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Home My WebLink About20113178.tiff RESOLUTION RE: APPROVE REVISIONS TO FEE SCHEDULE FOR FEES COLLECTED BY THE WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with revisions to the fee schedule for fees collected by the Weld County Department of Public Health and Environment, and WHEREAS, after study and review, the Board deems it advisable to approve the proposed revisions, effective January 1, 2012, copies of which are attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the revised fee schedule for fees collected by the Weld County Department of Public Health and Environment, as attached hereto, be, and hereby are, approved, effective January 1, 2012. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 14th day of December, A.D., 2011. BOARD OF COUNTY COMMISSIONERS W9LD COUNTY, COLORADO ATTEST:�zs4„��? f t� u� ' Barbara Kirkmeyer, Chair j Weld County Clerk to the Board EXCUSED t . E L®S,Sean PQc nway, Pro-Tem BY: �/f S Deputy C1-rk to the Boar, �e%' wu 861 li F. Garcia i i C r APP A z�� M:�r . i�'r' � , �® °e David E. Long % ' ��`1 � I rfty Attorney Douglas F ademacher Date of signature: l 18'l3- 2011-3178 HL0003 -1`1 13 PHS 2012 Fees Page 1 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT [ - PUBLIC HEALTH SERVICES and 2012 SLIDING FEE SCHEDULE HOUSEHOLD CODE SIZE Procedure Code Code Code Code Code Code Procedure 1 2 3 4 5 VISITS New Client 99201 Focused- nurse visit* 0.00 10.25 20.50 30.75 41.00 99202 Expanded* 0.00 24.50 49.00 73.50 98.00 99203 Detailed* 0.00 32.00 64.00 96.00 128.00 99204 Comprehensive* 0.00 47.75 95.50 143.25 191.00 Established Client 99211 Nurse Visit* 0.00 _ 9.50 19.00 28.50 38.00 99212 Focused* 0.00 16.00 32.00 48.00 64.00 99213 Expanded* _ ' 0.00 20.75 41.50 62.25 83.00 99214 Detailed* 0.00 32.50 65.00 97.50 130.00 Home Visits 99341 New Client- Focused 75.00 75.00 75.00 75.00 77.00 99342 New Client- Expanded 75.00 75.00 75.00 75.00 77.00 99347 Est. Client- Focused 75.00 75.00 75.00 75.00 77.00 99348 Est. Client- Expanded 75.00 75.00 75.00 75.00 77.00 Preventive Medicine Counseling 99401 Individual- 15 min* _ 0.00 10.25. 20.50 30.75 41.00 99402 Individual- 30 min* 0.00 12.50 25.00 37.50 50.00 99403 Individual-45 min* 0.00 14.25 28.50 42.75 57.00 Travel Visits 99404 Individual Initial Visit-60 64.00 64.00 64.00 64.00 64.00 ssa01W Return Visit _ 41.00 41.00 41.00 _ 41.00 41.00 99412 Group Initial Visit-60 41.00 41.00 41.00! 41.00 41.00 Preventive Medicine 99384 New Client 12-17 years old* 0.00 32.00 64.00 96.00 128.00 99385 New Client 18-39 years old* 0.00 32.00 64.00 96.00 128.00 99386 New Client 40-64 years old* 0.00 34.50 69.00 103.50 138.00 99394 Est. Client 12-17 years old* 0.00 _ 20.75 41.50 62.25_ 83.00 99395 Est. Client 18-39 years old* 0.00 20.75 41.50 62.25 83.00 99396 Est. Client 40-64 years old* 0.00 22.75 45.50 68.25 91.00 Miscellaneous INC Scv. Includes Follow-up Care 0.00 0.00 0.00 0.00 0.00 99212 Antepartum Care 1 visit 64.00 64.00 64.00 64.00 64.00 59425 Antepartum care 4-6 visits 586.00 586.00 586.00 586.00 586.00 59426 Antepartum care 7 or more visits 1205.00 1205.00 _ 1205.00 1205.00 1205.00 99402W PE Establishing Medical Record _ 56.00 56.00 56.00 56.00 56.00 0255W Phone visit 0.00 0.00 0.00 0.00 0.00 59430 Post Partum Only 106.00 106.00 106.00 106.00 106.00 H1005 Prenatal Plus(1-4 visits) 170.00 _ 170.00 170.00 170.00 170.00 H1005 Prenatal Plus (5-9)visits) 454.00 454.00 454.00 454.00 454.00 H1005 Prenatal Plus (10 visits) 852.00 852.00 852.00 852.00 852.00 ?O//-3/7 2' PHS 2012 Fees Page 2 Procedure Code Code Code Code Code Code Procedure 1 2 3 4 5 Miscellaneous(continued) H1005 Prenatal Plus (11 or more visits) 965.00 965.00 965.00 965.00 965.00 G9006 NHV Mother-Task Care Mgmt. 12.00 12.00 12.00 12.00 12.00 71017 NHV Child-Task Care Mgmt.