Mecklenburg County Health Department Fee Schedule,
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- Donald Wilkinson
- 6 years ago
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1 Service Fee Program Area Animal Holding Facilities Annual Permit (New & Renewal) $50.00 Animal Holding Facilities Care Coordination for Children No Charge to Patient Case Management Services Home Visit for Newborn & Postpartum Assessments No Charge to Patient Case Management Services Pregnancy Care Management No Charge to Patient Case Management Services CAP AIDS, CAP DA (Disabled Adults) & CAP C (Children) Medicaid Deductible Community Alternative Program (CAP) Applies Amalgam 1 surface $ Dental Health Amalgam 2 surfaces $ Dental Health Amalgam 3 surfaces $ Dental Health Amalgam 4+ surfaces $ Dental Health Analgesia N2O $57.00 Dental Health Apexification/recalcification final appt. $ Dental Health Apexification/recalcification initial visit $ Dental Health Apexification/recalcification interim $ Dental Health Apply desensitizing agents $ Dental Health Athletic mouthguard $ Dental Health Biopsy soft tissue $ Dental Health Bitewing single film $27.00 Dental Health Bitewings 2 films $41.00 Dental Health Bitewings 3 films $36.00 Dental Health Bitewings 4 films $57.00 Dental Health Complicated suture up to 5 cm. $1, Dental Health Composite crown anterior $ Dental Health Comprehensive oral evaluation $73.00 Dental Health Crown build up $ Dental Health Dental prophy - 13yrs. and under $63.00 Dental Health Dental prophy - 14yrs. and over $91.00 Dental Health Endodontics anterior $ Dental Health Extract single tooth / simple $ Dental Health Extract soft tissue impacted $ Dental Health Extract tooth erupted (surg.) $ Dental Health Full mouth debridement $ Dental Health Habit appliance $ Dental Health 1
2 Hospital Call $ Dental Health Incision & Drainage / abscess intra-oral $ Dental Health Intraoral periapical additional film $19.00 Dental Health Intraoral film (comp. series) $ Dental Health Intraoral occlusal film $36.00 Dental Health Intraoral periapical 1st film $24.00 Dental Health Limited oral evaluation -problem $70.00 Dental Health Misc.(duplicate X-rays) $21.00 Dental Health Oral Eval under 3 w/counseling $42.00 Dental Health Palliative treatment of dental pain minor $ Dental Health Periodic oral evaluation $42.00 Dental Health Pin retention per tooth $51.00 Dental Health Prefab SS w/resin window $ Dental Health Pulp cap direct $66.00 Dental Health Pulp cap indirect $52.00 Dental Health Pulpotomy therapeutic $ Dental Health Re-cement crown $93.00 Dental Health Re-cement space maintainer $69.00 Dental Health Resin 1 surface anterior $ Dental Health Resin 1 surface posterior $ Dental Health Resin 2 surfaces - posterior $ Dental Health Resin 2 surfaces anterior $ Dental Health Resin 3 surface - posterior $ Dental Health Resin 3 surfaces anterior $ Dental Health Resin 4 + surfaces - posterior $ Dental Health Resin 4+ surfaces involving incisal $ Dental Health Sealant per tooth $36.00 Dental Health Sedative filling $97.00 Dental Health Space maintainer fixed bilateral $ Dental Health Space maintainer fixed unilateral (quad) $ Dental Health Stainless steel crown, Perm. tooth $ Dental Health Stainless steel crown, primary tooth $ Dental Health Suture of recent small wounds $ Dental Health Tooth re-implantation $ Dental Health 2
