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Manager Recommended Fee Schedule - FY 2022 -23 52 <br /> Last <br /> Department/Program Description Current Fee Revision <br /> 99501 Home Visit Postpartum $200000 2015 <br /> 99502 Home Visit Newborn $200400 2015 <br /> D0145 Oral Evaluation <3 yrs with counseling $55 . 00 2012 <br /> D 1206 Topical Fluoride Appl $47 . 00 2012 <br /> G0008 Admin. Influenza Vaccine Medicare $ 18 . 00 2009 <br /> G0009 Admin. Pneumococcal Vaccine - Medicare $ 18 . 00 2009 <br /> G0010 Hep Be - Admin. - Medicare $ 18 . 00 2015 <br /> 2015 DSME Minimum Fee $20 . 00 2015 <br /> G0108 <br /> DSME/DSMT Individual Assessment " Medicare $ 52 . 00 2015 <br /> G0109 DSME/DSMT Group Class - Medicare $ 17 . 00 2015 <br /> G0270 Additional MD requested MNT indiv - Medicare $25 . 00 2010 <br /> G0271 <br /> Additional MD requested MNT group - Medicare $ 13 . 00 2010 <br /> 110001 Alcohol and/or drug assessment $20 . 00 2015 <br /> H0031 Mental health assessment, by non- h sician $22 . 00 2015 <br /> J0696 Ceftriaxone Sodium/Rocephin per 250mg $22 . 00 2008 <br /> J1050 Medroxyprogesterone acetate, 1 mg ( 150 units) $ 0 . 87 2022 <br /> Medicaid only JJ1050ud Medroxyprogesterone acetate, 1 mg ( 150 units) $ 0 . 87 2022 <br /> J1200 Di henh dramine HCL/Benadryl up to 50mg $ 6 . 00 2009 <br /> J1725 Injection hydroxyprogesterone caproate, 1 mg (250 <br /> units) $3 . 00 2015 <br /> J1885 Ketorolac IM Injection, per 15mg (Toradol) $20 . 00 2022 <br /> J2550 Promethazine _ mg $ 8 . 00 2009 <br /> J2790 Rhogam Injection $ 88 . 00 2012 <br /> J3420 B42Injection $ 6 . 00 2009 <br /> J7300 Paragard IUD $253 . 58 2022 <br /> Medicaid only J7300ud Paragard IUD $253058 2022 <br /> J7296 Kyleena IUD $249900 2021 <br /> Medicaid only J7296ud Kyleena IUD $249000 2021 <br /> J7301 Skyla IUD $ 142 .49 2022 <br /> Medicaid only J7301ud Skyla IUD $ 142449 2022 <br /> J7297 Liletta IUD $ 100000 2021 <br /> Medicaid only J7297ud Liletta IUD $ 100000 2021 <br /> J7298 Mirena IUD $249400 2019 <br /> Medicaid only J7298ud Mirena IUD $249 . 00 2019 <br /> J7303 Nuvaring (3 pack) $ 10 . 45 2020 <br /> J7303ud Nuvarin (3pack) $ 10 . 45 2020 <br /> J7307 Nexplanon $399 . 00 2019 <br /> Medicaid only J7307ud Nexplanon $399400 2019 <br /> Q2037 Fluvirin Vacc, 3 yrs & >, IM $31 . 00 2015 <br /> Q2038 Fluzone Vacc, 3 yrs & >, IM $40 . 00 2015 <br /> Medicaid only S0280 PMH Risk Screening $ 50 . 00 2015 <br /> Medicaid only S0281 Postpartum Risk Screening $ 150400 2015 <br /> Self-Pay only S4993 Oral Contraceptive Pills $5 . 00 2012 <br /> S5000 Prescription Drug Dispensing $4 . 00 2021 <br /> S9465 Diabetic management program, dietitian visit $35 . 00 2011 <br /> S9470 Nutritional counseling, dietitian visit $35 . 00 2011 <br /> S9442 Birthing classes 8 . 69/ 1 hr block 2013 <br /> S5001 Plan B/Ella Emergency Contraception $ 19 . 71 2022 <br /> T1002 RN Services up to 15 min . $21 . 00 2005 <br /> U0005 HC COVID49 High Throughput (UNC Lab Add on <br /> Payment) $ 0 . 00 12022 <br /> * * UNC and State Lab Fees are established by reference lab and not by OCHD <br />