- 12.00 12.00 12.00 12.00 12.00 0072W Swift Annual FP 302.00 302.00 302.00 302.00 302.00 STI Exam pre-pay 57.00 57.00 57.00 57.00 57.00 99499 TB Consultation 36.00 36.00 36.00 36.00 36.00 Lab 86850 Antibody Screen _ 31.00 31.00 31.00 31.00 31.00 82947 Assay, body fluid, glucose, (FBS)* 0.00 4.00 8.00 12.00 16.00 85025 CBC w/dill 17.00 17.00 17.00 17.00 17.00 85027 _ CBC w/o Diff 15.00 15.00 15.00 15.00 15.00 87491 Chlamydia PCR* _ _ 0.00 6.00 12.00 18.00 24.00 87491NS Chlamydia PCR*-full fee _ 24.00 24.00 24.00 24.00 24.00 0090W Court Ordered Lab Draw 15.00 15.00 15.00 15.00 15.00 83001 FSH 32.00 32.00 32.00 32.00 32.00 87591 Gonorrhea PCR* 0.00 6.00 12.00 18.00 24.00 87591 NS Gonorrhea PCR*-full fee 24.00 24.00 2.4.00 24.00 24.00 82948 Glucose Random 6.00 6.00 6.00 6.00 6.00 82951 Glucose Tolerance Test 2 hr (GTT) _ 21.00 21.00 21.00 21.00 21.00 87205 _ Gram Stain 23.00 23.00 23.00 23.00 23.00 84702 HCG Quantitative-Serum Pregnancy Test 37.00 37.00 37.00 37.00 37.00 84703 HCG Qualitative- Serum Pregnancy Test 37.00 37.00 37.00 37.00 37.00 86706 Hep B Surface Antibody 20.00 20.00 20.00 20.00 20.00 87250 Herpes Culture 64.00 64.00 64.00 64.00 64.00 86695 Herpes Select-Type I (89999A33) 62.00 62.00 62.00 62.00 62.00 86696 Herpes Select-Type II (89999A33) 62.00 62.00 62.00 62.00 62.00 85018 HGB-(Finger Stick)* 0.00 3.00 6.00 _ 9.00 12.00 86703 HIV Screen, ELISA 20.00 20.00 20.00 20.00 20.00 87621 HPV, High Risk 64.00 64.00 64.00 64.00 64.00 484006W Immunohistochemica I Stain _ 91.00 91.00 91.00 91.00 91.00 83002 LH 32.00 32.00 32.00 32.00 32.00 80061w Lipid Panel- SFS* 0.00 8.25 16.50 24.75 33.00 80061N Lipid Panel 33.00 33.00 33.00 33.00 33.00 80076 Liver Panel 26.00 26.00 26.00 26.00 26.00 80048 _ Metabolic Panel 2.7.00 27.00 27.00 27.00 27.00 82274 Occult Blood Test, Fecal, IA _ 0.00 6.25 12.50 18.75 25.00 88142 _ Pap-Thin Prep* _ 0.00 9.25 18.50 27.75 37.00 0080W Pap, repeat thin prep p _ 37.00 37.00 37.00, 37.00 37.00 84146 Prolactin 33.00 33.00 33.00 33.00 33.00 86592 RPR/Syphillis test 19.00 19.00 19.00 19.00 19.00 84480 T3 42.00 42.00 42.00 42.00 42.00 84436 T4 6.00 6.00 6.00 6.00 _ 6.00 82465 Total Cholesterol 21.00 21.00 21.00 21.00 21.00 84443 TSH 31.00 31.00 31.00 31.00 31.00 86480 Tuberculosis Test-Quantiferon (IGRA) 82.00 _ 82.00 82.00 82.00 82.00 81002 Urinalysis,w/o scope(UA) 8.00 8.00 8.00 8.00 8.00 81025 Urine Preganancy Test* 0.00 2.75 5.50 8.25 11.00 36415 Venipuncture 5.00 5.00 5.00 5.00 5.00 36415W Venipuncture with sliding fee lab _ 0.00 1.25 2.50 3.75 5.00 87210 I Wet Prep 21.00 21.00 21.00 21.00 21.00 PHS 2012 Fees Page 3 Procedure Code Code Code Code' Code Code Procedure 1 2 3 4 5 Medicines and Treatments 0020W Amoxicillin 875 mg#20 13.00 13.00 13.00 13.00 13.00 0062W Azythromycin, Z pack 13.00 13.00 13.00 13.00 13.00 101456W Azithromycin 1g-partner pack 1.1.00 11.00 11.00 11.00 _ _ 11.00 0456W Azithromycin State supplied 0.00 0.00 0.00 0.00 0.00 J0696 Ceftriaxone 250 mg 26.00 26.00 26.00 26.00 26.00 0696W Ceftriaxone 250 mg State Supplied 0.00 0.00 0.00 0.00 0.00 0007W Cephalexin 500mg#14 8.00 8.00 8.00 8.00 8.00 0058W Ciprofloxcin 500 m9 #6 13.00 13.00 13.00 13.00 