3 Topical fluoride Varnish $36.00 Dental Health Acute hepatitis panel $59.25 Family Planning, Women s Health Acyclovir injection $0.02 Family Planning, Women s Health Alanine amino (alt) (sgpt) $6.73 Family Planning, Women s Health Alcohol/Substance Abuse >30min $ Family Planning, Women s Health Alcohol/Substance Abuse 15-30m $70.00 Family Planning, Women s Health Artificial insemination $0.00 Family Planning, Women s Health Assay of creatinine $6.52 Family Planning, Women s Health Assay of ggt $9.15 Family Planning, Women s Health Assay of lead $15.39 Family Planning, Women s Health Assay, glucose, blood quant $4.99 Family Planning, Women s Health Azithromycin $17.33 Family Planning, Women s Health Azithromycin dihydrate, oral $0.37 Family Planning, Women s Health Bilirubin, direct $6.39 Family Planning, Women s Health Bilirubin, total $6.39 Family Planning, Women s Health Bx done w/colposcopy add-on $ Family Planning, Women s Health Ca screen;pelvic/breast exam $50.00 Family Planning, Women s Health Cannula nasal $5.00 Family Planning, Women s Health Cardioversion electric, ext $ Family Planning, Women s Health Case management $17.00 Family Planning, Women s Health Ceftriaxone sodium injection $0.54 Family Planning, Women s Health Chylmd trach, dna, quant $41.41 Family Planning, Women s Health Complete cbc w/auto diff wbc $9.88 Family Planning, Women s Health Comprehen Metabolic Panel $10.74 Family Planning, Women s Health Contraceptive vaginal ring $14.41 Family Planning, Women s Health Cytopath c/v auto fluid redo $33.04 Family Planning, Women s Health Cytopath, c/v, auto rescreen $13.43 Family Planning, Women s Health Cytopath, c/v, manual $26.00 Family Planning, Women s Health Cytopath, c/v, thin layer $26.00 Family Planning, Women s Health Depo-Provera Injections $23.79 Family Planning, Women s Health Destruct lesion, 1-14 $78.99 Family Planning, Women s Health Destruct lesion, 15 or more $94.04 Family Planning, Women s Health Developmental test, lim $33.00 Family Planning, Women s Health Diagnostic mammography digital $ Family Planning, Women s Health 3
4 Diflucan 150 mg $0.00 Family Planning, Women s Health Dilation of cervical canal $ Family Planning, Women s Health Drugs unclassified injection $18.91 Family Planning, Women s Health Dwelling lead investigation $ Family Planning, Women s Health Emergency Contraceptive /Plan B $0.00 Family Planning, Women s Health Enterovirus antibody, dfa $14.57 Family Planning, Women s Health Fecal blood scrn immunoassay $33.00 Family Planning, Women s Health Female condom $75.13 Family Planning, Women s Health Fitting of diaphragm/cap $ Family Planning, Women s Health Flulaval vacc, 3 yrs & >, im $15.03 Family Planning, Women s Health Gamma globulin 2 cc inj $13.00 Family Planning, Women s Health Gamma globulin 3 cc inj $13.00 Family Planning, Women s Health Gamma globulin 4 cc inj $13.00 Family Planning, Women s Health Glycosylated hemoglbin tests $0.00 Family Planning, Women s Health Group mnt 2 or more 30 mins $17.00 Family Planning, Women s Health Health risk assessment test $40.00 Family Planning, Women s Health Heart/lung resuscitation cpr $ Family Planning, Women s Health Hemoglobin chromotography $22.96 Family Planning, Women s Health Hemoglobin electrophoresis $15.48 Family Planning, Women s Health Hep b surface antibody $13.66 Family Planning, Women s Health Hep be antibody $14.71 Family Planning, Women s Health Hepatic function panel $10.19 Family Planning, Women s Health Hepatitis b surface ag, eia $11.83 Family Planning, Women s Health Hepatitis b, dna, quant $41.41 Family Planning, Women s Health Hepatitis c ab test $18.15 Family Planning, Women s Health Herpes simplex type 2 $24.62 Family Planning, Women s Health Hiv-1 $0.00 Family Planning, Women s Health Hiv-1, dna, quant $67.59 Family Planning, Women s Health Home visit, nb care $ Family Planning, Women s Health Home visit, postnatal $ Family Planning, Women s Health Hormonal Implant Insertion $ Family Planning, Women s Health Hormonal Implant Removal $ Family Planning, Women s Health 4
