9e97c4b1-50f7-4537-9197-b20fa32c1598.pdf
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- Attached to
- AZ|CTR070044
- Contract number
- CTR070044
- Issued by
- Arizona
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Exhibit E - Fee Schedule Summary
This document is a fee schedule effective July 1, 2025, establishing the contracted rates for medical, diagnostic, and evaluation services. The schedule does not identify specific state or agency parties but appears to be applicable to Arizona-based service delivery, as indicated by the "Arizona Service Description" column. The fee schedule governs pricing for services delivered across various medical specialties and diagnostic testing procedures.
The fee schedule is divided into two sections: pre-approved special project fees and individual service fees. Special project rates include $1,760.00 per scheduled project for physical examinations (up to seven exams per project) and psychological examinations (up to six exams per project), with a $400.00 add-on for home visits and mileage reimbursement at $0.67 per mile. Section 2.0 establishes individual service fees organized by CPT code and modifier, covering over 140 distinct services ranging from basic laboratory tests ($5.00 to $59.55) to comprehensive psychological and neuropsychological evaluations ($175.00 to $750.00). Services include imaging studies, blood work, hearing and speech evaluations, psychological testing, various medical examinations, and specialized assessments. Fees for individual services span from $5.50 (drawing fee) to $750.00 (Halstead-Reitan comprehensive neuropsychological battery), with most physician-level exams standardized at $217.00 and standardized psychological testing assessments uniformly priced at $175.00.
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1.0 Fee Schedule to be used when in Travel Status or Special Projects
PRE-APPROVED SPECIAL PROJECT FEES RATE
Physical and all Other Examinations with the Exception of Psychological Examinations: A Physical Exam Project May Include Up to Seven (7)
$1,760.00 Per Scheduled Project
Psychological Examination: A Psychological Exam Project May Include up to Six (6) Scheduled Exams $1,760.00 Per Scheduled Project
Home Visit add $400.00 to Fee
Mileage reimbursement to travel $0.67/mile
2.0 Fee Schedule for Services Delivered:
CPT Code Modifier Arizona Service Description Fee
00006 SPANISH ADJUST $ 75.00
00007 CDI CERTIFIED DEAT INT $ 116.00
00007 SL S/L TRANSLATION $ 55.00
00010 SPANISH SPEAKING SLP $ 35.00
00195 GAMMA GT TEST $ 19.00
03682 WESTERN BLOT $ 59.55
36415 DRAWING FEE $ 5.50
69210 WAX REMOVAL $ 38.36
71020 CHEST PA/LAT CT $ 61.76
72040 C-SPINE PA/LAT $ 61.76
72070 T-SPINE PA/LAT $ 61.76
72100 L-S PA/LAT $ 61.76
73020 LT SHOULDER, LEFT $ 41.18
73020 RT SHOULDER, RIGHT $ 41.18
73030 LT SHOULDER, LEFT 2 VIEW $ 61.76
73030 RT SHOULDER, RIGHT 2 VIEW $ 61.76
73070 LT ELBOW, PA/LAT (LEFT) $ 41.18
73070 RT ELBOW, PA/LAT (RIGHT) $ 41.18
73090 LT FOREARM PA/LAT LEFT $ 41.18
73090 RT FOREARM PA/LAT RT $ 41.18
73100 LT WRIST 2 VIEWS LEFT $ 41.18
73100 RT WRIST 2 VIEWS RIGHT $ 41.18
73120 LT HAND 2 VIEWS LEFT $ 41.18
73120 RT HAND 2 VIEWS RIGHT $ 41.18
73510 LT HIP 2 VIEWS LEFT $ 82.35
73510 RT HIP 2 VIEWS RIGHT $ 82.35
73550 LT FEMUR PA/LAT LEFT $ 61.76
