RICHMOND COUNTY HEALTH DEPARTMENT CLINIC FEE SCHEDULE SCHEDULE 2016 PROCEDURES PROCEDURES
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1 Revised: 5/11/2016 Effective: 7/4/2016 RICHMOND COUNTY HEALTH DEPARTMENT CLINIC FEE SCHEDULE SCHEDULE 2016 CODE PROCEDURES *FEES* CODE PROCEDURES *FEES* FAMILY PLANNING-NEW PT. LABORATORY SERVICES Prevention yrs. $ ABO Grouping $ Prevention yrs. $ AFP $ Prevention 40+ yrs. $ Amine Test $ FAMILY PLANNING-EST. PT Antibody screening $ Fecal Occult Blood $ Prevention yrs. $ GC Culture $ Prevention yrs. $ GC Smear $ Prevention 40+ yrs. $ Glucose $ S4993 Birth Control Pills/per Cycle $ Glucose - 1 hr. $ TREATMENT Glucose - each additional $ Office Visit $ Glucose Tolerance 3 hr $ Office Visit $ Hemoglobin $ Office Visit $ Hep B Surface Antibody Scrn $ Office Visit $ Pap Smear (Thin Prep) $ Office Visit $ Pregnancy Test $ MATERNAL HEALTH - NEW PT Rh Typing $ Office Visit I $ RPR $ Office Visit II $ Stat Male Smear $ Office Visit III $ Urinalysis w/o Microscope $ Office Visit IV $ Urine Micro Only $ Office Visit V $ Urine w/specific gravity 10 $ MATERNAL HEALTH - EST. PT Varicella Titer $ Office Visit I $ Venipuncture $ Office Visit II $ Wet Mount $ Office Visit III $ PHYSICALS Office Visit IV $ Head Lice / Scabies Exam $ Office Visit V $ A9180 Topical Solution for Head Lice/Scabies $ INJECTIONS/PROCEDURES Limited Pre-employment Physical $ J1050 Depo Provera $ School Sports Physicals $ J P $ Limited Physicals - Foster Car $ Rhogam Injection $ Limited Physicals - Camp $ COMMUNICABLE DISEASE Pre-College Limited Physical $ TB Skin Test $ Senior Companion LTD Phys $ DOC - Pre. Emp. Physicals $ LONG ACTING REVERSIBLE CONTRACEPTIVES OTHER CHARGES J7300 Paragard $ 1, Copy Medical Records Over $ IUD Removal $ pgs - 10 Cents Ea. Additional IUD Insertion $ (Insurance Companies, J7307 Nexplanon $ 1, Disability Claims, pts., etc.) Nexplanon Insertion $ Returned Check Fee $ Nexplanon Removal $ Post Natal Home Visit $ Nexplanon Removal/Reinsertion $ Newborn Home Visit $ J7302 Mirena $ 1, S9442 Childbirth Educ. Classes $ S4993 Plan B Pills $ 5.00 T1002 RN Services (per unit) $ PRENATAL SERVICES Anterpartum Care Only 4-6 $ Anterpartum Care Only 7+ $ 1, S0280 PMH RISK SCREENING $ S0281 PMH POSTPARTUM VISIT $ *
2 Revised: 5/11/2016 Effective: 7/4/2016 CODE PROCEDURES *FEES* CODE PROCEDURES *FEES* VACCINES/IMM. (NON STATE VACCINE) ACT HIB $ RABIES TITER TESTING $ HAVRIX - Hepatitis A ( Adults Only) $ HAVRIX - Hepatitis A ( PEDS ONLY) $ TWINRIX $ PEDVAX $ MENVEO $ HPV-9 $ FLU VACCINE $ FLUZONE $ PREVNAR - 13 PNEUM (PEDS $ RABIES IM (pre/post) $ RABIES ID (pre) $ ROTA TEQ (PEDS ONLY) $ ROTARIX $ TYPHOID $ KINRIX (DTAP & POLIO) $ PENTACEL $ INFANRIX (DTAP) $ MMR $ PROQUAD (MMR & VARICELLA $ IPOL $ BOOSTRIX (TDAP) $ VARIVAX (Chicken Pox) $ TD $ PNEUMONIA 23 $ MENACTRA (Meningitis) $ ZOSTAVAX (Shingles) $ Hepatitis B (Pediatric/Adoles.) $ ENERGIX B $ VACCINE ADMINISTRATION FEES Administration Fee $ Each Additional $ G0008 Medicare Admin - Flu $ G0009 Medicare Admin - Pneum. $ 13.71
