Home | Your Bill

Your bill at Sun River Health can be adjusted depending on your income

The higher your income, the more you will pay. The lower your income, the less you will pay. We calculate your bill based on your income and family size with a tool called a “sliding fee scale.” This helps ensure that everyone can access excellent health care at an appropriate cost.

Please enter your information below to get an estimate of how much you may need to pay for your visit. Please note this is only an estimate.

(For a sample payments please see chart below the calculator.)

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MEDICAL

Follow-up/Sick Visits - New Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99202 Expanded problem straightforward 20 min 299.00 N/A –
99203 Detailed low complexity 30 min 357.00 N/A –
99204 Comprehensive moderate complexity 45 min 449.00 N/A –
99205 Comprehensive high complexity 60 min 518.00 N/A –
99211 Brief Visit 5 Minutes 207.00 N/A –

Follow-up/Sick Visits - Established Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99212 Problem focused straightforward 10 min 276.00 N/A –
99213 Expanded problem low complexity 15 min 294.00 N/A –
99214 Detailed moderate complexity 25 min 351.00 N/A –
99215 Comprehensive high complexity 40 min 414.00 N/A –

Wellness Visits - New Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99381 <1 year 276.00 N/A –
99382 1-4 years 276.00 N/A –
99383 5-11years 276.00 N/A –
99384 12-17 years 276.00 N/A –
99385 18-39 years 290.00 N/A –
99386 40-64 years 311.00 N/A –
99387 >65 years 345.00 N/A –

Wellness Visits - Established Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99391 <1 year 276.00 N/A –
99392 1-4 years 276.00 N/A –
99393 5-11 years 276.00 N/A –
99394 12-17 years 276.00 N/A –
99395 18-39 years 290.00 N/A –
99396 40-64 years 311.00 N/A –
99397 >65 years 345.00 N/A –

Birth Control Method

CPT Code Description Standard Fee Supply Fee Your Fee
S4993 Oral Contraceptive Pills 14.00 –
S4993 Oral Contraceptive Pills-under age 19 14.00 –
J1050 Depoprovera 27.00 –
58300 IUD Insertion 300 –
58301 IUD Removal 250 –
J7300 Paragard IUD 260.00 –
J7301 Skyla 450.00 –
J7298 Mirena IUD 330.00 –
J7303 Vaginal Ring 14.00 –
J7297 Liletta 105.00 –
11981 Insertion Implanon/Nexplanon 200 –
11982 Removal Implanon/Nexplanon 200 –
11983 Removal and Insertion Implanon/Nexplanon 350 –
J7304 Harmone Patch 82.00 –
J7307 Etonogestrel implant (Implanon/Nexplanon) 400.00 –
J3490 Emergency Contraception 5 –

Office Procedures

CPT Code Description Standard Fee Supply Fee Your Fee
69210 Ear lavage 125.00 N/A –
93000 EKG w/ interpretation 65.00 N/A –
93224 Holter monitor 376.00 N/A –
94640 Inhalation treatment 25.00 N/A –
94760 Pulse Oxymmetry 20.00 N/A –
93040 Rhythm strip 35.00 N/A –
94060 Spirometry pre and post 113.00 N/A –
94010 Spirometry 61.00 N/A –
97811 Acupuncture w/ stimulation 75.00 N/A –
10060 Incision & drainage simple 120.00 N/A –
10120 Removl of foreign body - Sub q 115.00 N/A –
11200 Removal of skin tags (up to 15) 100.00 N/A –
17000 Wart Destruction (common planter) 86.00 N/A –

Genitourinary

CPT Code Description Standard Fee Supply Fee Your Fee
54150 Circumcision 333.00 N/A –

Immunizations and Injections - Children (Not Covered Under Vaccine for Children)

CPT Code Description Standard Fee Supply Fee Your Fee
90675,A P-Rabies (Imovax) 326.00 326.00 –
90691,A P-Typhoid 113.00 113.00 –
90717,A P - Yellow Fever 115.00 115.00 –

Immunizations and Injections - Adult

CPT Code Description Standard Fee Supply Fee Your Fee
90632 A-HepA 64.00 66.00 –
90636 A-Hep A/B (Twinrix) 96.00 96.00 –
90746 A-Hep B (20 and above) 15.00 15.00 –
90647 A-Hib 34.00 34.00 –
90651 A-HPV Nonavalent 9 Strains 3 dose 219.00 219.00 –
90713 A-IPV 358.00 358.00 –
90686 A-Influenza Quadrivalent 18.00 18.00 –
90734 A-Meningococcal 135.00 135.00 –
90620 A-Meningococcal Group B 159.00 159.00 –
90707 A-MMR 92.00 92.00 –
90710 A-MMRV Proquad 264.00 264.00 –
90732 A-Pneumococcal 124.00 124.00 –
90670 A-Pneumococcal 13 235.00 235.00 –
90675 A-Rabies 326.00 326.00 –
90750 A-Shingrix 154.00 154.00 –
90714 A-Td (>7 Yrs) 29.00 29.00 –
90715 A-Tdap 34.00 34.00 –
90691 A-Typhoid IM 138.00 138.00 –
90716 A-Varicella 159.00 159.00 –
90717 A-Yellow Fever 115.00 115.00 –
90736 A-Zostavax (Herpes Zoster) 235.00 235.00 –

