Proc. Type Code Procedure/Product Code Description ACA Primary Care Services Fees VFC 90585 TB $23.14 VFC 90632 Hep A $23.14 VFC 90633 Hep A $23.14 VFC 90634 Hep A $23.14 VFC 90636 Hep A - Hep B $23.14 VFC 90645 Hib $23.14 VFC 90646 Hib $23.14 VFC 90647 HIB $23.14 VFC 90648 HIB $23.14 VFC 90649 HPV Vaccine $23.14 VFC 90650 HPV Vaccine $23.14 VFC 90654 Flu Vaccine $23.14 VFC 90655 Flu Vaccine $23.14 VFC 90656 Flu Vaccine $23.14 VFC 90657 Flu Vaccine $23.14 VFC 90658 Flu Vaccine $23.14 VFC 90660 Flu Vaccine $23.14 VFC 90661 Flu Vaccine (effective 5/28/2013) $23.14 VFC 90669 Pneumococcal Conjugate Vaccine $23.14 VFC 90670 Pneumococcal Conjugate Vaccine $23.14 VFC 90672 Flu Vaccine (effective June 2013) $23.14 VFC 90675 Rabies $23.14 VFC 90676 Rabies $23.14 VFC 90680 Rotavirus $23.14 VFC 90681 Rotavirus $23.14 VFC 90686 Flu Vaccine (effective June 2013) $23.14 VFC 90690 Typhoid $23.14 VFC 90691 Typhoid $23.14 VFC 90692 Typhoid $23.14 VFC 90693 Typhoid $23.14 VFC 90696 Dtap/IPV $23.14 VFC 90698 Dtap/HWOP B/IPV $23.14 VFC 90700 Dtap $23.14 VFC 90702 DT $23.14 VFC 90703 Tetanus $23.14 VFC 90704 Mumps $23.14
VFC 90705 Measles $23.14 VFC 90706 Rubella $23.14 VFC 90707 MMR $23.14 VFC 90708 Measles and Rubella $23.14 VFC 90710 MMRV $23.14 VFC 90713 IPV (poliovirus) $23.14 VFC 90714 TD $23.14 VFC 90715 TDAP vaccine $23.14 VFC 90716 Chicken Pox Vaccine $23.14 VFC 90717 Yellow Fever $23.14 VFC 90718 TD (End date June 2013) $23.14 VFC 90719 Diphtheria $23.14 VFC 90721 Diptheria, Tetanus Toxoids, Acellular Pertussis, and Hemophilus influenza B $23.14 VFC 90723 Diptheria, Tetanus Toxoids, Acellular Pertussis, $23.14 Hepatitus B, Poliovirus Vaccine VFC 90725 Cholera $23.14 VFC 90727 Plague $23.14 VFC 90732 Pneumococcal polysaccharide vaccine $23.14 VFC 90733 Meningococcal polysaccharide $23.14 VFC 90734 Meningococcal conjugate, serogroups A,C,Y, & W $23.14 VFC 90735 Japanese encephalitis virus $23.14 VFC 90736 Zoster (shingles) $23.14 VFC 90743 Hep B Pediatric $23.14 VFC 90744 Hep B Pediatric $23.14 VFC 90746 Hep B $23.14 VFC 90747 Hep B $23.14 VFC 90748 Hep B/Hib $23.14 VFC 90749 Unlisted vaccine $23.14 VFC G0008 Administration of Flu Vaccine $23.14 VFC G0009 Administration of Pneumonia Vaccine $23.14 E&M 99201 Office/Outpatient visit, new $44.45 E&M 99202 Office/Outpatient visit, new $75.76 E&M 99203 Office/Outpatient visit, new $110.16 E&M 99204 Office/Outpatient visit, new $168.95 E&M 99205 Office/Outpatient visit, new $209.35 E&M 99211 Office/Outpatient visit, est $20.50 E&M 99212 Office/Outpatient visit, est $44.45 E&M 99213 Office/Outpatient visit, est $73.85
E&M 99214 Office/Outpatient visit, est $108.67 E&M 99215 Office/Outpatient visit, est $146.10 E&M 99221 Initial Hospital Care $103.01 E&M 99222 Initial Hospital Care $139.63 E&M 99223 Initial Hospital Care $205.14 E&M 99231 Subsequent Hospital Care $39.53 E&M 99232 Subsequent Hospital Care $72.59 E&M 99233 Subsequent Hospital Care $104.69 E&M 99238 Hospital Discharge Day $72.91 E&M 99239 Hospital Discharge Day $107.70 E&M 99241 Office Consultation $47.75 E&M 99242 Office Consultation $90.31 E&M 99243 Office Consultation $123.24 