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1 Proc. Type Code Procedure/Product Code Description ACA Primary Care Services Fees VFC TB $23.14 VFC Hep A $23.14 VFC Hep A $23.14 VFC Hep A $23.14 VFC Hep A - Hep B $23.14 VFC Hib $23.14 VFC Hib $23.14 VFC HIB $23.14 VFC HIB $23.14 VFC HPV Vaccine $23.14 VFC HPV Vaccine $23.14 VFC Flu Vaccine $23.14 VFC Flu Vaccine $23.14 VFC Flu Vaccine $23.14 VFC Flu Vaccine $23.14 VFC Flu Vaccine $23.14 VFC Flu Vaccine $23.14 VFC Flu Vaccine (effective 5/28/2013) $23.14 VFC Pneumococcal Conjugate Vaccine $23.14 VFC Pneumococcal Conjugate Vaccine $23.14 VFC Flu Vaccine (effective June 2013) $23.14 VFC Rabies $23.14 VFC Rabies $23.14 VFC Rotavirus $23.14 VFC Rotavirus $23.14 VFC Flu Vaccine (effective June 2013) $23.14 VFC Typhoid $23.14 VFC Typhoid $23.14 VFC Typhoid $23.14 VFC Typhoid $23.14 VFC Dtap/IPV $23.14 VFC Dtap/HWOP B/IPV $23.14 VFC Dtap $23.14 VFC DT $23.14 VFC Tetanus $23.14 VFC Mumps $23.14
2 VFC Measles $23.14 VFC Rubella $23.14 VFC MMR $23.14 VFC Measles and Rubella $23.14 VFC MMRV $23.14 VFC IPV (poliovirus) $23.14 VFC TD $23.14 VFC TDAP vaccine $23.14 VFC Chicken Pox Vaccine $23.14 VFC Yellow Fever $23.14 VFC TD (End date June 2013) $23.14 VFC Diphtheria $23.14 VFC Diptheria, Tetanus Toxoids, Acellular Pertussis, and Hemophilus influenza B $23.14 VFC Diptheria, Tetanus Toxoids, Acellular Pertussis, $23.14 Hepatitus B, Poliovirus Vaccine VFC Cholera $23.14 VFC Plague $23.14 VFC Pneumococcal polysaccharide vaccine $23.14 VFC Meningococcal polysaccharide $23.14 VFC Meningococcal conjugate, serogroups A,C,Y, & W $23.14 VFC Japanese encephalitis virus $23.14 VFC Zoster (shingles) $23.14 VFC Hep B Pediatric $23.14 VFC Hep B Pediatric $23.14 VFC Hep B $23.14 VFC Hep B $23.14 VFC Hep B/Hib $23.14 VFC Unlisted vaccine $23.14 VFC G0008 Administration of Flu Vaccine $23.14 VFC G0009 Administration of Pneumonia Vaccine $23.14 E&M Office/Outpatient visit, new $44.45 E&M Office/Outpatient visit, new $75.76 E&M Office/Outpatient visit, new $ E&M Office/Outpatient visit, new $ E&M Office/Outpatient visit, new $ E&M Office/Outpatient visit, est $20.50 E&M Office/Outpatient visit, est $44.45 E&M Office/Outpatient visit, est $73.85
3 E&M Office/Outpatient visit, est $ E&M Office/Outpatient visit, est $ E&M Initial Hospital Care $ E&M Initial Hospital Care $ E&M Initial Hospital Care $ E&M Subsequent Hospital Care $39.53 E&M Subsequent Hospital Care $72.59 E&M Subsequent Hospital Care $ E&M Hospital Discharge Day $72.91 E&M Hospital Discharge Day $ E&M Office Consultation $47.75 E&M Office Consultation $90.31 E&M Office Consultation $ E&M Office Consultation $ E&M Office Consultation $ E&M Inpatient Consultation $49.26 E&M Inpatient Consultation $75.86 E&M Inpatient Consultation $ E&M Inpatient Consultation $ E&M Inpatient Consultation $ E&M Emergency Dept. Visit $21.31 E&M Emergency Dept. Visit $41.98 E&M Emergency Dept. Visit $62.65 E&M Emergency Dept. Visit $ E&M Emergency Dept. Visit $ E&M Critical Care, First Hour $ E&M Critical Care, Add. 30 min $ E&M Nursing Facility Care, INIT $94.68 E&M Nursing Facility Care, INIT $ E&M Nursing Facility Care, INIT $ E&M Nursing Fac Care, Subseq $44.78 E&M Nursing Fac Care, Subseq $69.63 E&M Nursing Fac Care, Subseq $91.29 E&M Nursing Fac Care, Subseq $ E&M NURSING FAC DISCHARGE DAY $73.66 E&M NURSING FAC DISCHARGE DAY $ E&M Annual Nursing Fac Assessment $96.50 E&M Domicil/R-home visit New Pat $56.28 E&M Domicil/R-home visit New Pat $81.06 E&M Domicil/R-home visit New Pat $140.50
4 E&M Domicil/R-home visit New Pat $ E&M Domicil/R-home visit New Pat $ E&M Domicil/R-home visit Est Pat $61.09 E&M Domicil/R-home visit Est Pat $95.53 E&M Domicil/R-home visit Est Pat $ E&M Domicil/R-home visit Est Pat $ E&M Home Visit, New Patient $55.95 E&M Home Visit, New Patient $80.48 E&M Home Visit, New Patient $ E&M Home Visit, Est Patient $56.26 E&M Home Visit, Est Patient $85.16 E&M Home Visit, Est Patient $ E&M Home Visit, Est Patient $ E&M Physician Stand-by Service $62.15 E&M INIT PM E/M, New Pat, Inf $ E&M INIT PM E/M, New Pat, 1-4 yrs $ E&M Prev visit, New, age 5-11 $ E&M Prev visit, New, age $ E&M Prev visit, New, age $ E&M Prev visit, New, age $ E&M INIT PM E/M New Pat 65+ yrs $ E&M Per PM Reeval, Est Pat, INF $ E&M Prev visit, est, age 1-4 $ E&M Prev visit, est, age 5-11 $ E&M Prev visit, est, age $ E&M Prev visit, est, age $ E&M Prev visit, est, age $ E&M Prev visit, est, age 65+ yrs $ E&M BEHAV CHNG SMOKING > 10 MIN $27.75 E&M INIT NB EM PER DAY, HOSP $91.83 E&M INIT NB EM PER DAY, NON-FAC $ E&M SBSQ NB EM PER DAY, HOSP $42.05 E&M SAME DAY NB DISCHARGE $ E&M ATTENDANCE AT DELIVERY $77.09 E&M NB RESUSCITATION $ E&M NEONATE CRIT CARE, INITIAL $ E&M NEONATE CRIT CARE, SUBSQ $ E&M PED CRITICAL CARE, INITIAL $ E&M PED CRITICAL CARE, SUBSQ $ E&M PED CRIT CARE AGE 2-5, INIT $572.57
5 E&M PED CRIT CARE AGE 2-5, SUBSQ $ E&M INIT DAY HOSP NEONATE CARE $ E&M IC, LBW INF < 1500 GM SUBSQ $ E&M IC LBW INF G SUBSQ $ E&M IC INF PBW G SUBSQ $121.30
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