Pathways/Mental Health

CPT Code Description Standard Fee Supply Fee Your Fee
90791 Psychiatric Interview 426.00 N/A –
90832 Individual Psychotherapy (30 minutes) 276.00 N/A –
90833 Individual Psychotherapy (with medical E & M) 30 minutes 276.00 N/A –
90834 Individual Psychotherapy (45 minutes) 311.00 N/A –
90836 Individual Psychotherapy (with medical E & M) 45 minutes 288.00 N/A –
90837 Individual Psychotherapy (60 minutes) 374.00 N/A –
90838 Individual Psychotherapy (with medical E & M) 60 minutes 357.00 N/A –
90845 Psychoanalysis 299.00 N/A –
90846 Family Psychotherapy (without patient present) 299.00 N/A –
90847 Family Psychotherapy (with patient present) 322.00 N/A –
90849 Multi-Family Psychotherapy 230.00 N/A –
90853 Group Psychotherapy 213.00 N/A –
90785 Interactive Group Psychotherapy (add on) 213.00 N/A –
90863 Pharmacologic Management 173.00 N/A –
90875 Individual Psychophysiological Therapy (with Psychotherapy) 20-30 minutes 294.00 N/A –
90876 Individual Psychophysiological Therapy (with Psychotherapy) 45-50 minutes 351.00 N/A –
90882 Environmental intervention on Pyschiatric patients behalf with agencies employers and institutions 173.00 N/A –
90885 Psychiatric evaluation of Records 253.00 N/A –
90887 Interpretation or Explanation of Psychiatric Assessment 322.00 N/A –
90889 Report Preparation 173.00 N/A –
90899 Unlisted Psychiatric Service 173.00 N/A –

There may be additional fees and charges for lab / supply costs in addition to your nominal fee charge. Please refer to the Lab/Supply Fee Schedule.

OPTOMETRY

Follow-Up/Sick Visits - New Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99202 Expanded problem straightforward 20 min 299.00 N/A –
99203 Detailed low complexity 30 min 357.00 N/A –
99204 Comprehensive moderate complexity 45 min 449.00 N/A –
99205 Comprehensive high complexity 60 min 518.00 N/A –
99211 Brief Visit 5 min 207.00 N/A –

Follow-Up/Sick Visits - Established Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99212 Problem focused straightforward 10 min 248.00 N/A –
99213 Expanded problem low complexity 15 min 294.00 N/A –
99214 Detailed moderate complexity 25 min 351.00 N/A –
99215 Comprehensive high complexity 40 min 414.00 N/A –

Optometry - Exams

CPT Code Description Standard Fee Supply Fee Your Fee
92002 New-Intermediate 151.00 N/A –
92004 New-Comprehensive 262.00 N/A –
92012 Established-Intermediate 160.00 N/A –
92014 Established-Comprehensive 222.00 N/A –

Eyglasses and Lense

CPT Code Description Standard Fee Supply Fee Your Fee
V2020,15 15 FRAMES PURCHASES 15.00 N/A –
V2020,25 25 FRAMES PURCHASES 25.00 N/A –
V2100 Single Lens 30.00 N/A –
V2200 BIFOCAL LENS 45.00 N/A –
V2399 Progressive 70.00 N/A –
V2744,25 25 TINT PHOTOCHROMATIC PER LENS 25.00 N/A –
V2744,70 70 TINT PHOTOCHROMATIC PER LENS 70.00 N/A –
V2745 Tint any color/solid/grad 15.00 N/A –
V2750 ANTIREFLECTIVE COATING PER LENS 60.00 N/A –
V2755 U-V LENS PER LENS 20.00 N/A –
V2760 SCRATCH RESISTANT COATING PER LENS 15.00 N/A –
V2780 OVERSIZE LENS PER LENS 0 N/A –
V2782 Lens 1.54-1.65 p/1.60-1.79g 70.00 N/A –
V2783 Lens >= 1.66 p/>=1.80 g 0 N/A –
V2784 Lens polycarb or equal 70.00 N/A –
V2799 VISION SERVICE MISCELLANEOUS 70.00 N/A –

Office Procedures

CPT Code Description Standard Fee Supply Fee Your Fee
65205 REMOVE FOREIGN BODY FROM EYE 85.00 N/A –
65222 REMOVE FOREIGN BODY FROM EYE 85.00 N/A –
92082 VISUAL FIELD EXAMINATION(S) 84.00 N/A –
92083 VISUAL FIELD EXAMINATION(S) 112.00 N/A –
92340 FITTING OF SPECTACLES 160.00 N/A –
92341 FITTING OF SPECTACLES 160.00 N/A –
92342 FITTING OF SPECTACLES 160.00 N/A –
92370 REPAIR of SPECTACLES 160.00 N/A –

There may be additional fees and charges for lab / supply costs in addition to your nominal fee charge. Please refer to the Lab/Supply Fee Schedule.

