 TOBRAMYCIN 0.3%/5ML OPHTH SOLN $15.00 MED63 TRAZADONE 50MG/#30 $10.00 MED65 TRIAMCINOLONE/KENALOG CR 0.1%/15G $8.00 MED64 TRIAMCINOLONE/KENALOG INJECTABLE $15.00 FAMILY PLANNING J8499W APRI $25.00 J8499V AVIANE $30.00 J8499X CRYSELLE $30.00 96372B DEPO-PROVERA INJ, ADMIN, PT SUPPLIES MED $10.00 J1050 DEPO-PROVERA, 150MG/ML PER INJ (150 UNITS) $95.00 A4266 DIAPHRAGM $70.00 57170 DIAPHRAGM FITTING $30.00 J8499AL ELLA $30.00 J8499AD ERRIN $30.00 J7302 IUD MIRENA $775.00 J7300 IUD PARAGARD $750.00 J3490 IUD SKYLA $650.00 J8499AG JUNEL FE 1/20 $25.00 J8499Y JUNEL FE 1.5/30 $25.00 J8499AE NEXT CHOICE $20.00 J8499AC OCELLA $60.00 J8499U PORTIA $30.00 J8499Z SPRINTEC $25.00 J8499AA TRI-SPRINTEC $25.00 58300 UTERINE SOUNDING/IUD INSERTION $90.00 EQUIPMENT 29799 ANKLE COMPRESSION WRAP $12.00 E0100 CANE, WEEKLY RENTAL $5.00 L0120 CERVICAL COLLAR $10.00 L3660 CLAVICLE STRAP $18.00 99070D COLD/HOT PACK $3.00 E0116 CRUTCHES, IF NOT RETURNED IN 2 WKS $50.00 99070I ELASTIC BANDAGE WRAP 2" $7.00 99070J ELASTIC BANDAGE WRAP 3" $8.00 99070K ELASTIC BANDAGE WRAP 4" $10.00 99070L ELASTIC BANDAGE WRAP 6" $11.00 99070F HEEL CUP $10.00 99070P LIGHT BOX 30 DAY DEPOSIT $100.00 L1820 PATELLA STABILIZER $50.00 99070G PEAK FLOW METER $30.00 L0210 RIB BELT $13.00 99070B SHOE, ORTHOPEDIC $25.00 A4565 SLING $11.00 A4570A SPLINT, ANKLE, AIRCAST $53.00 A4570B SPLINT, ANKLE, SOFT SIDED $45.00 A4570F SPLINT, FINGER, ALL TYPES OF $7.50 A4570G SPLINT, KNEE, UNIVERSAL 18" $35.00 A4570H SPLINT, KNEE, UNIVERSAL 20" $37.00 A4570I SPLINT, KNEE, UNIVERSAL 22" $40.00 A4570K SPLINT, RYNOLACER $35.00 A4570C SPLINT, SHOULDER IMMOBILIZER $35.00 A4570L SPLINT, WALKING BOOT $85.00 A4570M SPLINT, WALKING BOOT, MID-CALF $80.00 A4570E SPLINT, WRIST FREE HAND $20.00 A4570D SPLINT, WRIST LACER $25.00 FEE SCHEDULE CODE DESCRIPTION PROCEDURES 69005A AURICULAR HEMATOMA I&D W/ SUTURE 58100 BIOPSY ENDOMETRIAL 11100 BIOPSY SKIN LESION, PATH FEE NOT INCLUDED 19000 BREAST CYST ASPIRATION 29085 CAST ON, GAUNTLET 29075 CAST ON, SHORT ARM 29700 CAST REMOVAL, APPLIED ELSEWHERE 16020A DEBRIDEMENT, SIMPLE 16020B DEBRIDEMENT, EXTENSIVE 17110 DESTR, SKIN LESION, PER VISIT 11200 DESTR, SKIN TAGS, PER VISIT 99070M DRESSING APP/CHANGE, SIMPLE 99070N DRESSING APP/CHANGE, INTERMEDIATE 69210 EAR LAVAGE, CERUMEN REMOVAL 93000 ELECTROCARDIOGRAM, COMPLETE 114** EXCISION BNGN LESN <0.5 to 2.0 CM 114** EXCISION BNGN LESN 2.1 to >4.0 CM 116** EXCISION MALGN LESN <0.5 to 2.0 CM 116** EXCISION MALGN LESN 2.1 to >4.0 CM 65205A FB REMOVAL, CONJUNCTIVA 65220 FB REMOVAL, CORNEA 69200 FB REMOVAL, EAR 10120 FB REMOVAL, SUBCUT, SIMPLE 10121 FB REMOVAL, SUBCUT, INTERMED 10060 INCISION/DRAINAGE, SIMPLE 10061 INCISION/DRAINAGE, COMPLEX 96372A INJECTION IM, ADMIN, PT SUPPLIES MED 96374 INJECTION IV, ADMIN, PT SUPPLIES MED 96360 IV THERAPY, INITIAL SETUP (NO FLUID) 96361 IV THERAPY, EACH BAG 20600 JOINT ASPIRATION/INJ, SIMPLE 20610 JOINT ASPIRATION/INJ, COMPLEX 11740 NAIL DRILLING 11765 NAIL FOLD WEDGE EXCISION 11730 NAIL PLATE AVULSION 94640 NEBULIZER THERAPY, PER TX 11055 PARING OR CURETTMENT, SKIN 99395A PHYSICAL PREVENTATIVE 18-39YRS 99395G PHYSICAL PREVENTATIVE BRIEF 99395E PHYSICAL PREVENTATIVE COMPREHENSIVE 99385 PHYSICAL PREVENTATIVE, TRAVEL APP 1200* REPAIR SIMPLE WND 1203* REPAIR INTMD WND 131** REPAIR COMPLEX WND 94010 SPIROMETRY 94060 SPIROMETRY W/ NEBULIZER TX 29515 SPLINT, ANKLE, PLASTER/FG 29125A SPLINT, FOREARM/WRIST, PLASTER/FG 29125B SPLINT, GUTTER, PLASTER/FG 29105 SPLINT, LONG ARM, PLASTER/FG 99211 TRAVEL CONSULT, WITH RN 99213 TRAVEL CONSULT, WITH MD, 15-MIN 99214 TRAVEL CONSULT, WITH MD, 30-MIN 20552 TRIGGER POINT INJECTION, ADMIN ONLY IMMUNIZATIONS/PPD 90715 IMMUNIZATION, ADACEL 90656 IMMUNIZATION, FLU 90649 IMMUNIZATION, GARDASIL 90649A IMMUNIZATION, GARDASIL, <19 YRS 90632 IMMUNIZATION, HEPATITIS A 90633 IMMUNIZATION, HEPATITIS A, <19 YRS 90746 IMMUNIZATION, HEPATITIS B 90744 IMMUNIZATION, HEPATITIS B, <20 YRS 90738 IMMUNIZATION, JAPANESE ENCEPHALITIS 90734B IMMUNIZATION, MENVEO 90734A IMMUNIZATION, MENACTRA, <19 YRS 90707 IMMUNIZATION, MMR 90732 IMMUNIZATION, PNEUMOVAX 23 COST $80.00 $80.00 $45.00 $32.00 $80.00 $70.00 $30.00 $30.00 $45.00 $12.00 $12.00 $10.00 $20.00 $25.00 $45.00 $65.00 $80.00 $65.00 $80.00 $20.00 $30.00 $30.00 $35.00 $65.00 $40.00 $65.00 $15.00 $15.00 $50.00 $40.00 $40.00 $55.00 $20.00 $80.00 $80.00 $25.00 $25.00 $85.00 $30.00 $120.00 $60.00 $55.00 $70.00 $90.00 $25.00 $45.00 $55.00 $40.00 $40.00 $55.00 $26.00 $55.00 $80.00 $25.00 $49.00 $25.00 $140.00 $20.00 $42.00 $20.00 $53.00 $20.00 $240.00 $100.00 $20.00 $20.00 $80.00 CODE 90713 90670 90675A 90675 90714A 90636 90690 90690A 90691 90716 90716A 90717 86580 LAB TESTS 87147A 87147B 36415 82962 85025 CBCMANDIFF 87491A 87491 87591A 87591 CTGCSPHL CTGCUPHL 87147C 80100QW 87804QW 87070A 82270 85018QW 86708 86695 86696 HSV1_2 87529 86703 87621 HPV_CT HPV_CT_GC 80061 83735 85007 86308QW 86735 87077 88175 PAP_CT PAP_GC PAP_CT_GC 88141 84132 81025 86765 SCREENPAN1 