ExhibitE-DDSAFeeSched-Jan24.pdf
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- Attached to
- AZ|CTR070044
- Contract number
- CTR070044
- Issued by
- Arizona
About this file
This is a Price Sheet effective January 1, 2024, establishing fee schedules for medical examination and diagnostic services in Arizona. The document appears to be part of a state or local contract award outlining standardized rates for services delivered.
The price sheet contains two primary fee schedules. Section 1.0 covers pre-approved special project fees for services delivered while in travel status, including physical examinations (up to seven scheduled exams per project at $1,760.00), psychological examinations (up to six scheduled exams per project at $1,760.00), home visits ($400.00 add-on), and mileage reimbursement at $0.625 per mile. Section 2.0 provides a comprehensive fee schedule for individual services delivered, organized by CPT code and modifier, encompassing over 150 line items ranging from basic procedures such as drawing fees ($5.50) and wax removal ($38.36) to complex diagnostic services including psychiatric examinations ($217.00), psychological testing batteries ($171.00 to $750.00), comprehensive blood work panels ($6.00 to $80.00), imaging services ($41.18 to $144.00), and specialized audiological and speech-language pathology evaluations ($39.00 to $229.00). All fees are denominated in U.S. dollars and apply uniformly regardless of service location within Arizona.
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PRICE SHEET
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 $0.625/mile
2.0 Fee Schedule for Services Delivered:
CPT Code Modifier Arizona Service Description Fee
00006 SPANISH ADJUST 75.00$
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$
Effective January 1, 2024
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$
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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