3 11981 Nexplanon Insertion $ Nexplanon Removal $ Nexplanon Removal/Reinsertion $ Venipuncture $ IUD Insertion $ IUD Removal $ Anterpartum Care Only 4-6 $ 1, Anterpartum Care Only 7+ $ 2, Urine w/specific gravity 10 $ Urinalysis w/o Microscope $ Urine Micro Only $ Pregnancy Test $ AFP $ Amine Test $ Fecal Occult Blood $ Glucose $ * Glucose - 1 hr. $ Glucose Tolerance 3 hr $ Glucose - each additional $ Hemoglobin $ TB Skin Test $ RPR $ Hep B Surface Antibody Scrn $ Varicella Titer $ Antibody screening $ ABO Grouping $ Rh Typing $ GC Culture $ GC Smear $ Stat Male Smear $ Wet Mount $ Pap Smear (Thin Prep) $ Rhogam Injection $ Administration Fee $ Each Additional $ Office Visit I $ Office Visit II $ Office Visit III $ Office Visit IV $ Office Visit V $
4 99211 Office Visit $ Office Visit I $ Head Lice / Scabies Exam $ Office Visit $ Office Visit II $ Office Visit $ Office Visit III $ Office Visit $ Office Visit IV $ Office Visit $ Office Visit V $ Prevention yrs. $ Prevention yrs. $ Prevention 40+ yrs. $ Prevention yrs. $ Prevention yrs. $ Prevention 40+ yrs. $ Limited Physicals - Foster Care $ Limited Physicals - Camp $ Pre-College Limited Physical $ Senior Companion LTD Phys $ DOC - Pre. Emp. Physicals $ School Sports Physicals $ Limited Pre-employment Physical $ Post Natal Home Visit $ Newborn Home Visit $ Topical Solution for Head A9180 Lice/Scabies $ G0008 Medicare Admin - Flu $ G0009 Medicare Admin - Pneum. $ J1050 Depo Provera $ J P $ J7300 Paragard $ 1, J7302 Mirena $ 1, J7307 Nexplanon $ S0280 PMH RISK SCREENING $ S0281 PMH POSTPARTUM VISIT $ S4993 Birth Control Pills/per Cycle $ 6.00 S4993 Plan B Pills $ 5.00 S9442 Childbirth Educ. Classes $ 13.00
5 T1002 RN Services (per unit) $
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SLIDING FEE SCALE APPLICATION FORM Today s Date Name Date of Birth Address City State ZIP Code Home Phone Work Phone Cell Phone Would you like to schedule an appointment with a Certified Enrollment Counselor
Participating MEMBER RESPONSIBILITY
DEDUCTIBLES AND MAXIMUMS Non- Annual Deductible Individual $2,000 $4,000 Family $4,000 $8,000 Out-of-Pocket Maximum (includes deductible, coinsurance, and copays) Individual Unlimited $10,000 Family Unlimited
To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits
To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits Beginning January 1, 2011 Medicare began covering an Annual Wellness Visit in addition to the one-time Welcome to Medicare
Medical Schedule of Benefits (Effective January 01, December 31, 2017) Johns Hopkins University Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Individual $250 $500 Family $750 $1500 Individual $2000 $4000 Family $6000 $12000 Unlimited Acupuncture
QHDHP 100% $1250 w/o HSA
QHDHP 100% $1250 w/o HSA Preferred Provider Organization Underwritten by Coventry Health and Life Insurance Company (d.b.a. HealthAmerica) DEDUCTIBLES AND MAXIMUMS Annual Deductible Individual $1,250 $2,500