5 HPV detection by DNA or RNA $46.90 Family Planning, Women s Health Imadm Any Route 1St Vac/Tox $23.98 Family Planning, Women s Health Immunoassay,infectious agent $35.00 Family Planning, Women s Health Inadm Any Route Addl Vac/Tox $12.29 Family Planning, Women s Health Influenza virus antibody $17.24 Family Planning, Women s Health Init Pm E/M, New Pat 1-4 Yrs $ Family Planning, Women s Health Init Pm E/M, New Pat 65+ Yrs $ Family Planning, Women s Health Init Pm E/M, New Pat, Inf $ Family Planning, Women s Health Intervene hlth/behave, indiv $43.00 Family Planning, Women s Health Lipid panel $17.04 Family Planning, Women s Health Male condom $0.00 Family Planning, Women s Health Med nutrition, indiv, subseq $53.00 Family Planning, Women s Health Medical nutrition, group $30.00 Family Planning, Women s Health Medical nutrition, indiv, in $65.00 Family Planning, Women s Health Medical Records Publishing Fee $1.00 Family Planning, Women s Health Medrxyprogester acetate inj $47.00 Family Planning, Women s Health Mirena - long term contraceptive $ Family Planning, Women s Health Mirena IUD Kit & Insertion $ Family Planning, Women s Health Mnt subs tx for change dx $17.00 Family Planning, Women s Health Mononuclear cell antigen, quan $33.02 Family Planning, Women s Health Mouth piece $5.00 Family Planning, Women s Health N.gonorrhoeae, dna, quant $41.41 Family Planning, Women s Health Neutralization test, viral $35.00 Family Planning, Women s Health Newborn metabolic screening $19.00 Family Planning, Women s Health Nexplanon - long term contraceptive $ Family Planning, Women s Health Obtaining screen pap smear $47.00 Family Planning, Women s Health Occult blood, other sources $14.00 Family Planning, Women s Health Office consultation $38.98 Family Planning, Women s Health Office/outpatient visit, est (fee depends on medical services provided) $48.00 Family Planning, Women s Health Office/outpatient visit, est (fee depends on medical services provided) $80.00 Family Planning, Women s Health Office/outpatient visit, est (fee depends on medical services provided) $ Family Planning, Women s Health 5
6 Office/outpatient visit, est (fee depends on medical services provided) $ Family Planning, Women s Health Office/outpatient visit, est (fee depends on medical services provided) $ Family Planning, Women s Health Office/outpatient visit, new (fee depends on medical services provided) $84.00 Family Planning, Women s Health Office/outpatient visit, new (fee depends on medical services provided) $ Family Planning, Women s Health Office/outpatient visit, new (fee depends on medical services provided) $ Family Planning, Women s Health Office/outpatient visit, new (fee depends on medical services provided) $ Family Planning, Women s Health Office/outpatient visit, new (fee depends on medical services provided) $ Family Planning, Women s Health Oral Contraceptive Pills $9.00 per pack Family Planning, Women s Health Oral prescrip drug non chemo $0.00 Family Planning, Women s Health Other specified case mgmt $15.00 Family Planning, Women s Health Ova and parasites smears $50.00 Family Planning, Women s Health Pap Smears $21.46 Family Planning, Women s Health Paraguard IUD Kit & Insertion ( Intraut copper contraceptive) long term $ Family Planning, Women s Health contraceptive Penicillin g benzathine inj $0.02 Family Planning, Women s Health Per Pm Reeval Est Pat 65+ Yr $ Family Planning, Women s Health Per Pm Reeval, Est Pat, Inf $ Family Planning, Women s Health Prev Visit, Est, Age $ Family Planning, Women s Health Prev Visit, Est, Age 1-4 $ Family Planning, Women s Health Prev Visit, Est, Age $ Family Planning, Women s Health Prev Visit, Est, Age $ Family Planning, Women s Health Prev Visit, Est, Age 5-11 $ Family Planning, Women s Health Prev Visit, New, Age $ Family Planning, Women s Health Prev Visit, New, Age $ Family Planning, Women s Health Prev Visit, New, Age $ Family Planning, Women s Health Prev Visit, New, Age 5-11 $ Family Planning, Women s Health Preventive counseling, group $98.00 Family Planning, Women s Health 6