E&M 99244 Office Consultation $182.24 E&M 99245 Office Consultation $223.25 E&M 99251 Inpatient Consultation $49.26 E&M 99252 Inpatient Consultation $75.86 E&M 99253 Inpatient Consultation $115.24 E&M 99254 Inpatient Consultation $165.87 E&M 99255 Inpatient Consultation $206.37 E&M 99281 Emergency Dept. Visit $21.31 E&M 99282 Emergency Dept. Visit $41.98 E&M 99283 Emergency Dept. Visit $62.65 E&M 99284 Emergency Dept. Visit $119.85 E&M 99285 Emergency Dept. Visit $175.76 E&M 99291 Critical Care, First Hour $279.71 E&M 99292 Critical Care, Add. 30 min $125.11 E&M 99304 Nursing Facility Care, INIT $94.68 E&M 99305 Nursing Facility Care, INIT $134.51 E&M 99306 Nursing Facility Care, INIT $169.76 E&M 99307 Nursing Fac Care, Subseq $44.78 E&M 99308 Nursing Fac Care, Subseq $69.63 E&M 99309 Nursing Fac Care, Subseq $91.29 E&M 99310 Nursing Fac Care, Subseq $136.00 E&M 99315 NURSING FAC DISCHARGE DAY $73.66 E&M 99316 NURSING FAC DISCHARGE DAY $105.61 E&M 99318 Annual Nursing Fac Assessment $96.50 E&M 99324 Domicil/R-home visit New Pat $56.28 E&M 99325 Domicil/R-home visit New Pat $81.06 E&M 99326 Domicil/R-home visit New Pat $140.50
E&M 99327 Domicil/R-home visit New Pat $187.94 E&M 99328 Domicil/R-home visit New Pat $217.91 E&M 99334 Domicil/R-home visit Est Pat $61.09 E&M 99335 Domicil/R-home visit Est Pat $95.53 E&M 99336 Domicil/R-home visit Est Pat $135.26 E&M 99337 Domicil/R-home visit Est Pat $194.64 E&M 99341 Home Visit, New Patient $55.95 E&M 99342 Home Visit, New Patient $80.48 E&M 99343 Home Visit, New Patient $132.77 E&M 99347 Home Visit, Est Patient $56.26 E&M 99348 Home Visit, Est Patient $85.16 E&M 99349 Home Visit, Est Patient $128.96 E&M 99350 Home Visit, Est Patient $179.52 E&M 99360 Physician Stand-by Service $62.15 E&M 99381 INIT PM E/M, New Pat, Inf $112.01 E&M 99382 INIT PM E/M, New Pat, 1-4 yrs $116.49 E&M 99383 Prev visit, New, age 5-11 $121.47 E&M 99384 Prev visit, New, age 12-17 $137.43 E&M 99385 Prev visit, New, age 18-39 $133.57 E&M 99386 Prev visit, New, age 40-64 $154.37 E&M 99387 INIT PM E/M New Pat 65+ yrs $167.93 E&M 99391 Per PM Reeval, Est Pat, INF $100.62 E&M 99392 Prev visit, est, age 1-4 $107.34 E&M 99393 Prev visit, est, age 5-11 $107.01 E&M 99394 Prev visit, est, age 12-17 $117.14 E&M 99395 Prev visit, est, age 18-39 $119.59 E&M 99396 Prev visit, est, age 40-64 $127.78 E&M 99397 Prev visit, est, age 65+ yrs $137.76 E&M 99407 BEHAV CHNG SMOKING > 10 MIN $27.75 E&M 99460 INIT NB EM PER DAY, HOSP $91.83 E&M 99461 INIT NB EM PER DAY, NON-FAC $101.27 E&M 99462 SBSQ NB EM PER DAY, HOSP $42.05 E&M 99463 SAME DAY NB DISCHARGE $116.24 E&M 99464 ATTENDANCE AT DELIVERY $77.09 E&M 99465 NB RESUSCITATION $149.04 E&M 99468 NEONATE CRIT CARE, INITIAL $970.34 E&M 99469 NEONATE CRIT CARE, SUBSQ $398.55 E&M 99471 PED CRITICAL CARE, INITIAL $861.34 E&M 99472 PED CRITICAL CARE, SUBSQ $411.06 E&M 99475 PED CRIT CARE AGE 2-5, INIT $572.57
E&M 99476 PED CRIT CARE AGE 2-5, SUBSQ $354.17 E&M 99477 INIT DAY HOSP NEONATE CARE $354.57 E&M 99478 IC, LBW INF < 1500 GM SUBSQ $142.61 E&M 99479 IC LBW INF 1500-2500 G SUBSQ $129.53 E&M 99480 IC INF PBW 2501-5000 G SUBSQ $121.30