DENTAL

Diagnostic Treatment

CPT Code Description Standard Fee Lab Fee Your Fee
D0120 PERIODIC RECLL EXAM 103.00 N/A –
D0140 EMERGENCY ORAL EXAM 158.00 N/A –
D0145 INFANT/TODDLER EVALUATION 145.00 N/A –
D0150 INITIAL ORAL EXAM 185.00 N/A –
D0170 RE-EVAL- LIMITED PROB FOCUSED(EST PT; NOT POST-OP VISIT) 151.00 N/A –
D0210 COMPLETE INTRAORAL SERIES 251.00 N/A –
D0220 INTRAOR PERIAPICAL RADIO 1ST 60.00 N/A –
D0230 INTRAORAL PERIAP-EA ADDL FILM 51.00 N/A –
D0240 INTRAORAL OCCLUSAL FILM 77.00 N/A –
D0270 BITEWING RADIOGRAPH 1ST 57.00 N/A –
D0272 BITEWINGS 2 FILMS 89.00 N/A –
D0274 BITEWING 4 FILMS 125.00 N/A –
D0330 PANORAMIC FILM 224.00 N/A –
D0460 PULP VITALITY TEST 113.00 N/A –
D0470 DIAGNOSTIC CASTS 302.00 N/A –

Preventative Treatment

CPT Code Description Standard Fee Lab Fee Your Fee
D1110 PROPHYLAXIS-ADULT 177.00 N/A –
D1120 PROPHYLAXIS - CHILD 131.00 N/A –
D1206 FLUORIDE VARNISH 78.00 N/A –
D1208 FLUORIDE NON-VARNISH 78.00 N/A –
D1310 NUTRITIONAL COUNSELING 124.00 N/A –
D1330 ORAL HYGIENE INSTRUCTION 125.00 N/A –
D1351 SEALANTS-PER TOOTH 103.00 N/A –
D1510 SPACE MAINT FX-UNILATERAL 574 N/A –

Restorative Treatment

CPT Code Description Standard Fee Lab Fee Your Fee
D2140 AMALGAM 1 SURFACE 280.00 N/A –
D2150 AMALGAM 2 SURFACE 358.00 N/A –
D2160 AMALGAM 3 SURFACE 426.00 N/A –
D2161 AMALGAM 4 OR MORE SURF 507.00 N/A –
D2330 RESIN 1/SURFACE ANTEIOR 326.00 N/A –
D2331 RESIN 2 SURFACES ANTERIOR 393.00 N/A –
D2332 RESIN 3 SURFACES ANTERIOR 479.00 N/A –
D2335 RESIN:4/+ SURFS.OR INVOLV.INCIS.ANG 613.00 N/A –
D2390 RESIN-BASED COMPOSITE CROWN ANTERIO 921.00 N/A –
D2391 RESIN-1 SURFACE POSTERIOR 349.00 N/A –
D2392 RESIN-2 SURFACE POSTERIOR 440.00 N/A –
D2393 RESIN-3 SURFACE POSTERIOR 542.00 N/A –
D2394 RESIN-4 OR MORE SURFACES POSTERIOR 639 N/A –
D2542** 2 Surface Gold Onlay 1920.00 150 –
D2543** 3 Surface Gold Onlay 1988.00 175 –
D2544** 4 Surface Gold Onlay 2074.00 200.00 –
D2740**T CROWN-PORC/CERAMIC SUBSTRATE 2000.00 150 –
D2750**T CROWN-PORC FUSED HIGH NOBLE METAL 2000.00 200 –
D2752**T CROWN-PORC FUSED/NOBLE METAL 2000.00 150 –
D2790**T CROWN/FULL CAST HIGH NOBLE METAL 2000.00 200 –
D2792**T CROWN/FULL CAST NOBLE METAL 2000.00 150 –
D2920 RECEMENT CROWN 235.00 N/A –
D2930 STAINLESS STEEL CROWN 527.00 N/A –
D2940 SEDATIVE FILLING 271.00 N/A –
D2950 CROWN BUILD/UP (AMALG.OR COMPOSITE) 525.00 N/A –
D2951 CROWN BUILD-UP (COMPOSITE) 168.00 N/A –
D2952** POST AND CORE CAST 823 100.00 –
D2954 PREFAB POST&CORE IN ADD CROWN 633.00 N/A –
D2961** LABIAL VENEER/RESIN/LAB 1918.00 100.00 –
D2962** PORCELAIN VENEER LAMINATE 2254.00 150.00 –
D2970 TEMP/CROWN FRACTURE TOOTH 935 40.00 –

