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Commissioner Approved Fee Schedule - FY 2024-25 51 <br /> Last <br /> Department/Program Description Current Fee Revision <br /> 99391 Preventive/Estab Pt<1 yr. $225.00 2012 <br /> 99392 Preventive/Estab Pt 1-4 yrs. $225.00 2012 <br /> 99393 Preventive/Estab Pt 5-11 yrs. $200.00 2012 <br /> 99394 Preventive/Estab Pt 12-17 yrs. $205.00 2012 <br /> 99395 Preventive/Estab Pt 18-39 yrs. $225.00 2012 <br /> 99396 Preventive/Estab Pt 40-64 yrs. $220.00 2012 <br /> 99397 Preventive/Estab Pt 65+yrs. $212.00 2004 <br /> 99401 Covid Counseling-Preventive Medicine Counseling, <br /> 15 min. $45.00 2022 <br /> 99406/G0436 Tobacco Use Cessation Counseling-(3-10 min) $13.00 2015 <br /> 99407/G0437 Tobacco Use Cessation Counseling-(10+min) $32.00 2015 <br /> 99408/G0396 ETOH&Substance Abuse Screening(15-30 min) $35.00 2018 <br /> 99409/G0397 ETOH&Substance Abuse Screening(30+min) $67.00 2018 <br /> 99441 Telephone Evaluation 5-10 min $26.00 2024 <br /> 99442 Telephone Evaluation 11-20 min $44.00 2024 <br /> 99443 Telephone Evaluation 21-30 min $49.00 2024 <br /> 99499 DOT Physical $100.00 2019 <br /> 99501 Home Visit Postpartum $200.00 2015 <br /> 99502 Home Visit Newborn $200.00 2015 <br /> D0145 Oral Evaluation<3 yrs with counseling $55.00 2012 <br /> D1206 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 B.-Admin.-Medicare $18.00 2015 <br /> 2015 DSME Minimum Fee $20.00 2015 <br /> G0108 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 Additional MD requested MNT group-Medicare $13.00 2010 <br /> G9919 Screening Performed and Positive $47.17 2024 <br /> 110001 Alcohol and/or drug assessment $20.00 2015 <br /> H0031 Mental health assessment,by non-physician $22.00 2015 <br /> J0696 Ceftriaxone Sodium/Rocephin per 250mg $22.00 2008 <br /> J1050 Medroxyprogesterone acetate, 1 mg(150 units) At acquisition cost 2023 <br /> Medicaid only J1050ud Medroxyprogesterone acetate, 1 mg(150 units) At acquisition cost 2023 <br /> J1200 Diphenhydramine HCLBenadryl up to 50mg $6.00 2009 <br /> Injection y roxyprogesterone caproate, 1 mg 50 <br /> J1725 units) $3.00 2015 <br /> J1885 Ketorolac IM Injection,per 15mg(Toradol) At acquisition cost 2023 <br /> J2550 Promethazine_mg $8.00 2009 <br /> J2790 Rhogam Injection $88.00 2012 <br /> J3420 B-12Injection $6.00 2009 <br /> J7300 Paragard IUD At acquisition cost 2023 <br /> Medicaid only J7300ud Paragard IUD At acquisition cost 2023 <br /> J7296 Kyleena IUD At acquisition cost 2023 <br /> Medicaid only J7296ud Kyleena IUD At acquisition cost 2023 <br /> J7301 Skyla IUD At acquisition cost 2023 <br /> Medicaid only J730lud Skyla IUD At acquisition cost 2023 <br /> J7297 Liletta IUD At acquisition cost 2023 <br /> Medicaid only JJ7297ud Liletta IUD IAt acquisition cost 12023 <br /> J7298 Mirena ND 1$249.00 12019 <br />