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Page 6 of 6 <br />CPT Code Description Current Fee <br />Requested Fee <br />Change for FY <br />2015-16 <br />Last <br />Revision <br />ORANGE COUNTY HEALTH DEPARTMENT FEE SCHEDULE <br />PERSONAL HEALTH SERVICES + NUTRITION <br />85018QW Hemoglobin $11.00 2009 <br />88175-90 Pap, Thin Prep (State Lab)$18.38 2012 <br />D0145 Oral Evaluation <3 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 />G0008 Adm of Influenza Vaccine $18.00 2009 <br />G0008 Admin. Influenza Vaccine - Medicare $18.00 2009 <br />G0009 Adm of Pneumococcal Vaccine $18.00 2009 <br />G0009 Admin. Pneumococcal Vaccine - Medicare $18.00 2009 <br />New DSME Minimum Fee $20.00 2015 <br />G0108 DSME/DSMT Individual Assessment $22.00 $51.82 2010 <br />G0109 DSME/DSMT Group Class $12.00 $17.00 2010 <br />G0270 Additional MD requested MNT indiv - Medicare $25.00 2010 <br />G0271 Additional MD requested MNT group - Medicare $13.00 2010 <br />H0001 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 IUD $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 />JO696 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 PMH 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.