Endodontics

CPT Code Description Standard Fee Lab Fee Your Fee
D3110 PULP CAP DIRECT 180.00 N/A –
D3120 PULP CAP INDIRECT 175.00 N/A –
D3220 VITAL PULPOTOMY 443.00 N/A –
D3310 Endodontic therapyANTERIOR tooth-excl final restor 1493.00 N/A –
D3320 Endodontic therapyPREMOLAR tooth-excl final restor 1650.00 N/A –
D3330 Endodontic therapyMOLAR tooth-excl final restor 1988.00 N/A –
D3351 APEXIFICATION-INITIAL VISIT 768.00 N/A –
D3352 APEXIFICATION/RECALCIFICATION-INTER 517.00 N/A –
D3353 APEXIFICATION/RECALCIF FINAL VISIT 991.00 N/A –
D3410 APICOECTOMY(PER TOOTH) 1 ROOT 1521.00 N/A –
D3421 APICOECTOMY (BICUSPID) 1631.00 N/A –
D3425 APICOECTOMY (MOLAR) 1809.00 N/A –
D3430 RETROGRADE FILLING 603.00 N/A –
D3450 ROOT AMPUTATION-PER ROOT 1025.00 N/A –
D3920 HEMISECTION 902.00 N/A –

Periodontics

CPT Code Description Standard Fee Lab Fee Your Fee
D4210 GINGIVECTOMY QUAD 1206.00 N/A –
D4211 GINGIVECTOMY PER TOOTH 722.00 N/A –
D4240 GINGIVAL FLAP PROC PER QUAD 1568.00 N/A –
D4249 CROWN LENGTHENING 1532.00 N/A –
D4260 OSSEOUS SQ 2220.00 N/A –
D4270 PEDICLE GRAFT 1877.00 N/A –
D4341 PERI.SCALING & ROOT PLANING.PER QUAD 503.00 N/A –
D4342 PERI.SCAL.&ROOT 1 TO 3 TEETH 385.00 N/A –
D4355 FULL MOUTH DEBRIDEMENT 417.00 N/A –
D4910 PERIO PROPHYLAXIS 264.00 N/A –

Prosthodontics - Removable

CPT Code Description Standard Fee Lab Fee Your Fee
D5110**D COMPLETE MAX DENTURE 2600.00 300.00 –
D5120**D COMPLETE MAND DENTURE 2600.00 300.00 –
D5130**D COMPLETE IMM. UPPER DENTURE 2600.00 300.00 –
D5140**D COMPLETE IMM. LOWER DENTURE 2600.00 300.00 –
D5211**D MAX PARTIAL DENTURE - RESIN BASE 2600.00 300.00 –
D5212**D MAND PARTIAL DENTURE - RESIN BASE 2600.00 300.00 –
D5213**D PARTIAL MAX DENTURE CAST BASE 2600.00 300.00 –
D5214**D PARTIAL MAND DENTURE CAST BASE 2600.00 300.00 –
D5410* ADJUST COMPLETE DENTURE UPPER 198.00 N/A –
D5411* ADJUST COMPLETE DENTURE LOWER 182.00 N/A –
D5421* DENTURE ADJ PART/UPPPER 175.00 N/A –
D5422* DENTURE ADJ PART/LOWER 186.00 N/A –
D5225**D MAXILLARY PARTIAL DENTURE FLEX BA 2600.00 300.00 –
D5226**D MANDIBULAR PART DENTURE FLEX BASE 2600.00 300.00 –
D5511**D REPAIR BROKEN COMPL DENT BASE MAND 456.00 75.00 –
D5512**D REPAIR BROKEN COMPL DENT BASE MAX 462.00 75.00 –
D5611**D REPAIR RESIN PD BASE MANDIBULAR 422.00 75.00 –
D5612**D REPAIR RESIN PD BASE MAXILLARY  445.00 75.00 –
D5621**D REPAIR CAST PART FRAMEWORK MAND 528.00 75.00 –
D5622**D REPAIR CAST PART FRAMEWORK MAX 528.00 75.00 –
D5630**T REPAIR PARTIAL BROKEN CLASP 507.00 75.00 –
D5650**T ADD TOOTH-EXSTNG PART.DENT 453.00 75.00 –
D5730*D RELINE COMP UPPER DENT/CHAIR 709.00 N/A –
D5731*D RELINE/COMPL.LOWR DENT/CHAIR 709.00 N/A –
D5740*D RELINE UPPER PART DENT-CHAIR 691.00 N/A –
D5741*D RELINE/LOWER PART/DENT CHAIR 692.00 N/A –
D5750**D RELINE COMPLETE UPPER DENT-LAB 905.00 125.00 –
D5751**D RELINE COMPLETE LOWER DENT-LAB 905.00 125.00 –
D5760**D RELINE UPPER PARTIAL DENT-LAB 901.00 125.00 –
D5761**D RELINE LOWER PART DENT-LAB 902.00 125.00 –
D5820** TEMP/PART STAYPLATE UPPER-DENT 1439.00 125.00 –
D5821** TEMP/PARTIAL LOWER-DENT 1420.00 125.00 –