13.00 0035W Condylox 6.00 6.00 6.00 6.00 6.00 0006W Cytotec 200 mcg#2 6.00 6.00 6.00 6.00 6.00 0005W Doxycycline 100 mg#14 9.00 9.00 9.00 9.00 9.00 0059W Estradiol 1 mg-#100 13.00 13.00 13.00 13.00 13.00 0011W Fluconazole 150 mg#1 16.00 16.00 16.00 16.00 16.00 0012W Iron 10.00 10.00 10.00 10.00 10.00 J0580 LA Bicillin 2.4 Units 0.00 0.00 0.00 0.00 0.00 0060W Medroxyprogesterone 10 mg-#5 13.00 13.00 13.00 13.00 13.00 0008W Metrogel - 8.00 8.00 8.00 8.00 _ 8.00 0009W Metronidazole 500 mg#4 8.00 8.00 8.00 8.00 8.00 0010W Metronidazole 500 mg#14 9.00 9.00 9.00 9.00 9.00 0013W Metronidazole 250 mg#28 14.00 14.00 _ 14.00 14.00 14.00 0061W Nitrofurantoin Macrocrystals-#14 40.00 40.00 40.00 40.00 40.00 0034W Ofloxacin 93.00 93.00 93.00 93.00 93.00 0016W Podophyllin/TCA 13.00 13.00 13.00 13.00 _ 13.00 00oo6W Premarin Vaginal Cream 12.00 12.00- 12.00 12.00 12.00 0192W Prenatal Vitamins 11.00 11.00 11.00 11.00 11.00 0004W Sulfatrim SMX/TMP 8.00 8.00 8.00 8.00 8.00 00180W Suprax 400 mg#1 - partner pak 22.00 22.00 22.00 22.00 22.00 00180NC Suprax 400 mg#1 - State Supplied 0.00 0.00 0.00 0.00 0.00 Procedures 56420 Bartholin Cyst 29.00 29.00 29.00 2900 29.00 11100 Biopsy of skin, single 27.00 27.00 27.00 27.00 27.00 57500 Cervical Lesion Biopsy 32.00 32.00 32.00 32.00 32.00 0116W Chest X-Ray (Prepay) 55.00 55.00 55.00 55.00 _ 55.00 57452 Colposcopy w/o Biopsy** 90.00 90.00 90.00 90.00 90.00 57454 Colposcopy with Biopsy'= 90.00 90.00 90.00 90.00 90.00 57511 Cryocautery cervix-initial or repeat 99.00 99.00 99.00 _ 99.00 99.00 17000 Cryotherapy first lesion** 26.00 26.00 26.00 26.001 26.00 17003 Cryotherapy 2-14 lesions** 26.00 26.00 26.00 26.00 26.00 17004 :Cryotherapy 15+ lesions ** 26.00 26.00 26.00 26.00 26.00 56501 Destruction Lesion Vulva 88.00 88.00 88.00 88.00 88.00 57170 Diaphragm/Cervical Cap Fitting ' 0.00 19.75 39.50 59.25 79.00 58100 Endometrial biopsy w/wo Biopsy 44.00 44.00 44.00 44.00 44.00 58110 Endometrial biopsy with Colposcopy 56.00 56.00 56.00 56.00 56.00 Essure by referral*** 0.00 0.00 0.00 0.00 0.00 11400 Excisions, benign lesion 77.00 77.00 77.00 77.00 77.00 11975 Implanon Insertion 0.00 41.00 82.00 123.00 1.6.4.00_ Incision&drainage of abcess, single or 10060 jsimple 31.00 31.00 31.00 31.00 31.00 58300 Insertion IUD* 0.00 41.25 82.50 123.75 165.00 57460 LEEP with biopsy - 135.00 135.00 135.00 135.00 135.00 57461 LEEP with conization 225.00 225.00 225.00 225.00 225.00 88305 Level 4- Surgical pathology 1st site 90.00 90.00 90.00 90.00 90.00 88305W Level 4-Surgical Pathology 2nd site 8 each add' 90.00 90.00 90.00 90.00 90.00 PHS 2012 Fees Page 4 Procedure Code Code Code Code Code Code Procedure _ — 1 2 3 4 5 Procedures (continued) _ 59025 Non Stress Test lnterp 0.00 0.00 0.00 0.00 0.00 11976 Removal, implant contraceptive(Implanon) 0.00 48.75 97.50 146.25 195.00 11977 Removal implant, with reinsertion 0.00 75.00 150.00 225.00 300.00 58301 Removal IUD* _ 0.00 33.00 66.00 99.00 132.00 A4550 Surgical Tray _ 59.00 59.00 59.00 _ 59.00 59.00 Shaving of epidermal lesion, single on trunk, 11300 arms or legs, .5cm 37.00 37.00 37.00 37.00 37.00 Additional Codes — 0071W Community Education 1 hr. 62.00 62.00 62.00 62.00 62.00 0069W Travax Printout 7.00 7.00 7.00 7.00 7.00 FAMILY PLANNING SUPPLIES A4267 Condoms pkg. 12* 0.00 1.50 _ 3.00 4.50 6.00 0052W Cycle Beads* 0.00 2.75 5.50 8.25 11.00 A4266 Diaphragm* 0.00 6.25 12.50 18.75 25.00 A4269 Foam Contraception* _ 0.00 2.50 5.00 7.50 10.00 J7307NC Implanon _ 0.00 92.75 185.50 278.25 