7 Preventive counseling, indiv $80.00 Family Planning, Women s Health Preventive counseling, indiv $ Family Planning, Women s Health Preventive counseling, indiv $ Family Planning, Women s Health Preventive counseling, indiv $ Family Planning, Women s Health Pure tone hearing test, air $28.00 Family Planning, Women s Health Quantitative assay, drug $84.00 Family Planning, Women s Health Rbc sickle cell test $7.02 Family Planning, Women s Health Removal of contraceptive cap (Norplant) $ Family Planning, Women s Health Remove intrauterine device $ Family Planning, Women s Health Remove/insert drug inplant $ Family Planning, Women s Health Rn services up to 15 minutes $45.00 Family Planning, Women s Health Sc Ther Infusion, Reset Pump $0.00 Family Planning, Women s Health Screeningmammographydigital $ Family Planning, Women s Health Smoking/Tobacco Cess. >10min $68.00 Family Planning, Women s Health Smoking/Tobacco Cess min $34.00 Family Planning, Women s Health Special supplies $12.00 Family Planning, Women s Health Spun microhematocrit $13.00 Family Planning, Women s Health Strep a ag, eia $14.57 Family Planning, Women s Health Support broker waiver/15 min $17.00 Family Planning, Women s Health Syphilis Test Non-Trep Quant $5.61 Family Planning, Women s Health T cell, absolute count $34.04 Family Planning, Women s Health T cell, absolute count/ratio $59.74 Family Planning, Women s Health T cells, total count $47.96 Family Planning, Women s Health Targeted case management $23.61 Family Planning, Women s Health Tb Ag Response T-Cell Susp $60.00 Family Planning, Women s Health Ther/Proph/Diag Inj, Sc/Im $26.00 Family Planning, Women s Health Tobacco-use counsel 3-10 min $14.00 Family Planning, Women s Health Tobacco-use counsel>10min $28.00 Family Planning, Women s Health Toxoplasma antibody $18.27 Family Planning, Women s Health Treponema Pallidum $17.26 Family Planning, Women s Health Urinalysis, auto, w/o scope $15.00 Family Planning, Women s Health Varicella-zoster antibody $16.38 Family Planning, Women s Health Virus inoculation, tissue $20.71 Family Planning, Women s Health Visual acuity screen $11.00 Family Planning, Women s Health 7
8 Visualization of windpipe $ Family Planning, Women s Health Wet mounts/ w preparations $7.00 Family Planning, Women s Health Foreign Travel Clinic Nurse Consultation $48.00 per person Foreign Travel Class Registration for Contractors $70.00 Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee > 50 wells $ Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee wells $ Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee wells $ Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee 3 wells $ Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee 4 wells $ Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee 5 wells $ Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee 6 wells $ Groundwater - Environmental Health Contamination Sites/Monitoring Well - Site Fee 7-10 wells $ Groundwater - Environmental Health Copies $.05 per page Groundwater - Environmental Health Day Care Education Program $10.00 Home Day Cares New Registration & Permit $70.00 Home Day Cares Injectable Vaccine Administration; each additional vaccine $13.71 Immunizations Injectable Vaccine Administration; single vaccine $15.00 Immunizations Oral - Intranasal Administrative; each additional vaccine $13.71 Immunizations Oral - Intranasal Vaccine Administration; single vaccine $15.00 Immunizations Admin hepatitis b vaccine (Medicare clients only) $12.00 Immunizations Admin influenza virus vac (Medicare clients only) $12.00 Immunizations Admin pneumococcal vaccine (Medicare clients only) $12.00 Immunizations Flu Mist with administration (intranasal) $25.00 Immunizations Flu Vaccine (3 yrs+) with administration multi dose $16.57 Immunizations Flu Vaccine (6-35 months) with administration single dose - no $20.82 Immunizations preservative Flu vaccine 6-35 months multi dose $20.82 Immunizations Flu virus vaccine, multidose (6-35 months) $20.82 Immunizations Fluzone with administration (Intradermal) $34.33 Immunizations Hep A (adult) $47.83 Immunizations Hep a/hep b vaccine, adult im (Twinrix) $71.04 Immunizations Hepatitis A - Pediatric/Adolescent, 2 dose $24.56 Immunizations Hib vaccine ActHib (PRP-T) $25.00 Immunizations Hib vaccine, prp-omp, im $24.00 Immunizations 8