Prosthodontics - Fixed

CPT Code Description Standard Fee Lab Fee Your Fee
D6065**T Implant Supported Porcelain/Ceramic Crown 2800.00 300.00 –
D6066**T Implant Supported Porcelain Fused to Metal Crown (titanium titanium alloy high noble metal) 2800.00 300.00 –
D6067**T Implant Supported Metal Crown (titanium titanium alloy high noble metal) 2800.00 300.00 –
D6211** MARYLAND BR PONTIC 1974.00 150.00 –
D6242** PONTIC PORC/FUSE NOBLE-METAL 2000.00 150.00 –
D6545** MARYLAND BR. RET 2000.00 150.00 –
D6740** PORCELINE RETAINER 2000.00 150.00 –
D6752**T PORCL/FSE SEMI/PRECS ABTMT 2000.00 150.00 –
D6792**T CROWN FULL CAST NOBLE METAL 2024.00 150.00 –
D6930 RECEMENT BRIDGE 346.00 N/A –

Oral and Maxillofacial Surgery

CPT Code Description Standard Fee Lab Fee Your Fee
D7111 CORONAL REMNANTS-DECIDUOUS TOOTH 277.00 N/A –
D7140 EXTRACTION-ERUPT TOOTH/EXPOSED ROOT 397.00 N/A –
D7210 SURG EXTRACT ERUPT TOOTH 563.00 N/A –
D7220 RMVL/IMPCTED TOOTH-S TISSUE 633.00 N/A –
D7230 PARTIAL BONY IMPACTION 736.00 N/A –
D7240 COMPLETE BONY IMPACTION 902.00 N/A –
D7250 SRG RMVL RESDL TOOTH ROOTS 633.00 N/A –
D7260 OROANTRAL FISTULA CLOSURE 2704.00 N/A –
D7270 TOOTH REIMPLANT/STABLELIZE 1067.00 N/A –
D7272 TOOTH TRANSPLANTATION 1464.00 N/A –
D7280 SURGICAL EXPOSURE FOR ERUP 1030.00 N/A –
D7286 BIOPSY ORAL TISSUE-SOFT 693.00 N/A –
D7310 ALVEOLPLASTY/PER QUAD W/EXT 615.00 N/A –
D7320 ALVEOLOPLASTY NOT IN CONJUNC W EXT 954.00 N/A –
D7340 VESTIBULOPLASTY 2740.00 N/A –
D7350 VESTIBULOPLASTY-INCL.SOFT TISS GRAF 6293.00 N/A –
D7471 REMOVAL OF LATERAL EXOSTOSIS 1575.00 N/A –
D7510 I&D INTRAORAL SOFT TISSUE 484.00 N/A –
D7520 I&D ABSCESS-EXTRAORAL 1254.00 N/A –
D7530 REMOVAL F/B: SKIN/SUBCUT. TISSUE 754.00 N/A –
D7560 MAXILLARY SINUSOSTOMY 3512.00 N/A –
D7880** OCCLUSAL APPLIANCE 2709.00 125.00 –
D7960 FRENULECTOMY 819.00 N/A –
D7970 EXCISION HYPERPLASTIC TISSUE 1026.00 N/A –
D7971 EXCISION PERICORONAL GINGIVA 599.00 N/A –

Other

CPT Code Description Standard Fee Lab Fee Your Fee
D9110 PALLIATIVE TX (EMERGENCY) 300.00 N/A –
D9910 APPLICATION OF DESEN. MEDICATION 145.00 N/A –
D9941 FABRICATION OF ATHLETIC MOUTHGUARD 544 125 –
D9942 REPAIR AND/OR RELINE OF OCCLUSAL GUARD 476.00 N/A –
D9943 OCCLUSAL GUARD ADJUSTMENT 302.00 N/A –
D9944 OCCLUSAL GUARD – HARD APPL FULL ARCH 1126.00 125.00 –
D9945 OCCLUSAL GUARD – SOFT APPL FULL ARCH 1006.00 125.00 –
D9946 OCCLUSAL GUARD – HARD APPL PARTIAL ARCH 1060.00 125.00 –
D9951 OCCLUSAL ADJST-LTD 406.00 N/A –
D9952 OCCLUSAL ADJUSTMENT-COMPLETE 1271.00 N/A –
D9975** EXTERNAL BLEACHING FOR HOME APPLIC 566 50 –
D9974 INTERNAL BLEACHING-PER TOOTH 544.00 N/A –

KEY DESCRIPTION
** Professional fee does not include lab fee
* Adjustments included for first 6 months at no extra cost
D The Dental Lab Fee is PER DENTURE and the Dental Visit Fee for Slide A/Nominal Fee patients also applies PER DENTURE.
T The Dental Lab Fee is PER TOOTH, including any missing teeth, AND the Dental Visit fee for slide A/Nominal Fee patients also applies PER TOOTH.
Example: Patient A has two porcelain to noble crowns constructed at the same time. Two visits are needed to complete the procedures.
Their lab fee is $150 x 2 crowns = $300.
Their total Sliding Fee Scale A/Nominal Fee would be $75/visit x 2 visits x 2 crowns = $300
Their Slide A/Nominal Fee Dummy Code would be DNT2C entered once per tooth per visit (Example: Tooth # 8 x DNT2C + Tooth #9 x DNT2C)
Their total fee would be their dental lab fee + their visit fees = $300 + $300 = $600

