URGENT CARE Provider # Fed

LOCATION (CIRCLE ONE) 13

15
CPT DESCRIPTION FEE CPT DESCRIPTION FEE
NEW PATIENTS X-RAY; (cont'd)
99201 LEVEL 1, BRIEF; 10 min 73060 HUMERUS; 2+ VIEWS
99202 LEVEL 2, LIMITED: 20 min 73560 KNEE; AP & LAT
99203 LEVEL 3, EXPANDED; 30 min 72110 LS SPINE; COMPLETE W/OBLIQUES
99204 LEVEL 4, COMPREHENSIVE; 45 min 70110 MANDIBLE; COMPLETE
99205 LEVEL 5, COMPREHENSIVE; 60 min 70160 NASAL BONES; COMPLETE
99025 NEW PT. INITIAL VISIT W/*PROC. 72190 PELVIS; 3+VIEWS
ESTABLISHED PATIENTS 04209 POST REDUCTION
90025 OFFICE VISIT, NO CHARGE N/C 71100 RIB, UNILATERAL, 2 VIEWS
99211 LEVEL 1, BRIEF: 72220 SACRUM & COCCYX; 2+ VIEWS
99212 LEVEL 2, LIMITED: 73050 SHOULDER AC JTS; BILATERAL
99213 LEVEL 3, EXPANDED: 73030 SHOULDER; COMPLETE
99214 LEVEL 4, COMPREHENSIVE: 70360 SOFT TISSUE
99215 LEVEL 5, COMPREHENSIVE: 72070 THORACIC SPINE; AP&LAT
99354 PROLONGED SERVICE 1st HOUR 73590 TIB-FIB; AP&LAT
99355 PROLONGED SERV. EA ADD'L 30min 73110 WRIST; COMPLETE
PROCEDURES LAB (POST CHARGES FROM LAB TICKET ONLY)
46600 ANOSCOPY 36415 VENIPUNCTURE
11730* AVULSION NAIL, SIMPLE 86308 MONO SCREEN (HETEROPHILE)
16030* BURN CARE; LG, NO ANEST 81025 PREGNANCY TEST - URINE
16025* BURN CARE, MED, NO ANEST 87880 RAPID STREP ANTIGEN
16020* BURN CARE, SMALL, NO ANEST 81001 UA COMPLETE
53670 CATHETERIZATION (ADD TRAY) 80100 Urine Drug Screen
30903 EPISTAXIS CONTROL; COMPLEX
30901 EPISTAXIS CONTROL, SIMPLE SUPPLIES (SENT HOME WITH PATIENT)
10060* I&D ABSCESS; SIMPLE 02074 ACE WRAP 4"
10140* I&D HEMATOMA/SEROMA/FLUID 02075 ACE WRAP 6"
10120* REM. FB SUB Q; SIMPLE 02786 ADAPTIC DRESSING
65222* REM. FB CORNEA W/SLIT LAMP 02019 ANKLE BRACE
07008 REMOVE CONSTRICTING RING 02620 ANKLE BRACE: AIR CAST
LACERATION REPAIRS 02604 ANKLE, E-Z WRAP; RIGID
12001* REP LAC 2.5cm OR LESS 02686 BURN DRESSING, LARGE
12002* REP LAC 2.6 - 7.5cm 02685 BURN DRESSING, SMALL
12004* REP LAC 7.6 - 12.5cm 02066 CERVICAL COLLAR
12011* FACIAL LAC 2.5cm OR LESS 02007 CLAVICLE STRAP
12013* FACIAL LAC 2.6 - 5.0 cm 02077 DRESSINGS; LARGE
12031* LAYER CLOS. SCALP/AXILLA/TRUNK ; <2.5CM 03201 DRESSINGS; MEDIUM
12032* LAYER CLOS.SCALP/AXILLA/TRUNK 2.6-7.5CM 02076 DRESSINGS; SMALL
12041* LAYER CLOSURE; NECK/HANDS/FEET <2.5CM 02011 ELBOW SUPPORT
12042* LAYER CLOSURE;NECK/HANDS/ FEET 2.6-7.5CM 02082 FINGER SPLINT
SPLINTS / SUPPLIES 02013 KNEE IMMOBILIZER
29505 APPLY LONG LEG SPLINT 02087 KNEE SLEEVE
29515 APPLY SHORT LEG SPLINT 02387 KWIK COLD
29125 APPLY SHORT ARM SPLINT 02200 MALLET FINGER SPLINT
29105 APPLY LONG ARM SPLINT 02127 ORTHO SHOE
02222 ORTHOGLASS; ARM 02129 RIB BELT
02223 ORTHOGLASS; LEG
X-RAY
74000 ABDOMEN (1 VIEW)
74022 ABDOMINAL SERIES
73610 ANKLE; COMPLETE
72052 CERVICAL SPINE; COMPLETE
71020 CHEST PA & LAT
73000 CLAVICLE; COMPLELTE
73080 ELBOW; COMPLETE
70150 FACIAL BONES; COMPLETE
73630 FOOT; COMPLETE
73090 FOREARM; AP&LAT
73130 HAND; 3+ VIEWS
73510 HIP; COMPLETE, UNILATERAL
Provider # Federal ID #

