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Dublin Primary Care Fee Disclosure of Medical Service (PDF) Dublin Primary Care Fee Disclosure CPT Office Visits FEE CPT LABORATORY FEE CPT IMMUNIZATIONS FEE CPT TESTS FEE New Patient 87420 RSV 25 86580 PPD Z23 13 99173 Visual Acuity 15 99201 Focused 70 82947 Glucose 20 90632 Hep A Adult Z23 90 92567 Tympanometry 22 99202 Expanded 118 83051 Hemoglobin 5 90633 Hep A Peds Z23 55 93000 EKG 28 99203 Detailed 171 87880 Rapid Strep 30 90648 Hib Vac Z23 38 94150 Peak Flow 6 99204 Comp -Med 259 81002 UA W/O Micro 22 90651 Gardasil 9 Z23 220 99205 Comp-High 326 81025 Urine Pregnancy 15 90687 Flu 0.25 ml Z23 16 83036 A1C 25 90688 Flu 0.50 ml Z23 32 Established 82270 Guaiac 15 90670 Prevnar 13 Z23 195 CPT PROCEDURES FEE 99211 Minimal 32 87210 Wet Mount 15 90680 Rota Teq Z23 104 10060 I & D Simple 187 99212 Focused 69 87220 Tissue Exam 10 90698 Pentacel (Dtap-Hib-IPV) Z23 89 10061 I & D Comprehensive 329 99213 Expanded 115 87804 Influenza Test 30 90700 Dtap <7 Z23 47 11100 Skin Biopsy, Single 165 99214 Detailed 170 85014 HCT (Hematocrit) 7 90707 MMR Z23 80 11101 Skin Biopsy, Ea. Addl. 52 99215 Comprehensive 228 82274 FOBT 20 90710 ProQuad (MMR-V) Z23 165 17000 Destruction of Lesion, 1 106 90713 IPV Z23 44 17003 Destruction of Lesion, 2-14 8 Preventative New Pt 90715 Adacel Tdap >7 Z23 48 17004 Destruction of Lesions >15 239 99381 Infant < 1 yr 174 CPT SUPPLIES FEE 90702 Pediatric Tetanus <7 Z23 66 17110 Plantar Wart Removal <15 176 99382 1-4 yrs 182 99070 Lumbar Tray 40 90714 Adult Tetanus >7 Z23 45 17111 Plantar Wart Removal >15 210 99383 5-11 yrs 190 99070 Eye Tray 40 90716 Varicella Z23 124 20600 Arthrocentesis, small joint 76 99384 12-17 yrs 213 99070 LP Tray 40 90732 Pneumonia 2+yrs Z23 107 20605 Arthrocentesis, Inter joint 80 99385 18-39 yrs 206 99070 Suture Tray 40 90734 Meningococcal Z23 137 20610 Arthrocentesis, Lrg Joint 97 99386 40-64 yrs 240 99070 Burn Supply 40 90744 Hep B Peds Z23 45 92551 Audiogram 20 99387 Over 64 yrs 260 90746 Hep B Adult Z23 75 69210 Ear Lavage 78 A4351 Straight Catheter 5 90748 Comvax (HepB-Hib) Z23 60 46600 Anoscopy 142 Preventative Est Pt A4352 Catheter 5 90736 Zostavax (Shingles) Z23 223 54150 Circumcision 248 99391 Infant < 1 yr 156 A4550 Surgical tray 40 80750 Shingrix Z23 153 58100 Endometrial Biopsy 174 99392 1-4 yrs 167 57500 Biopsy Single/Mult. Cervical 203 99393 5-11 yrs 166 A4570 Splint 10 VFC/Self Pay $21.50 Per Vaccine 57505 Endometrial Currettage 163 99394 12-17 yrs 182 A4565 Sling 5 CPT INJECTIONS FEE 57454 Colposcopy 243 99395 18-39 yrs 186 A4590 Fiberglass Casting 50 J1050 Depo Provera 150mg 74 57170 Diaphram Fitting 97 99396 40-64 yrs 199 A6441 Ace Bandage 6 J1071 Testosterone 200mg 74 11981 Insertion Nexplanon 500 99397 Over 64 yrs 214 S0630 Suture Removal 30 J1200 Benadryl 50mg 20 11982 Removal Nexplanon 202 J0171 Epinephrine up to 1ml 18 11983 Removal w/reinsertion Nexplanon 328 J1100 Decadron 10mg 4 Counseling Pre-Operative J0561 CR or LA Bicillin 600 102 58300 Insertion IUD 140 99401 Up to 15 min 62 99211 Minimal 32 J0561 CR or LA Bicillin 1.2mil 204 58301 Removal Of IUD 151 99402 Up to 30 min 103 99212 Focused 69 J0696 Rocephin per 250mg 21 30901 Nasal Cautery 152 99403 Up to 45 min 144 99213 Expanded 115 J0694 Rocephin 1gram 25 11730 Avulsion,nail (partial) 167 99404 Up to 60 min 185 99214 Detailed 170 J2550 Phenergan up to 50mg 18 11732 Avulsion,each addl. 51 99215 Comprehensive 228 J3420 Vitamin B12 up to 1000mcg 17 20550 Injection, tendon sheath 84 Osteo Manipulation J1030 Depo Medrol 40mg 20 20552 Injection, tendon multiple 88 98925 1-2 Regions 50 Dept of Transportation J1380 Estradial up to 10mg 48 20553 Injection, tendon 3 or more 101 98926 3-4 Regions 72 99455 DOT PHYSICAL 127 J0697 Cefuroxime 750mg 39 11200 Removal of skin tags <15 141 98927 5-6 Regions 95 J1040 Depo-Medrol 80mg 24 11201 Removal of skin tags ea. Addl. 30 J2405 Zofran 1mg 20 12001 Simple Repair 2.5cm or less 143 J3301 Kenalog per 10mg 20 12002 Simple Repair 2.6 to 7.5 173 J7307 Nexplanon 1046 12004 Simple Repair 7.6 to 12.5 203 J7120 Ringers, lactate infusion 10 51701 Insertion of Catheter 76 96360 Intravenous Infusion 86 VFC/Self Pay $21.50 Per Vaccine 96372 Therapeutic injection fee 31 96372 Therapeutic injection 33 CPT NEBULIZER FEE 90471 Vac Admin 42 94640 NEB Treatment 29 90472 Vac Admin: Each Addl Vac 21 J7626 Pulmicort 14 VFC/Self Pay $21.50 Per Vaccine J7620 Albuterol 1 !1.
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