If 2 dentures are being constructed at the same time,
the Slide A/Nominal Fee Dummy Code would be DNT2D entered once per arch per visit (Example: Maxillary Complete Denture x DNT2D + Mandibular Complete x DNT2D)

If 1 crown or 1 denture is being constructed per visit for a Slide A/Nominal Fee patient, then use DUMMY CODE DENT2 ($75)
If 1 crown and 1 denture are both being constructed together per visit for a Slide A/Nominal Fee patient, then use DUMMY CODES DNT2C ($75) + DENT2 ($75)
If 1 crown and 2 dentures are being constructed per visit for a Slide A/Nominal Fee patient, then use DUMMY CODES DNT2C ($75) + DNT2D [Maxillary] ($75) + DNT2D [Mandibular] ($75)
If 2 crowns and 2 dentures are being constructed per visit for a Slide A/Nominal Fee patient, then use DUMMY CODES DNT2C ($75) + DNT2C ($75) + DNT2D [Maxillary] ($75) + DNT2D [Mandibular] ($75)

There may be additional fees and charges for lab / supply costs in addition to your nominal fee charge. Please refer to the Lab/Supply Fee Schedule.

TITLE X

Peekskill, Beacon, Poughkeepsie Partnership, South Broadway, Coram, Southampton, Amityville, Wyandanch, Shirley, Patchogue, Brentwood, Riverhead Sites ONLY

Follow-up/Sick Visits - New Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99202 Expanded problem straightforward 20 min 299.00 N/A –
99203 Detailed low complexity 30 min 357.00 N/A –
99204 Comprehensive moderate complexity 45 min 449.00 N/A –
99205 Comprehensive high complexity 60 min 518.00 N/A –
99211 Brief Visit 5 min 207.00 N/A –

Follow-up/Sick Visits - Established Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99212 Problem focused straightforward 10 min 276.00 N/A –
99213 Expanded problem low complexity 15 min 294.00 N/A –
99214 Detailed moderate complexity 25 min 351.00 N/A –
99215 Comprehensive high complexity 40 min 414.00 N/A –

Wellness Visits - New Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99381 <1 year 276.00 N/A –
99382 1-4 years 276.00 N/A –
99383 5-11years 276.00 N/A –
99384 12-17 years 276.00 N/A –
99385 18-39 years 290.00 N/A –
99386 40-64 years 311.00 N/A –
99387 >65 years 345.00 N/A –

Wellness Visits - Established Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99391 <1 year 276.00 N/A –
99392 1-4 years 276.00 N/A –
99393 5-11 years 276.00 N/A –
99394 12-17 years 276.00 N/A –
99395 18-39 years 290.00 N/A –
99396 40-64 years 311.00 N/A –
99397 >65 years 345.00 N/A –

Birth Control Method

CPT Code Description Standard Fee Supply Fee Your Fee
S4993 Oral Contraceptive Pills 14.00 14.00 –
S4993 Oral Contraceptive Pills-under age 19 14.00 14.00 –
J1050 Depoprovera 27.00 27.00 –
58300 IUD Insertion 300.00 N/A –
58301 IUD Removal 276.00 N/A –
J7300 Paragard IUD 260.00 260.00 –
J7301 Skyla 500.00 450.00 –
J7298 Mirena IUD 330.00 330.00 –
J7303 Vaginal Ring 5.00 14.00 –
J7297 Liletta 105.00 105.00 –
11981 Insertion Implanon/Nexplanon 200.00 N/A –
11982 Removal Implanon/Nexplanon 200.00 N/A –
11983 Removal and Insertion Implanon/Nexplanon 350.00 N/A –
J7304 Harmone Patch 82.00 82.00 –
J7307 Etonogestrel implant (Implanon/Nexplanon) 400.00 400.00 –
J3490 Emergency Contraception 5.00 N/A –

Counseling

CPT Code Description Standard Fee Supply Fee Your Fee
99401 Pre-test HIV counseling 115.00 N/A –
99402 Post-test HIV counseling negative 95.00 N/A –
99403 post-test HIV counseling positive 105.00 N/A –
86703 HIV Test 15.00 N/A –
90649 P-HPV-Gardisal (0-18 yrs old) 186.00 N/A –
90649 A-HPV-Gardisal (over 18 yrs old) 186.00 186.00 –

There may be additional fees and charges for lab / supply costs in addition to your nominal fee charge. Please refer to the Lab/Supply Fee Schedule.