SCREENPAN2 85652 87186 SCCONFIRM 85660 87880QW 87081 87808 TSH_FT4 81000 82044 87086 82306 REV 1/29/15 COST $40.00 $160.00 $225.00 $230.00 $30.00 $64.00 $50.00 IMMUNIZATION, TYPHOID, ORAL REPLACEMENT $22.00 IMMUNIZATION, TYPHOID, TYPHIM-VI $70.00 IMMUNIZATION, VARIVAX $104.00 IMMUNIZATION, VARIVAX, <19 YRS $20.00 IMMUNIZATION, YELLOW FEVER $109.00 $15.00 TB SKIN TEST DESCRIPTION IMMUNIZATION, POLIO IMMUNIZATION, PREVNAR 13 IMMUNIZATION, RABIES IM, IMOVAX IMMUNIZATION, RABIES IM, RABAVERT IMMUNIZATION, TENIVAC TD IMMUNIZATION, TWINRIX IMMUNIZATION, TYPHOID, ORAL BETA STREP, FIRST TYPING 68812 BETA STREP, FIRST TYPING 68811 BLOOD DRAW@SHC (OUTSIDE REQ) BLOOD GLUCOSE BY GLUCOMETER CBC W/ AUTOMATED DIFFERENTIAL CBC W/ HAND DIFFERENTIAL COUNT CT-SWAB PHL CT-URINE PHL GC-SWAB PHL GC-URINE PHL CT/GC-SWAB PHL CT/GC-URINE PHL CULTURE TYPING, AGGLUT DRUG SCREEN CUP-SHC FLU TEST, BINAXNOW A/B GENITAL CULTURE, WITHOUT SENSITIVITY HEMACULT, SERIES OF 3 HEMOGLOBIN HEPATITIS A ANTIBODY TOTAL IGG & IGM HERPES IGG TYPE 1 HERPES IGG TYPE 2 HERPES IGG TYPES 1 & 2 HERPES PCR TYPES 1 & 2 HIV 1&2 ANTIBODIES PHL HPV DNA AMP PROBE HPV AND CT FROM NWP HPV W/ CT AND GC FROM NWP LIPID PANEL 1 (PHL) MAGNESIUM MANUAL DIFFERENTIAL (for cbc, use with SP) MONO TEST, RAPID MUMPS TITER ORGANISM ID, AEROBIC PAP SMEAR, AUTOCYTE LP PAP AND CT FROM NWP PAP AND GC FROM NWP PAP W/ CT AND GC FROM NWP PAP SMEAR INTERPRETATION POTASSIUM PREGNANCY TEST, RAPID RUBEOLA TITER SCREENING PANEL 1, NO LYTES SCREENING PANEL 2, WITH LYTES SED RATE SENSITIVITY (GRAM POS. & NEG.) SICKLE CELL CONFIRMATION TEST SICKLE CELL TEST STREP A TEST, RAPID THROAT CULTURE, GRP-A STREP ONLY TRICHOMONAS TEST, RAPID TSH/FREE T4 PANEL URINALYSIS INCLUDING MICRO URINALYSIS MICROALBUMIN URINE CULTURE, WITHOUT SENSITIVITY VITAMIN D, 25-HYDROXY $13.00 $34.00 $15.00 $8.00 $16.00 $21.00 $41.00 $41.00 $41.00 $41.00 $72.00 $72.00 $14.00 $15.00 $25.00 $17.00 $8.00 $8.00 $36.00 $36.00 $36.00 $62.00 $117.00 $24.00 $59.00 $85.00 $105.00 $26.00 $19.00 $11.00 $10.00 $26.00 $26.00 $45.00 $70.00 $70.00 $90.00 $20.00 $12.00 $6.00 $36.00 $77.00 $82.00 $13.00 $19.00 $28.00 $16.00 $20.00 $16.00 $10.00 $44.00 $15.00 $7.00 $16.00 $58.00 FEE SCHEDULE CODE DESCRIPTION 57500 CERVICAL POLYP REMOVAL (NO COLPO) 57455 COLPOSCOPY W/ BIOPSY 57452 COLPOSCOPY W/OUT BIOPSY 57454 COLPOSCOPY W/ BIOPSY & ECC 57456 COLPOSCOPY W/ ECC (NO BIOPSY) 57505 ECC ONLY (NO COLPO) REV 7/1/14 COST $35.00 $170.00 $130.00 $190.00 $170.00 $60.00