371.00 J7302 NC IUD Mirena _ 0.00 103.00 206.00 309.00 412.00 J7300NC IUD Paragard 0.00 _ 64.50 129.00 193.50 258.00 J1055 Medroxyprogesterone 150mg IM (Depo)* 0.00 4.25 8.50 12.75 17.00 J7303 Nuva Ring 0.00 7.75 15.50 23.25 31.00 S4993 _ Oral Contraceptives* 0.00 5.75 11.50 17.25 23.00 0068W Seasonale 0.00 15.00 30.00 45.00 60.00 0065W Today's Sponge 0.00 1.00 2.00 3.00 4.00 Immunizations 90748 Comvax- Hep B &Rib _ 0.00 0.00 0.00 0.00 0.00 90700 DTAP 0.00 0.00 0.00 0.00 0.00 90702 DT 0.00 0.00 0.00 0.00 0.00 90633 Hepatitis A-VFC 0.00 0.00 0.00 0.00 0.00 90632 Hepatitis A-Adult _ 45.00 45.00 45.00 45.00 45.00 90744 Hepatitis B-VFC 0.00 0.00 0.00 0.00 0.00 90746 Hepatitis B-Adult 45.00 45.00 45.00 45.00 45.00 90647 RIB 0.00 0.00 0.00 0.00 0.00 90649 HPV-VFC 0.00 0.00 0.00 0.00 0.00 90649A HPV-Adult 160.00 160.00 160.00 160.00 160.00 90649AT HPV-Adult - 317 vaccine 0.00 0.00 0.00 0.00 0.00 90281 IG Hepatitis A 0.00 0.00 0.00 0.00 0.00 90471 Imm. Admin-one vaccine 14.70 14.70 14.70 14.70 14.70 90472 Imm Admin-each addl. Vaccine 14.70 _ 14.70 14.70 14.70 14.70 90473 _ Imm.Admin-intranasal or oral 14.70 14.70 _ 14.70 14.70 14.70 90657 Influenza-Child (6 mo thru 35 mo) 0.00 0.00 0.00 0.00 0.00 90658 Influenza-Child (3 years thru 18 years) 0.00 0.00 0.00 0.00 0.00 90658A Influenza-Adult(Ages 19 &over) 0.00 0.00 _ 0.00 0.00 0.00 00658W Influenza-Adult(State Vaccine) _ 0.00 _ 0.00 0.00 0.00 0.00 90660 Influenza- intranasal use 0.00 0.00 0.00 0.00 0.00 90660A Influenza- Intranasal Adult 25.00 25.00 25.00 25.00 25.00 G0008 Influenza-Admin. -MEDICARE _ _ 14.70 14.70 14.70 14.70 14.70 90713 IPV-VFC 0.00 0.00 0.00 0.00 0.00 90713A IPV-Adult 45.00 45.00 _ 45.00 45.00 45.00 90735 Japanese Encephalitis (new formulation) 230.00 _ 230.00 23.0.00 230.00 230.00 90696 Kinrix 0.00 0.00 _ 0.00 0.00 0.00 90734 Menectra-Child 0.00 0.00 0.00 0.00 0.00 PHS 2012 Fees Page 5 Procedure Code Code Code Code Code Code Procedure 1 2 3 4 5 Immunizations (continued) 90734A Menectra-Adult(Menveo) (conjugate) 120.00 120.00 120.00 120.00 120.00 90734AT Menectra Adult-317 Vaccine 0.00 0.00 0.00 0.00 0.00 90733 Meningitis-(Menomune)(polysaccharide) 120.00 120.00 120.00 120.00 120.00 90707 MMR-VFC 0.00 0.00 0.00 0.00 0.00 90707A MMR-Adult 61.00 61.00 61.00 61.00 61.00 90707AT MMR-Adult-317 Vaccine 0.00 0.00 0.00 0.00 0.00 90710 MMRV(MMR&Varivax) Proquad 0.00 0.00 0.00 0.00 0.00 90723 Pediarix- DTAP, Hep B& IPV 0.00 0.00 0.00 0.00 0.00 90698 Pentacel 0.00 0.00 0.00 0.00 0.00 90670 Pneumococal 90732 _ ugate 0.00 Pneumovax-'JFC 0.00 0.00 0.00 0.00 0.00 90732A Pneumovax -Adult 67.00 67.00 67.00 67.00 67.00 90732AT Pneumovax-Adult-317 Vacc. 0.00 - 0.00 0.00 0.00 0.00 G0009 Pneumovax Admin. -MEDICARE 14.70 14.70 14.70 14.70 14.70 90669 Prevnar 0.00 0.00 0.00 0.00, 0.00 90675 Rabies IM 227.00 227.00 227.00 227.00 227.00 90675AT Rabies IM -Adult Temporary 0.00 0.00 0.00 0.00 0.00 90680 Rotavirus 0.00 0.00 0.00 0.00 0.00 90681 Rotarix 0.00 0.00 0.00 0.00 0.00 90718 TD 0.00 0.00 0.00 0.00 0.00 90715 Tdap 0.00 0.00 0.00 0.00 0.00 90715AT Tdap Adult-317 vaccine 0.00 0.00 0.00 0.00 0.00 86580 Tuberculosis Interdermal Skin Test(PPD) 25.00 25.00 25.00 25.00 25.00 6580W Tuberculosis Interdermal Skin test PPD N/C 0.00 0.00 0.00 0.00 0.00 Tuberculosis Interdermal Skin Test(PPD) 8658W reading only 0.00 0.00 0.00 0.00 0.00 90636 Twinrix- Hep A& Hep B 67.00 67.00 67.00 67.00 67.00 90636AT Twinrix Adult-317 vaccine-Hep A&Hep B 0.00 0.00 0.00 0.00 0.00 90691 liphoid- 1 Shot 67.00 