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8 <br /> ORANGE COUNTY HEALTH DEPARTMENT FEE SCHEDULE <br /> PERSONAL HEALTH SERVICES+NUTRITION <br /> Requested Fee <br /> CPT Code Change for FY Last <br /> Description Current Fee 2015-16 Revision <br /> 85018QW Hemoglobin $11.00 2009 <br /> 88175-90 Pap,Thin Prep(State Lab) $18.38 2012 <br /> D0145 Oral Evaluation G3 yrs with counseling $55.00 2012 <br /> D1206 Topical Fluoride Appl $47.00 2012 <br /> Recode Employee Varicella Titer(UNC Lab) $78.00 2009 <br /> Recode Employee Measles(Rubeola)Titer $48.00 2009 <br /> Recode Employee Mumps Titer $50.00 2009 <br /> Recode Employee Rubella Titer $75.00 2009 <br /> 00008 Adm of Influenza Vaccine $18.00 2009 <br /> 00008 Admin.Influenza Vaccine-Medicare $18.00 2009 <br /> 00009 Adm of Pneumococcal Vaccine $18.00 2009 <br /> 00009 Admin.Pneumococcal Vaccine-Medicare $18.00 2009 <br /> New DSME Minimum Fee $20.00 2015 <br /> 60108 DSME/DSMT Individual Assessment $22.00 2010 <br /> 60109 DSME/DSMTGroup Class $12.00 2010 <br /> 60270 Additional MD requested MNT indiv-Medicare $25.00 2010 <br /> 60271 Additional MD requested MNT group-Medicare $13.00 2010 <br /> 110001 Alcohol and/or drug assessment New $20.00 <br /> H0031 Mental health assessment,by non-physician New $22.00 <br /> J1055 Depo Provera Injection $40.00 2012 <br /> J1050 Injection,medroxyprogesterone acetate,1 mg New $0.67 <br /> J1200 Diphenhydramine HCL/Benadryl up to 50mg $6.00 2009 <br /> J1725 Injection hydroxyprogesterone caproate,1 mg New $3.00 <br /> J2550 Promethazine_mg $8.00 2009 <br /> J2790 Rhogam Injection $88.00 2012 <br /> J3420 B-12 Injection $6.00 2009 <br /> J3490 17 Alpha-hydroxprogesterone $21.00 2012 <br /> J7300 Paragard ND $390.00 2012 <br /> J7301 Skyla IUD $0.00 $726.00 <br /> J7302 Mirena IUD $745.23 2014 <br /> J7303 Nuvaring $57.00 2008 <br /> J7307 Implanon $698.99 2014 <br /> J0696 Ceftriaxone Sodium/Rocephin per 250mg $22.00 2008 <br /> Recoded Sports Physical $44.00 2008 <br /> Recoded Camp Physical $44.00 2009 <br /> Recoded College Physical $44.00 2009 <br /> Recoded I-693 Form $0.00 2015 <br /> Recoded Primary Care Minimum Fee $20.00 2012 <br /> Recoded MNT Minimum Fee $20.00 2012 <br /> Recoded Adult Medicaid Co-pay $3.00 2010 <br /> Q2037 Fluvirin Vacc,3 yrs&>,IM New $31.00 <br /> Q2038 Fluzone Vacc,3 yrs&>,IM New $40.00 <br /> S0280 PMII Risk Screening New $50.00 <br /> S4993 Oral Contraceptive Pills $5.00 2012 <br /> S9465 Diabetic management program,dietitian visit $35.00 2011 <br /> S9470 Nutritional counseling,dietitian visit $35.00 2011 <br /> T1002 RN Services up to 15 min. $21.00 2005 <br /> S9442 Birthing classes 8.69/1 hr block 2013 <br /> 90714 TD Vaccine $35.00 2013 <br /> **UNC and State Lab Fees in BOLD are established by reference lab and not by OCHD <br /> **"No Code and Recode"represent local use codes that can be billed,however are not recognized by ICD-10. <br /> Page 6 of 6 <br />