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Commissioner Approved Fee Schedule - FY 2025-26 58 <br /> Last <br /> Department/Program Description Current Fee Revision <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 /> G0328 Colorectal Cancer Screening;Fecal Occult(UNC Lab) $19.96 2025 <br /> G0416 PROSTATE BIOPSY,ANY MTHD(UNC Lab) $346.05 2025 <br /> G9919 Screening Performed and Positive $47.17 2024 <br /> G9920 ACE Screening Performed and Negative $45.17 2025 <br /> G9921 ACE Screening Incomplete or Positive with No Rec $45.17 2025 <br /> H0001 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 m (150 units) At acquisition cost 2023 <br /> J1200 Diphenhydramine HCL/Benadryl up to 50mg $6.00 2009 <br /> J1725 Injection hydroxyprogesterone caproate,1 mg(250 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-12 Injection $6.00 2009 <br /> J7300 Paragard IUD At acquisition cost 2023 <br /> Medicaid Only J7300ud Para and IUD At acquisition cost 2023 <br /> J7296 Kyleena IUD At acquisition cost 2023 <br /> Medicaid Only J7296ud K Leena 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 J7297ud Liletta IUD At acquisition cost 2023 <br /> J7298 Mirena IUD $249.00 2019 <br /> Medicaid Only J7298ud Mirena ND $249.00 2019 <br /> J7303 Nuvaring(3 pack) At acquisition cost 2023 <br /> Medicaid Only J7303ud Nuvarin (3pack) At acquisition cost 2023 <br /> J7307 Nexplanon At acquisition cost 2023 <br /> Medicaid Only J7307ud Nexplanon At acquisition cost 2023 <br /> Injection,tixagevimab and cilgavimab,for the pre-exposure <br /> prophylaxis only,for certain adults and pediatric individuals <br /> (12 years of age and older weighing at least 40kg)with no <br /> known sars-cov-2 exposure,who either have moderate to <br /> severely compromised immune systems or for whom <br /> M0220 vaccination with any available covid-19 vaccine is not $150.50 2025 <br /> recommended due to a history of severe adverse reaction to a <br /> covid-19 vaccine(s)and/or covid-19 vaccine component(s), <br /> includes injection and post administration monitoring(UNC <br /> Lab) <br /> Medicaid Only IS0280 JPMH Risk Screening $50.00 12015 <br /> Medicaid Only IS0281 JPostpartum Risk Screening J$150.00 12015 <br /> Self-Pay Only IS4993 1 Oral Contraceptive Pills J$5.00 12012 <br />