67.00 67.00 67.00 67.00 90690 Typhoid-Oral 57.00 57.00 57.00 57.00 57.00 90716 Varivax-VFC 0.00 0.00 0.00 0.00 0.00 90716A Varivax-Adult 98.00 98.00 98.00 98.00 98.00 90716AT Varivax-Adult-317 Vaccine 0.00 0.00 0.00 0.00 0.00 90717 Yellow Fever 103.00 103.00 103.00 103.00 103.00 * Fees only slide for the Family Planning Program. Charges for r all oth er programs are the Code 5 fee. ** Services include surgical procedure only, — These items are free of charge to the client through the Colorado Family Planning Initiative Rev. 11/21/2011 PHS 2012 Fees Page 1 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PUBLIC HEALTH SERVICES and 2012 SLIDING FEE SCHEDULE HOUSEHOLD CODE SIZE Procedure Code Code Code Code Code Code Procedure 1 2 3 4 5 RISITS New Client 99201 Focused - nurse visit* 0.00 10.25 20.50 30.75 41 .00 99202 Expanded* 0.00 24.50 49.00 73.50 98.00 99203 Detailed* 0.00 32.00 64.00 96.00 128.00 99204 Comprehensive* 0.00 47.75 95.50 143.25 191 .00 Established Client 99211 Nurse Visit* 0.00 9.50 , 19.00 28.50 38.00 99212 Focused* 0.00 16.00 32.00 48.00 64.00 99213 Expanded* 0.00 20.75 41 .50 62.25 83.00 99214 Detailed* 0.00 32.50 65.00 97.50 130.00 Home Visits 99341 New Client - Focused 75.00 75.00 75.00 75.00 77.00 99342 New Client - Expanded 75.00 75.00 75.00 75.00 77.00 99347 Est. Client - Focused 75.00 75.00 75.00 75.00 77.00 99348 Est. Client - Expanded 75.00 75.00 75.00 75.00 77.00 Preventive Medicine Counseling 99401 Individual - 15 min* 0.00 10.25 20.50 30.75 41 .00 99402 Individual - 30 min* 0.00 12.50 25.00 37.50 50.00 99403 Individual - 45 mint 0.00 14.25 28.50 42.75 57.00 Travel Visits 99404 Individual Initial Visit - 60 64.00 64.00 64.00 64.00 64.00 99401W Return Visit 41 .00 41 .00 41 .00 41 .00 41 .00 99412 Group Initial Visit - 60 41 .00 41 .00 41 .00 41 .00 41 .00 Preventive Medicine 99384 New Client 12-17 years old* 0.00 32.00 64.00 96.00 128.00 99385 New Client 18-39 years old* 0.00 32.00 64.00 96.00 128.00 99386 New Client 40-64 years old* 0.00 34.50 69.00 103.50 138.00 99394 Est. Client 12-17 years old* 0.00 20.75 41 .50 62.25 83.00 99395 Est. Client 18-39 years old* 0.00 20.75 41 .50 62.25 83.00 99396 Est. Client 40-64 years old* 0.00 22.75 45.50 68.25 91 .00 Miscellaneous INC Scv. Includes Follow-up Care 0.00 0.00 0.00 0.00 0.00 99212 Antepartum Care 1 visit 64.00 64.00 64.00 64.00 64.00 59425 Antepartum care 4-6 visits 586.00 586.00 586.00 586.00 586.00 59426 Antepartum care 7 or more visits 1205.00 1205.00 1205.00 1205.00 1205.00 a 99402W PE Establishing Medical Record 56.00 56.00 56.00 56.00 56.00 rs 0255W Phone visit 0.00 0.00 0.00 0.00 0.00 0 59430 Post Partum Only 106.00 106.00 106.00 106.00 106.00 H1005 Prenatal Plus (1-4 visits) 170.00 170.00 170.00 170.00 170.00 c H1005 Prenatal Plus (5-9) visits) 454.00 454.00 454.00 454.00 454.00 H1005 Prenatal Plus (10 visits) 852.00 852.00 852.00 852.00 852.00 PHS 2012 Fees Page 2 Procedure Code Code Code Code Code Code Procedure 1 2 3 4 5 Miscellaneous (continued) H1005 Prenatal Plus (11 or more visits) 965.00 965.00 965.00 965.00 965.00 G9006 NHV Mother - Task Care Mgmt. 12.00 12.00 12.00 12.00 12.00 T1017 NHV Child - Task Care Mgmt. 12.00 12.00 12.00 12.00 12.00 0072W Swift Annual FP 302.00 302.00 302.00 302.00 302.00 STI Exam pre-pay 57.00 57.00 57.00 57.00 57.00 99499 TB Consultation 36.00 36.00 36.00 36.00 36.00 Lab 86850 Antibody Screen 31 .00 31 .00 31 .00 31 .00 31 .00 82947 Assay, body fluid, glucose, (FBS)* 0.00 4.00 8.00 12.00 16.00 