73550 RT FEMUR PA/LAT RIGHT $ 61.76
73560 LT KNEE, PA/LAT LEFT $ 41.18
73560 RT KNEE, PA/LET RIGHT $ 41.18
73590 LT TIBIA/FIBULA LEFT $ 41.18
73590 RT TIBIA/FIBULA RIGHT $ 41.18
73610 LT ANKLE, COMPLETE LEFT $ 61.76
73610 RT ANKLE, COMP. RIGHT $ 61.76
73620 LT FOOT, PA/LAT LEFT $ 41.18
73620 RT FOOT, PA/LAT RIGHT $ 41.18
77073 BONE LENGTH STUDY $ 90.00
80053 COMP METABOLIC $ 16.85
80069 RENAL FUNCTION $ 16.15
80076 HEPATIC FUN PAN $ 14.59
80154 KLONOPIN $ 42.25
80156 TEGRETOL $ 33.50
80164 DEPAKENE $ 27.00
80184 PHENOBARBITAL $ 27.00
Effective July 1, 2025 Exhibit E - Fee Schedule
80185 DILANTIN $ 26.50
80188 PRIMIDONE $ 20.50
80299 KE KEPPRA $ 59.50
80299 LA LAMICTAL $ 26.50
82575 CREAT CLEARANCE $ 13.00
82654 TRIDONE LEVEL $ 48.62
82803 BLOOD GAS REST $ 48.00
84550 URIC ACID $ 8.00
85013 HEMATOCRIT $ 5.00
85025 COMPLETE BLOOD COUNT (CBC) $14.00
85031 TOPIRAMATE LEVEL $ 6.00
85032 CBC - DIFFER $ 6.00
85610 PROTHROMBIN $ 7.50
85651 SEDIMENTATION RATE $ 6.75
86038 ANA AND TITER $ 21.94
86140 C-REACTIVE PRO $ 9.75
86360 T CELLS ABSOLUTE CD4 & CD8 COU $ 80.00
86430 RA TEST $ 10.80
86803 HEPATITIS C $ 30.26
88262 CHROMOSOME ANALYSIS $ 300.00
90791 PSYCHIATRIC EX $ 217.00
90791 x2 PSYCHIATRIC (x2) $ 248.00
92004 COMP OP & FIELD $ 136.00
92015 MANIFEST REFRACTION $ 15.00
92082 VISUAL FIELDS $ 61.00
92083 HUMPHREY VTAP $ 75.00
92506 SPEECH LANG PATH $ 229.00
92557 AUDIO COMPREHENSIVE $ 75.00
92567 TYMPANOMETRY $ 45.00
92579 VISUAL REINFORCEMENT AUDIOMETRY $ 80.00
92582 CONDITIONING PLAY AUDIOMETRY $ 100.00
92588 EVOKED OTOACOUSTIC EMISSIONS $ 150.00
92591 SOUND FIELDS (BINA) $ 39.00
92595 HEARING AID EVALUATION: BINAUR $ 55.00
92626 EVAL AUD AND REHAB STATUS $ 82.00
93000 EKG RESTING $ 46.00
93923 DOPPLER RESTING $ 111.00
93970 VENOUS DOPPLER $ 135.81
93922 LOWER EXTREMITY LEG STUDY $ 144.00
94060 PFS $ 95.00
94720 CO DIFUSION $ 64.00
94760 OXIMETRY TEST $ 29.00
96101 CB CHILD CHECKLIST $ 92.00
96101 CO CONNORS $ 92.00
96101 CT C-TONI 2 $ 175.00
96101 MM MMPI $ 92.00
96101 RV RAVEN'S $ 175.00
96101 TN TONI-3 $ 175.00
96101 UT UNIT $ 175.00
96101 VL VINELAND $ 92.00
96101 WC WISC - IV $ 175.00
96101 WP WPPSI-3 $ 175.00
96101 WS WAIS - IV $ 175.00
96111 WT WIAT-III $ 175.00
96111 AB ABAS - II $ 92.00
96111 AS ASDS $ 92.00
96111 BS BASC - II $ 92.00
96111 BY BAYLEY $ 175.00
96111 CR CARS - 2 $ 92.00
96111 KB KABC $ 175.00
96111 LT LEITER $ 175.00
96111 SB STANFORD - BINET - 5 $ 175.00
96111 WJ WOODCOCK JOHNSON - III $ 171.00
96111 WR WRAT - 4 $ 171.00
96118 BV BVRT $ 175.00
96118 HR HALSTEAD -REITAN $ 750.00
96118 WM WMS IV $ 227.00
96118 WR WRAML $ 227.00
97001 PT EVALUATION $ 80.00
97750 WORK EVALUATION-Travel $ 550.00
97750 WORK EVALUATION $ 392.00
99080 ODAR FOR COMP $ 15.00
99091 NARRATIVE $ 56.00
99199 x2 REVIEW OF RECORDS $ 112.00
99199 REVIEW RECORDS $ 56.00
99243 TP TP EXAM $ 217.00
99244 CA CARDIAC EXAM $ 217.00
99244 CAL INTERNAL MED FOR CA $ 217.00
99244 IM INTERNAL MED EXAM $ 217.00
99244 NE NEURO EXAM $ 217.00
99244 OR ORTHOPEDIC EXAM $ 217.00
99244 OT OTO EXAM $ 217.00
99244 PC CARDIAC PED $ 217.00
99244 PE PEDIATRIC EXAM $ 217.00
99244 PL PULMONARY EXAM $ 217.00
99244 PM P.M. EXAM $ 217.00
99244 PN PEDIATRIC NEURO $ 217.00
99244 ST PED 16 + $ 217.00
99244 TP TREATING PHYSICIAN $ 217.00
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