URGENT CARE

Follow-up/Sick Visits - New Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99202 Expanded problem straightforward 20 min 299.00 N/A –
99203 Detailed low complexity 30 min 357.00 N/A –
99204 Comprehensive moderate complexity 45 min 449.00 N/A –
99205 Comprehensive high complexity 60 min 518.00 N/A –
99211 Brief Visit 5 min 207.00 N/A –

Follow-up/Sick Visits - Established Patient

CPT Code Description Standard Fee Supply Fee Your Fee
99212 Problem focused straightforward 10 min 248.00 N/A –
99213 Expanded problem low complexity 15 min 294.00 N/A –
99214 Detailed moderate complexity 25 min 351.00 N/A –
99215 Comprehensive high complexity 40 min 414.00 N/A –

There may be additional fees and charges for lab / supply costs in addition to your nominal fee charge. Please refer to the Lab/Supply Fee Schedule.

INPATIENT

Inpatient

CPT Code Description Standard Fee Supply Fee Your Fee
45560 REPAIR OF RECTOCELE 1140.00 N/A –
49000 EXPLORATION OF ABDOMEN 1300.00 N/A –
49320 DIAG LAPARO SEPARATE PROC 550.00 N/A –
54150 Circumcision 260.00 N/A –
56405 Incision & drainage of vulva or perineal abscess 180.00 N/A –
56440 Marsupialization of Bartholin's gland cyst 300.00 N/A –
56501 Destruction of lesion(s) vulva; simple (eg laser electrosurgery cryosurgery) 220.00 N/A –
56515 Destruction of lesion(s) vulva; extensive (eg laser electrosurgery cryosurgery) 380.00 N/A –
56605 Biopsy of vulva or perineum; one lesion 140.00 N/A –
57100 Biopsy of vulva mucosa; simple 150.00 N/A –
57105 Biopsy of vaginal mucosa; estensive requiring suture (including cysts) 230.00 N/A –
57150 Irrigation of vagina and/or application of medicament for treatment of bacterial parasitic or fungoid disease 80.00 N/A –
57410 Pelvic examination under anesthesia 180.00 N/A –
57452 Colposcopy (vaginoscopy) 180.00 N/A –
57500 Biopsy single or multiple or local excision of lesion with or without fulguration 210.00 N/A –
57505 Endocervical curettage 170.00 N/A –
57510 Cautery of cervix; electro or thermal 220.00 N/A –
57511 Cautery of cervix; cryocautery initial or repeat 240.00 N/A –
57520 Conization of cervix with or without fulguration with or without dilation & curretage with or without repair; cold knife or laser 510.00 N/A –
57700 Cerclage of uterine cervix non obstetrical 520.00 N/A –
57800 Dilation of cervical canal instrumental 100.00 N/A –
58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy) without cervical dilation any method 180.00 N/A –
58120 Dilation and curettage diagnostic or therapeutic 430.00 N/A –
58140 Myomectomy excision of fibroid tumor(s) of uterus 1-4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach 1500.00 N/A –
58145 Myomectomy excision of fibroid tumor(s) of uterus 1-4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; vaginal approach 900.00 N/A –
58146 Myomectomy excision of fibroid tumor(s) of uterus 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams abdominal approach 1880.00 N/A –
58150 Total abdominal hysterectomy (corpus or cervix) with or without removal of tube(s) with or without removal of ovary(s) 1670.00 N/A –
58152 Total abdominal hysterectomy (corpus and cervix) with or without removal of tube(s)with or without removal of ovary(s); with colpo-urethrocystopexy (eg Marshall-Marchetti-Krantz Burch) 2040.00 N/A –
58180 Supracervical abdominal hysterectomy with or without removal of tube(s) with or without removal of ovary(s) 1580.00 N/A –
58200 Total abdominal hysterectomy including partial vaginectomy with para-aortic and pelvic lymph node sampling with or without removal of tube(s) with or without removal of ovary(s) 2290.00 N/A –
58210 Radical abdominal hysterectomy with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) with or without removal of tube(s) with or without removal of ovary(s) 3090.00 N/A –
58260 Vaginal hysterectomy for uterus 250 grams or less 1340.00 N/A –
58267 Vaginal hysterectomy for uterus 250 grams or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type Pereyra type) with or without endoscopic control 1700.00 N/A –
58270 Vaginal hysterectomy for uterus 250 grams or less; with repair of enterocele 1440.00 N/A –
58350 Chromotubation of oviduct including materials 160.00 N/A –
58550 Laparoscopy surgical with vaginal hysterectomy uterus 250 grams or less 1440.00 N/A –
58555 Hysteroscopy diagnostic 440.00 N/A –