85025 CBC w/diff 17.00 17.00 17.00 17.00 17.00 85027 CBC w/o Diff _ 15.00 15.00 15.00 15.00 15.00 87491 Chlamydia PCR* 0.00 6.00 12.00 18.00 24.00 87491NS Chlamydia PCR* - full fee 24.00 24.00 24.00 24.00 24.00 mow Court Ordered Lab Draw 15.00 15.00 15.00 15.00 15.00 83001 FSH 32.00 32.00 32.00 32.00 32.00 87591 Gonorrhea PCR* 0.00 6.00 12.00 18.00 24.00 87591NS Gonorrhea PCR* - full fee 24.00 24.00 24.00 24.00 24.00 82948 Glucose Random 6.00 6.00 6.00 6.001 6.00 82951 Glucose Tolerance Test 2 hr (GTT) 21 .00 21 .00 21 .00 21 .00 21 .00 87205 Gram Stain 23.00 23.00 23.00 23.00 23.00 84702 HCG Quantitative - Serum Pregnancy Test 37.00 37.00 37.00 37.00 37.00 84703 HCG Qualitative - Serum Pregnancy Test 37.00 37.00 37.00 37.00 37.00 86706 Hep B Surface Antibody 20.00 20.00 20.00 20.00 20.00 87250 Herpes Culture 64.00 64.00 64.00 64.00 64.00 86695 Herpes Select - Type I (89999A33) 62.00 62.00 62.00 62.00 62.00 86696 Herpes Select - Type II (89999A33) 62.00 62.00 62.00 62.00 62.00 85018 HGB - (Finger Stick)* 0.00 3.00 6.00 9.00 12.00 86703 HIV Screen, ELISA 20.00 20.00 20.00 20.00 20.00 87621 HPV, High Risk 64.00 64.00 64.00 64.00 64.00 484006W Immunohistochemical Stain 91 .00 91 .00 91 .00 91 .00 91 .00 83002 LH 32.00 32.00 32.00 32.00 32.00 80061W Lipid Panel - SFS* 0.00 8.25 16.50 24.75 33.00 80061N Lipid Panel 33.00 33.00 33.00 33.00 33.00 80076 Liver Panel 26.00 26.00 26.00 26.00 26.00 80048 Metabolic Panel 27.00 27.00 27.00 27.00 27.00 82274 Occult Blood Test, Fecal, IA 0.00 6.25 12.50 18.75 25.00 88142 Pap - Thin Prep* 0.00 9.25 18.50 27.75 37.00 0080W Pap, repeat thin prep 37.00 37.00 37.00 37.00 37.00 84146 Prolactin 33.00 33.00 33.00 33.00 33.00 86592 RPR/Syphillis test 19.00 19.00 19.00 19.00 19.00 84480 T3 42.00 42.00 42.00 42.00 42.00 84436 T4 6.00 6.00 6.00 6.00 6.00 82465 Total Cholesterol 21 .00 21 .00 21 .00 21 .00 21 .00 84443 TSH 31 .00 31 .00 31 .00 31 .00 31 .00 86480 Tuberculosis Test-Quantiferon (IGRA) 82.00 82.00 82.00 82.00 82.00 81002 Urinalysis, w/o scope (UA) 8.00 8.00 8.00 8.00 8.00 81025 Urine Preganancy Test* 0.00 2.75 5.50 8.25 11 .00 36415 Venipuncture 5.00 5.00 5.00 5.00 5.00 36415W Venipuncture with sliding fee lab 0.00 1 .25 2.50 3.75 5.00 87210 Wet Prep 21 .00 21 .00 21 .00 21 .00 21 .00 PHS 2012 Fees Page 3 Procedure Code Code Code Code Code Code Procedure 1 2 3 4 5 Medicines and Treatments 0020W Amoxicillin 875 mg #20 13.00 13.00 13.00 13.00 13.00 0062W Azythromycin, Z pack 13.00 13.00 13.00 13.00 13.00 101456W Azithromycin 1g - partner pack 11 .00 11 .00 11 .00 11 .00 11 .00 0456W Azithromycin State supplied 0.00 0.00 0.00 0.00 0.00 J0696 Ceftriaxone 250 mg 26.00 26.00 26.00 26.00 26.00 0696W Ceftriaxone 250 mg State Supplied 0.00 0.00 0.00 0.00 0.00 0007W Cephalexin 500mg #14 8.00 8.00 8.00 8.00 8.00 0058W Ciprofloxcin 500 mg #6 13.00 13.00 13.00 13.00 13.00 0035W Condylox 6.00 6.00 6.00 6.00 6.00 0006W Cytotec 200 mcg #2 6.00 6.00 6.00 6.00 6.00 0005W Doxycycline 100 mg #14 9.00 9.00 9.00 9.00 9.00 0059W Estradiol 1 mg- #100 13.00 13.00 13.00 13.00 13.00 00111/4/ Fluconazole 150 mg #1 16.00 16.00 16.00 16.00 16.00 0012W Iron 10.00 10.00 10.00 10.00 10.00 J0580 LA Bicillin 2.4 Units 0.00 0.00 0.00 0.00 0.00 006ow Medroxyprogesterone 10 mg - #5 13.00 13.00 13.00 13.00 13.00 0oo8W Metrogel 8.00 8.00 8.00 8.00 8.00 0009W Metronidazole 500 mg #4 8.00 8.00 8.00 8.00 8.00 001 ow Metronidazole 500 mg #14 9.00 9.00 9.00 9.00 9.00 0013W Metronidazole 250 mg #28 14.00 14.00 14.00 14.00 14.00 0061W