INJURY DATE:

CPT DESCRIPTION FEE

SUPPLIES (SENT HOME WITH PATIENT)
02110 SLING, ARM
02084 UNIVERSAL THUMB SPLINT
02150 WRIST BRACE, LIBERTY
02010 WRIST SPLINT
TRAYS AND OTHER SUPPLIES
02534 EYE TRAY
02111 SIMPLE TRAY
02097 SMALL SUTURE TRAY W/ANES
02033 SUTURE REMOVAL KIT
02094 TRAY, PELVIC / SMALL W/ANESTHESIA
02795 TRAY, SMALL W/O ANESTHESIA
02101 INSERTION TRAY W/FOLEY W/O BAG
02389 STRAIGHT TIP CATHETER
02027 IV SUPPLIES
02795 I&D TRAY
J7030 INFUSION NORMAL SALINE: 1000 cc
J7040 INFUSION N/S, STERILE; 500ml = 1 UNIT
J7120 LACTATED RINGERS; 1000cc
MISCELLANEOUS
93000 EKG; COMPLETE
99291 CRITICAL CARE; 1ST HOUR
99292 CRITICAL CARE; EA ADD'L 30 MIN
TOTAL TIME:________ to __________
02474 DISPOSABLE CAUTERY UNIT
69210 EAR IRRIGATION
94640 NEBULIZER TREATMENT
02026 OXYGEN SUPPLIES
94760 OXIMETRY
INJECTIONS AND ADMINISTRATIONS
90780 IV INFUSION; UP TO 1 HOUR
90781 IV INFUSION; EA ADD'L HR TO 8 HRS
90782 THERAP/ DIAG INJECTION; SUB Q/ IM
90784 THERAP/ DIAG INJECTION; IV
90788 IM INJECTION OF ANTIBIOTIC

J0150 ADENOSINE; 6mg X _____

J1200 BENADRYL; 50mg
03524 CARDIAZEM PER 25MG X ______
J0702 CELESTONE; 3mg/ml X ______
J2175 DEMEROL; PER 100mg X _____
J1030 DEPOMEDROL 40mg X ______
J1160 DIGOXIN UP TO 0.5mg
J0170 EPINEPHRIN/SUSPHRINE; 1ml amp
J3030 IMITREX 6mg
J1940 LASIX UP TO 20mg X ______
J2550 PHENERGAN 50mg X _____
J0696 ROCEPHIN PER 250mg: X _________
J2930 SOLUMEDROL; 125MG X _______
J1885 TORADOL; PER 15mg: X ________