9 High Dose Fluzone with administration (65 yrs+) $31.91 Immunizations HPV, 9 antigens $ Immunizations Immune Globulin $13.00 Immunizations Influenza vac quad 6-35 mos IM $20.82 Immunizations Influenza Vaccine (3 yrs+) with administration single dose $16.82 Immunizations Influenza Vaccine (3 yrs+) with administration single dose - no preservative $16.75 Immunizations Pneumococcal vaccine (Prevnar) $ Immunizations Rabies vaccine, im $ Immunizations Rotovirus vacc 3 dose, oral $87.00 Immunizations Chicken Pox (Varicella) $ Immunizations Diptheria-Tetanus $47.37 Immunizations Dtap $22.83 Immunizations Dtap-hep b-ipv vaccine, im $57.45 Immunizations Dtap-hib-ip vaccine, im $93.00 Immunizations Dtap-Ipv Vacc 4-6 Yr Im $41.31 Immunizations Hep B Adult vaccine $38.72 Immunizations Hepatitis B - Pediatric/Adolescent, 3 dose $11.85 Immunizations Influenza Vaccine (3 yrs +) with administration multi dose $15.00 Immunizations Measles, Mumps, Rubella $62.73 Immunizations Measles,Mumps,Rubella,Varicella (Proquad) $ Immunizations Meningococcal vaccine, im (55 years of age and younger) $ Immunizations Meningococcal vaccine, sc (56 years of age and older) $ Immunizations Pneumonia Vaccine $77.32 Immunizations Poliovirus (Inactivated), ipv, sc/im $30.00 Immunizations Shingles (Zoster) $ Immunizations Tetanus-diptheria (Td) $29.73 Immunizations Tetanus-diptheria acellular pertussis (Tdap) $33.01 Immunizations Typhoid vaccine, im $88.34 Immunizations Yellow fever vaccine, sc $ Immunizations Chlamydia; Amplified Probe $92.00 Laboratory Finger, Heel, Ear Stick $12.00 Laboratory 9
10 Gram Stain $22.00 Laboratory Hemoglobin $15.00 Laboratory N.gonorrhoeae, dna, amp prob $92.00 Laboratory Occult Blood, Feces $14.00 Laboratory Ova & Parasite Smear $50.00 Laboratory Routine venipuncture $14.00 Laboratory Screening Culture $24.00 Laboratory Special Stains, All Other $ Laboratory Specimen handling $19.33 Laboratory Syphilis Test - RPR Qualitative $31.00 Laboratory Tb Test Cell Immun Measure $ Laboratory TRICHOMONAS VAGINALIS AMPLIF $29.84 Laboratory Urinalysis, Dipstick $12.00 Laboratory Urine Pregnancy Test $25.00 Laboratory Wet Mount $19.00 Laboratory Administrative Attorney/Insurance Request $10.00 Medical Records Administrative Attorney/Insurance Request, Pages 100+ $0.25 Medical Records Administrative Attorney/Insurance Request, Pages 1-25 $0.75 Medical Records Administrative Attorney/Insurance Request, Pages $0.50 Medical Records Disability Determination Request $12.00 Medical Records General Patient Record/Lab Results per page $1.00 Medical Records Immunization Record Free Medical Records Permit to Construct a Public pool $ Plan Review - Environmental Health Annual Pools - Permit to Operate (received after February) $ Public Pools - Environmental Health Annual Pools - permit to operate (received prior to March 1) $ Public Pools - Environmental Health Seasonal Pools - Permit to Operate (Received after February) $ Public Pools - Environmental Health Seasonal Pools - Permit to Operate (Received Prior to March 1) $ Public Pools - Environmental Health Completion of Refugee Immigration Record $25.00 Refugee Services Permit to Construct Residential Pool $75.00 Residential Pools - Environmental Health Basic Food Service Worker Certification (2 hours) $50.00 Restaurants/Foodservice - Environmental Health Document Copies $0.05 per page Restaurants/Foodservice - Environmental Health 10