Nitrofurantoin Macrocrystals - #14 40.00 40.00 40.00 40.00 40.00 0034W Ofloxacin 93.00 93.00 93.00 93.00 93.00 0016W Podophyllin/TCA 13.00 13.00 13.00 13.00 13.00 00006W Premarin Vaginal Cream 12.00 12.00 12.00 12.00 12.00 0192W Prenatal Vitamins 11 .00 11 .00 11 .00 11 .00 11 .00 0004W Sulfatrim SMX/TMP 8.00 8.00 8.00 8.00 8.00 oo180W Suprax 400 mg #1 - partner pak 22.00 22.00 22.00 22.00 22.00 00180NC Suprax 400 mg #1 - State Supplied 0.00 0.00 0.00 0.00 0.00 Procedures 56420 Bartholin Cyst 29.00 29.00 29.00 29.00 29.00 11100 Biopsy of skin, single 27.00 27.00 27.00 27.00 27.00 57500 Cervical Lesion Biopsy 32.00 32.00 32.00 32.00 32.00 0116W Chest X-Ray (Prepay) 55.00 55.00 55.00 55.00 55.00 57452 Colposcopy w/o Biopsy ** 90.00 90.00 90.00 90.00 90.00 57454 Colposcopy with Biopsy ** 90.00 90.00 90.00 90.00 90.00 57511 Cryocautery cervix- initial or repeat 99.00 99.00 99.00 99.00 99.00 17000 Cryotherapy first lesion ** 26.00 26.00 26.00 26.00 26.00 17003 Cryotherapy 2-14 lesions ** 26.00 26.00 26.00 26.00 26.00 17004 Cryotherapy 15 + lesions ** 26.00 26.00 26.00 26.00 26.00 56501 Destruction Lesion Vulva 88.00 88.00 88.00 88.00 88.00 57170 Diaphragm/Cervical Cap Fitting * 0.00 19.75 39.50 59.25 79.00 58100 Endometrial biopsy w/wo Biopsy 44.00 44.00 44.00 44.00 44.00 58110 Endometrial biopsy with Colposcopy _ 56.00 56.00 56.00 56.00 56.00 Essure by referral*** 0.00 0.00 0.00 0.00 0.00 11400 Excisions, benign lesion 77.00 77.00 77.00 77.00 77.00 11975 Implanon Insertion 0.00 41 .00 82.00 123.00 164.00 Incision & drainage of abcess, single or 10060 simple 31 .00 31 .00 31 .00 31 .00 31 .00 58300 Insertion IUD* 0.00 41 .25 82.50 123.75 165.00 57460 LEEP with biopsy 135.00 135.00 135.00 135.00 135.00 57461 LEEP with conization 225.00 225.00 225.00 225.00 225.00 88305 Level 4 - Surgical pathology 1st site 90.00 90.00 90.00 90.00 90.00 88305W Level 4-Surgical Pathology 2nd site & each add! 90.00 90.00 90.00 90.00 90.00 PHS 2012 Fees Page 4 Procedure Code Code Code Code Code e Code Procedure 1 2 3 4 5 Procedures (continued) 59025 Non Stress Test Interp 0.00 0.00 0.00 0.00 0.00 11976 Removal, implant contraceptive (Implanon) 0.00 48.75 97.50 146.25 195.00 11977 Removal implant, with reinsertion 0.00 75.00 150.00 225.00 300.00 58301 Removal IUD* 0.00 33.00 66.00 99.00 132.00 A4550 Surgical Tray r 59.00 59.00 59.00 59.00 59.00 Shaving of epidermal lesion, single on trunk, 11300 arms or legs, .5cm 37.00 37.00 37.00 37.00 37.00 Additional Codes 0071W Community Education 1 hr. 62.00 62.00 62.00 62.00 62.00 0069W Travax Printout 7.00 7.00 7.00 7.00 7.00 FAMILY PLANNING SUPPLIES A4267 Condoms pkg. 12* 0.00 1 .50 3.00 4.50 6.00 0052W Cycle Beads* 0.00 2.75 5.50 8.25 11 .00 A4266 Diaphragm* 0.00 6.25 12.50 18.75 25.00 A4269 Foam Contraception* 0.00 2.50 5.00 7.50 10.00 J7307NC Implanon 0.00 92.75 185.50 278.25 371 .00 J7302 NC IUD Mirena 0.00 103.00 206.00 309.00 412.00 J7300NC IUD Paragard 0.00 64.50 129.00 193.50 258.00 J1055 Medroxyprogesterone 150mg IM (Depo)* 0.00 4.25 8.50 12.75 17.00 J7303 Nuva Ring 0.00 9.00 18.00 27.00 36.00 S4993 Oral Contraceptives* 0.00 5.75 11 .50 17.25 23.00 0068W Seasonale 0.00 15.00 30.00 45.00 60.00 0065W Tod ayls Sponge 0.00 1 .00 2.00 3.00 _ 4.00 Immunizations 90748 Comvax - Hep B & Hib 0.00 0.00 0.00 0.00 0.00 90700 DTAP 0.00 0.00 0.00 0.00 0.00 90702 DT 0.00 0.00 0.00 0.00 0.00 90633 Hepatitis A - VFC 0.00 0.00 0.00 0.00 0.00 90632 Hepatitis A - Adult 45.00 45.00 45.00 45.00 45.00 90744 Hepatitis