58558 Hysteroscopy surgical; with sampling (biopsy) endometrium and/or polypectomy with or without D&C 2220.00 N/A –
58559 Hysteroscopy surgical; with lysis of intrauterine adhesions (any method) 480.00 N/A –
58561 Hysteroscopy surgical; with removal of leiomyomata 720.00 N/A –
58600 Ligation or transection of fallopian tube(s) abdominal or vaginal approach unilateral or bilateral 590.00 N/A –
58605 Ligation or transection of fallopian tube(s) abdominal or vaginal approach postpartum unilateral or bilateral during the same hospitalization 540.00 N/A –
58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery 130.00 N/A –
58660 Laparoscopy surgical; with lysis of adhesions (salpingolysis ovariolysis) 1100.00 N/A –
58661 Laparoscopy surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 1070.00 N/A –
58662 Laparoscopy surgical with fulguration or excision of lesions of the ovary pelivic viscera peritoneal surface by any method 1160.00 N/A –
58670 Laparoscopy surgical; with fulguration of oviducts (with or without transection) 600.00 N/A –
58671 Salpingectomy complete or partial unilateral or bilateral 590.00 N/A –
58700 Salpingectomy complete or partial unilateral or bilateral 1280.00 N/A –
58720 Salpingo-oophorectomy complete or partial unilateral or bilateral 1220.00 N/A –
58740 Lysis of adhesions (salpingolysis ovariolysis) 1450.00 N/A –
58800 Drainage of ovarian cyst(s) unilateral or bilateral; vaginal approach 520.00 N/A –
58805 Drainage of ovarian cyst(s) unilateral or bilateral; abdominal approach 660.00 N/A –
58925 Ovarian cysectomy unilateral or bilateral 1230.00 N/A –
58940 Oophorectomy partial or total unilateral or bilateral 870.00 N/A –
59120 Surgical treatment of ectopic pregnancy; tubal or ovarian requiring salpingectomy and/or oophorectomy abdominal or vaginal approach 1340.00 N/A –
59150 Laprascopic treatment of ectopic pregnancy; without sappingectomy and/or oophorectomy 1300.00 N/A –
59160 Curretage postpartum 350.00 N/A –
59200 Insert cervical dilation 120.00 N/A –
59409 Vaginal delivery 2000.00 N/A –
59410 OB VAGINAL DELIVERY INCL POSTPARTUM 4000.00 N/A –
59414 DELIVER PLACENTA 160.00 N/A –
59510 OB GLOBAL CESAREAN DELIVERY 6000.00 N/A –
59514 Cesarean Section 4000.00 N/A –
59515 CESAREAN DELIVERY 2500.00 N/A –
59610 VBAC DELIVERY Global 3710.00 N/A –
59612 VBAC DELIVERY ONLY 2400.00 N/A –
59620 ATTEMPTED VBAC DELIVERY ONLY 1590.00 N/A –
99217 OBS-DISC DAY 120.00 N/A –
99218 OBS-LOW COMPLEX 170.00 N/A –
99219 OBS-MOD COMPLEX 220.00 N/A –
99220 HOSPITAL OBS-HI CPLX 300.00 N/A –
99221 Detailed or comprehensive hx exam straightfoward or low MDM 170.00 N/A –
99222 Comprehensive hx exam moderate MDM 220.00 N/A –
99223 Comprehensive hx exam high MDM 330.00 N/A –
99231 Problem focused interval hx exam straightforward low MDM 70.00 N/A –
99232 Expanded problem focused interval hx exam straightforward moderate MDM 120.00 N/A –
99233 Detailed interval hx detailed exam high MDM 170.00 N/A –
99234 Admit/Discharge same day-low complexity 220.00 N/A –
99235 Admit/Discharge same day-moderate complexity 270.00 N/A –
99236 Admit/Discharge same day-high complexity 350.00 N/A –
99238 HOSPITAL D/C DAY 120.00 N/A –
99238 Hospital Discharge day mgmt;30 min or less 120.00 N/A –
99239 Hospital Discharge day mgmt >30 min 180.00 N/A –
99251 Problem focused hx problem focused exam straightforward MDM 85.00 N/A –
99252 Expanded problem focused hx expanded problem focused exam straightforward MDM 95.00 N/A –
99253 Detailed hx detailed exam low MDM 200.00 N/A –
99254 Comprehensive hx comprehensive exam moderate MDM 280.00 N/A –
99255 Comprehensive hxcomprehensive exam high MDM 340.00 N/A –
99291 CRITICAL CARE 1ST HR 450.00 N/A –
99292 CC EACH ADD 30 MIN 200.00 N/A –
99292 ICU-ADD'L 15MIN 200.00 N/A –
99355 ADD'L 30M OPD W/CONTACT 160.00 N/A –
99356 HOSP PROL C W/C 1ST HR 150.00 N/A –
99357 ADD'L 30M HOSP W/CON 150.00 N/A –
99359 ADD'L 30MIN-W/O CONT 90.00 N/A –
99460 Initial hospital or birth center care per day for e/m of normal infant 170.00 N/A –
99462 Subsequent hospital care per day for e/m of normal newborn 80.00 N/A –

There may be additional fees and charges for lab / supply costs in addition to your nominal fee charge. Please refer to the Lab/Supply Fee Schedule.

For the full table of sliding fees, please click below

Medical  -  Dental  -  Optometry - Title X - Urgent Care - Inpatient