11 Food Training Tape $10.00 Restaurants/Foodservice - Environmental Health Food/Lodging Plan Review $ Restaurants/Foodservice - Environmental Health Push Cart/Mobile Food Unit Plan Review $ Restaurants/Foodservice - Environmental Health Temporary Event Fee $75.00 Restaurants/Foodservice - Environmental Health Modify Plot Plan (residential or commercial) $ Septic - Environmental Health New Septic System (commercial) *Includes all required permits & $ Septic - Environmental Health Inspections New Septic System (commercial) *Includes Soil test & Improvement Permit ONLY. Additional $400 required for system installation. $ Septic - Environmental Health New Septic System (residential) *Includes all required permits & Inspections New Septic System (residential) *Includes Soil test & Improvement Permit ONLY. Additional $400 required for system installation. $ Septic - Environmental Health $ Septic - Environmental Health Septic System Alteration (residential or commercial) $ Septic - Environmental Health HIV post test results $0.00 STD HIV pretest counseling $0.00 STD New Tattoo Artist Permit Annual Fee $ Tattoo - Environmental Health Tattoo Renewal Annual Fee $ Tattoo - Environmental Health Chest x-ray $61.00 TB Record TB Screening $20.00 TB Tuberculin Skin Test (Employment Assessment Skin test) $22.00 TB Birth Amendment - Preparation $10.00 Vital Records Birth Amendment - Preparation of Legitimation $10.00 Vital Records Birth Amendment/Legitimation $15.00 Vital Records Birth Amendment/Legitimation (copy from State) $24.00 Vital Records Birth Amendment/Legitimation (State Fee) $15.00 Vital Records Birth Amendment/Notary - to County $3.00 Vital Records Certified Birth Certificate $10.00 Vital Records 11
12 Certified Death Certificate $10.00 Vital Records Copies $1.00 Vital Records Wallet Certificates - laminated $7.50 Vital Records Wallet Certificates - laminated (2 or more) $5.00 Vital Records -First Draw Lead $40.00 Wells - Environmental Health -Pesticides $74.00 Wells - Environmental Health -Volatile Organic Compounds $74.00 Wells - Environmental Health Additional Analysis that may be added to option 1, 2, or 3 Wells - Environmental Health Community and NTNC Well Registration $ Wells - Environmental Health Option #1 - Bacteria Analysis (includes total coliform bacteria) $75.00 Wells - Environmental Health Option #2 - Bacteria and Nitrate/Nitrate Analysis (includes total coliform $ Wells - Environmental Health bacteria, Nitrate) Option #3 - Bacteria Nitrate/Nitrate and Inorganic Analysis $ Wells - Environmental Health Private Well - Additional (2) site visits for sampling $ Wells - Environmental Health Private Well - Major Repair $ Wells - Environmental Health Private Well - Retained Fee if request is denied $ Wells - Environmental Health Private Well New (includes 2 site visits for sampling) $ Wells - Environmental Health Transient Non-Community Well - Annual Registration $ Wells - Environmental Health Transient Non-Community Well (New) $ Wells - Environmental Health Transient Non-Community Well- Major Repair $ Wells - Environmental Health Optional Site Evaluation $ Wells/Septic - Environmental Health Use Existing System (residential or commercial) $ Wells/Septic - Environmental Health 12
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South Carolina North Carolina Louisiana. Norplant implant removal. Diaphragm fitting with instructions
P a g e 1 00840 00851 00921 Anesthesia, intraperitoneal procedure, lower abdomen, Including laparoscopy; tubal ligation/transection Anesthesia for vaginal procedure 00952 (including biopsy of labia, vagina,
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: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
LOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
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An immunization that does not fall under one of the exclusions in the Certificate of Coverage is considered covered after the following conditions are satisfied: (1) FDA approval; (2) explicit ACIP recommendation
kernfamilyhealthcare.com. Si necesita esta información en español, por favor llámenos.