B - VFC 0.00 0.00 0.00 0.00 0.00 90746 Hepatitis B - Adult 45.00 45.00 45.00 45.00 45.00 90647 HIB 0.00 0.00 0.00 0.00 0.00 90649 HPV - VFC 0.00 0.00 0.00 0.00 0.00 90649A HPV - Adult 160.00 160.00 160.00 160.00 160.00 90649AT HPV - Adult - 317 vaccine 0.00 0.00 0.00 0.00 0.00 90281 IG Hepatitis A 0.00 0.00 0.00 0.00 0.00 90471 Imm. Admin - one vaccine 14.70 14.70 14.70 14.70 14.70 90472 Imm Admin - each addl. Vaccine 14.70 14.70 14.70 14.70 14.70 90473 Imm. Admin - intranasal or oral 14.70 14.70 14.70 14.70 14.70 90657 Influenza - Child (6 mo thru 35 mo) 0.00 0.00 0.00 0.00 0.00 90658 Influenza - Child (3 years thru 18 years) 0.00 0.00 0.00 0.00 0.00 90658A Influenza - Adult (Ages 19 & over) 0.00 0.00 0.00 0.00 0.00 00658W Influenza - Adult (State Vaccine) 0.00 0.00 0.00 0.00 0.00 90660 Influenza - intranasal use 0.00 0.00 0.00 0.00 0.00 90660A Influenza - Intranasal Adult 25.00 25.00 25.00 25.00 25.00 G0008 Influenza - Admin. - MEDICARE 14.70 14.70 14.70 14.70 14.70 90713 IPV-VFC 0.00 0.00 0.00 0.00 0.00 90713A IPV - Adult 45.00 45.00 45.00 45.00 45.00 90735 Japanese Encephalitis (new formulation) 230.00 230.00 230.00 230.00 230.00 90696 Kinrix i 0.00 0.00 0.00 0.00 0.00 90734 Menectra - Child 0.00 0.00 0.00 0.00 0.00 PHS 2012 Fees Page 5 Procedure Code Code Code Code Code Code Procedure 1 2 3 4 5 Immunizations (continued) 90734A Menectra - Adult (Menveo) (conjugate) 120.00 120.00 120.00 120.00 120.00 90734AT Menectra Adult - 317 Vaccine 0.00 0.00 0.00 0.00 0.00 90733 Meningitis-(Menomune)(polysaccharide) 120.00 120.00 120.00 120.00 120.00 90707 MMR - VFC 0.00 0.00 0.00 0.00 0.00 90707A MMR - Adult 61 .00 61 .00 61 .00 61 .00 61 .00 90707AT MMR - Adult - 317 Vaccine 0.00 0.00 0.00 0.00 0.00 90710 MMRV (MMR & Varivax) Proquad 0.00 0.00 0.00 0.00 0.00 90723 Pediarix - DTAP, Hep B & IPV 0.00 0.00 0.00 0.00 0.00 90698 Pentacel 0.00 0.00 0.00 0.00 0.00 90670 Pneumococal conjugate 0.00 0.00 0.00 0.00 0.00 90732 Pneumovax - VFC 0.00 0.00 0.00 0.00 0.00 90732A Pneumovax - Adult 67.00 67.00 67.00 67.00 67.00 90732AT Pneumovax - Adult - 317 Vacc. 0.00 0.00 0.00 0.00 0.00 G0009 Pneumovax Admin. - MEDICARE 14.70 14.70 14.70 14.70 14.70 90669 Prevnar 0.00 0.00 0.00 0.00 0.00 90675 Rabies IM 227.00 227.00 227.00 227.00 227.00 90675AT Rabies IM - Adult Temporary 0.00 0.00 0.00 0.00 0.00 90680 Rotavirus 0.00 0.00 0.00 0.00 0.00 90681 Rotarix 0.00 0.00 0.00 0.00 0.00 90718 TD 0.00 0.00 0.00 0.00 0.00 90715 Tdap 0.00 0.00 0.00 0.00 0.00 90715AT Tdap Adult - 317 vaccine 0.00 0.00 0.00 _ 0.00 0.00 86580 Tuberculosis Interdermal Skin Test (PPD) 25.00 _ 25.00 25.00 25.00 _ 25.00 6580W Tuberculosis Interdermal Skin test PPD N/C 0.00 0.00 0.00 0.00 0.00 Tuberculosis Interdermal Skin Test(PPD) 8658W reading only 0.00 0.00 0.00 0.00 0.00 90636 Twinrix - Hep A & Hep B 67.00 _ 67.00 67.00 67.00 67.00 90636AT Twinrix Adult -317 vaccine - Hep A & Hep B 0.00 0.00 0.00 0.00 0.00 90691 Typhoid - 1 Shot 67.00 67.00 67.00 67.00 67.00 90690 Typhoid - Oral 57.00 57.00 57.00 57.00 57.00 90716 Varivax - VFC 0.00 0.00 0.00 0.00 0.00 90716A Varivax - Adult 98.00 98.00 98.00 98.00 98.00 90716AT Varivax - Adult - 317 Vaccine 0.00 0.00 0.00 0.00 0.00 90717 Yellow Fever 103.00 103.00 103.00 103.00 103.00 * Fees only slide for the Family Planning Program. Charges for all other programs are the Code 5 fee. ** Services include surgical procedure only. *** These items are free of charge to the client through the Colorado Family Plannin Initiative Rev. 11/21/2011 Hello