OTHER:
99211 ADMINISTER PPD W/NO MD VISIT
86580 PPD
90718 TETANUS; Td (V06.5 or Injury code)
FAMILY PRACTICE
CODE MOD DESCRIPTION CODE MOD DESCRIPTION CODE MOD DESCRIPTION
OFFICE VISITS - NEW PATIENTS 10060 I&D ABSCESS/CYST, SIMPLE TRAYS (ADD TO SURGICAL PROCEDURES)
99201 LEVEL 1, BRIEF; 10 min 10061* I&D ABSCESS, COMPL. OR MULT. 02094 TRAY, SMALL W/ANESTHESIA
99202 LEVEL 2, LIMITED: 20 min 11200 SKIN TAG REMOVAL, UP TO 15 02097 SUTURE TRAY W/ANESTHESIA
99203 LEVEL 3, EXPANDED; 30 min 11201 SKIN TAG REMOVAL, EA ADDL 10 02098 TRAY, MEDIUM W/SPEC. ROOM(SIG)
99204 LEVEL 4, COMPREHENSIVE; 45 min 17000 DEST.BEN LESION,ANY METHD, 1st 02095 TRAY, LARGE + RM + SPEC. EQUIP
99205 LEVEL 5, COMPREHENSIVE; 60 min 17003 2nd THROUGH 14th LESIONS EA SUPPLIES
99025 NEW PT. INITIAL VISIT W/*PROC. 17004 DEST BEN LES. ANY METH. > 15 02113 CANVAS KNEE BRACE
PREVENTIVE EXAM - NEW PATIENTS 93000 EKG, COMPLETE 02010 CANVAS WRIST SUPPORT
99381 PREVENTIVE MEDICINE < 1 YEAR 93005 EKG, TRACING ONLY 02112 ELASTIC ANKLE WRAP
99382 PREVENTIVE MEDICINE, 1 - 4 20550 INJ TENDON/LIGAMENT/CYST/TRIGGER PT 02018 ELASTIC ANKLET
99383 PREVENTIVE MEDICINE, 5-11 20600* INJECT.SMALL JT/BURSA/CYST 02579 FINGER SPLING
99384 PREVENTIVE MEDICINE, 12-17 20605* INJECT. INT. JOINT/BURSA/CYST 02129 RIB BELT
99385 PREVENTIVE MEDICINE, 18-39 20610* INJECT.MAJOR JOINT/BURSA/CYST 02525 SLING
99386 PREVENTIVE MEDICINE, 40-64 94150 VITAL CAPACITY; SEPARATE PROC 02488 STERI-STRIPS
99387 PREVENTIVE MEDICINE, 65+ 69210 REMOVAL IMPACTED CERUMEN 02033 SUTURE REMOVAL KIT
OFFICE VISITS - EST. PATIENTS 45330 SIGMOIDOSCOPY; FLEXIBLE 02011 TENNIS ELBOW SUPPORT
99211 LEVEL 1, BRIEF: 5 min 94010 SPIROMETRY W/GRAPHIC RECORD 02084 UNIVERSAL THUMB SPLINT
99212 LEVEL 2, LIMITED: 10 min DIAGNOSTICS OTHER: SPECIFY
99213 LEVEL 3, EXPANDED: 15 min 87220 KOH
99214 LEVEL 4, COMPREHENSIVE: 25 min 82270 OCCULT BLOOD
99215 LEVEL 5, COMPREHENSIVE: 40min Q0091 PAP SMEAR HANDLING
PREVENTIVE EXAM - EST. PATIENTS 86580 PPD CASTS/SPLINTS
99391 PREVENTIVE MEDICINE < 1 YEAR 81000 URINALYSIS, ROUTINE 29065 LONG ARM CAST
99392 PREVENTIVE MEDICINE, 1 - 4 87210 WET MOUNT 29075 SHORT ARM CAST
99393 PREVENTIVE MEDICINE, 5-11 87880 QUICK STREP 29105 LONG ARM SPLINT
99394 PREVENTIVE MEDICINE, 12-17 INJECTIONS UNITS 29125 SHORT ARM SPLINT
99395 PREVENTIVE MEDICINE, 18-39 90782 SUB Q OR IM INJECTION OF MED 29405 SHORT LEG CAST
99396 PREVENTIVE MEDICINE, 40-64 J3420 B-12 ; up to 1000 mcg 29515 SHORT LEG SPLINT
99397 PREVENTIVE MEDICINE, 65+ J0702 CELESTONE SOLUSPAN 1cc 02220 CAST MATERIAL, PLASTER, ARM
INITIAL NURSING FACILITY CARE J2175 DEMEROL PER 100mg 02221 CAST MATERIAL, PLASTER, LEG
99301 LEVEL 1 , ANNUAL ASSESSMENT J1460 GAMMA GLOBULIN; IM 1cc 02222 CAST MATERIAL, FIBERG, ARM
99302 LEVEL 2, NEW PROBLEM J2000 LIDOCAINE 02223 CAST MATERIAL, FIBERG, LEG
99303 LEVEL 3, INITIAL ADMIT TO NH J2550 PHENERGAN UP TO 50 mg
SUBSEQUENT NURSING FACILITY CARE J0696 ROCEPHIN 250 mg X ____ UNITS
99311 LEVEL 1, STABLE NH VISIT J3030 IMITREX 6mg X _____ UNITS
99312 LEVEL 2, MINOR PROBLEM J1055 DEPO-PROVERA 150mg (CONTRACEPTIVE)
99313 LEVEL 3, MAJOR PROBLEM J1070 DEPO-TESTOSTERONE 100mg
PROCEDURES J1080 DEPO-TESTOSTERONE 200mg
94640 AIRWAY INHALATION TREATMENT J9215 INTERFERON .05cc
46600 ANOSCOPY;DIAGNOSTIC J3301 KENALOG, PER 10mg
92551 AUDIOMETRY AIR ONLY

22022197.xls FAMILY PRACTICE 09/13/2009 FEES SUBJECT TO CHANGE WITHOUT NOTICE