Together in... p revention Preventive Care Gu id e Kern Family Health Care wants you to get good health care. These preventive care guidelines help you stay healthy by preventing diseases or by finding
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Out-of-Network providers require prior authorization to render services to Neighborhood members.
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Headline. Preventive care covered with no cost sharing
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OFFICE VISITS Community Fee Range Student Discounted Rate Primary Care Visit $120-.00-$277.00 $20.00 Special Visit $120.00 - $295.00 $45.00 WOMEN S HEALTH (Additional Fees May Apply) Well Woman Exam w/pap
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SoonerCare Fax Blast February 15, 2008 Subject: EPSDT and 4 th DPT/DTaP Encounters Dear Provider: Please note the following: EPSDT All encounters for EPSDT for 2007 dates of service must be filed before
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PREVENTIVE CARE To help you live the healthiest life possible, we offer free preventive services for most Network Health members. Please refer to your member materials, which you received when you enrolled
PREVENTIVE IMMUNIZATIONS. PREVENTIVE IMMUNIZATIONS These codes do not have a diagnosis code requirement for preventive benefits to apply.
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OFFICE VISITS Community Fee Range Student Discounted Rate. WOMEN S HEALTH (Additional Fees May Apply) COUNSELING / PSYCHOLOGICAL SERVICES
OFFICE VISITS Primary Care Visit $90.00 - $225.00 $20.00 Special Visit $107.00 - $120.00 $45.00 WOMEN S HEALTH (Additional Fees May Apply) Well Woman Exam w/pap $151.00 - $210.00 $50.00 - $120.00 Well
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OSHA Charge for disposables for patients protection, per person, per visit* $5.00 120 Periodic oral exam $5.00 140 Limited oral exam $30.00 150 Comprehensive oral evaluation $20.00 180 Comprehensive Perio
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: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
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HSCSN Table Top Reference Guide
Age Limitation Covered One per 6 months per dentist or dental group. Only one exam (D0120) every 6 months per dentist or dental D0120 iodic oral evaluation 0-20 No group. D0140 Limited oral evaluation
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Managed DentalGuard Texas
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ANNUAL HEALTH SCREENINGS AND IMMUNIZATIONS GUIDE MEN WOMEN ALL ADULTS CHILDREN
AND IMMUNIZATIONS GUIDE MEN WOMEN ALL ADULTS CHILDREN MEN PROSTATE CANCER Testicular exam Age 18+ PSA test Ages 50-75, based on risk WOMEN BREAST CANCER Self breast exam Monthly Clinical breast exam Annually
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This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General
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Procedure Description Modifier 33 Required? Screening test of visual acuity, quantitative, bilateral No Z Z00.129
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2008-2009 CODE DESCRIPTION FEE D0120 Periodic Oral Evaluation $33.00 D0140 Limited Oral Evaluation $51.00 D0145 Oral Evaluation - under 3 yrs of age $50.00 D0150 Comprehensive Oral Evaluation $56.00 D0210