ExhibitE-FeeSchedSpecProjects-May2024Travel.pdf
PDF 112 KB Posted
- Attached to
- AZ|CTR070044
- Contract number
- CTR070044
- Issued by
- Arizona
About this file
This document is a Fee Schedule for medical examination and diagnostic services provided by a contractor to Arizona. The schedule establishes the pricing structure for healthcare-related services across multiple service categories and examination types.
The fee schedule contains two primary sections: Section 1 addresses pre-approved special project fees for travel status or special projects, including physical examinations at $1,760.00 per scheduled project (accommodating up to seven exams), psychological examinations at $1,760.00 per scheduled project (accommodating up to six exams), home visit add-ons of $400.00, and mileage reimbursement at $0.655 per mile. Section 2 provides a comprehensive fee schedule for individual services delivered, containing over 100 CPT-coded services spanning imaging studies (ranging from $5.50 to $90.00), laboratory tests (ranging from $5.00 to $300.00), psychological and standardized testing (ranging from $92.00 to $750.00), and various medical examinations (uniformly priced at $217.00). Services include radiological studies, blood work, hearing evaluations, cardiac assessments, neurological examinations, and standardized psychological assessments. Modifiers are used to differentiate services by anatomical location (left/right designations) and test variations. The fee structure accommodates specialized services such as certified deaf interpretation, Spanish language services, and specific pharmaceutical level testing. All fees are fixed rates with no identified option periods, renewals, or set-aside provisions noted in this document.
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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 $0.655/mile
2.0 Fee Schedule for Services Delivered:
CPT Code Arizona Service Description Fee
00006 SPANISH ADJUST $ 75.00
00007 CERTIFIED DEAT INT $ 116.00
00007 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 SHOULDER, LEFT $ 41.18
73020 SHOULDER, RIGHT $ 41.18
73030 SHOULDER, LEFT 2 VIEW $ 61.76
73030 SHOULDER, RIGHT 2 VIEW $ 61.76
73070 ELBOW, PA/LAT (LEFT) $ 41.18
73070 ELBOW, PA/LAT (RIGHT) $ 41.18
73090 FOREARM PA/LAT LEFT $ 41.18
73090 FOREARM PA/LAT RT $ 41.18
73100 WRIST 2 VIEWS LEFT $ 41.18
73100 WRIST 2 VIEWS RIGHT $ 41.18
73120 HAND 2 VIEWS LEFT $ 41.18
73120 HAND 2 VIEWS RIGHT $ 41.18
73510 HIP 2 VIEWS LEFT $ 82.35
73510 HIP 2 VIEWS RIGHT $ 82.35
73550 FEMUR PA/LAT LEFT $ 61.76
73550 FEMUR PA/LAT RIGHT $ 61.76
73560 KNEE, PA/LAT LEFT $ 41.18
73560 KNEE, PA/LET RIGHT $ 41.18
73590 TIBIA/FIBULA LEFT $ 41.18
73590 TIBIA/FIBULA RIGHT $ 41.18
73610 ANKLE, COMPLETE LEFT $ 61.76
73610 ANKLE, COMP. RIGHT $ 61.76
73620 FOOT, PA/LAT LEFT $ 41.18
73620 FOOT, PA/LAT RIGHT $ 41.18
KE
LA
x2
CB
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 KEPPRA $ 59.50
80299 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 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 CHILD CHECKLIST $ 92.00
CO
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RV
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WP
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AS
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BY
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KB
LT
SB
WJ
WR
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WR
x2
TP
CA
CAL
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NE
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PC
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96101 CONNORS $ 92.00
96101 C-TONI 2 $ 175.00
96101 MMPI $ 92.00
96101 RAVEN'S $ 175.00
96101 TONI-3 $ 175.00
96101 UNIT $ 175.00
96101 VINELAND $ 92.00
96101 WISC - IV $ 175.00
96101 WPPSI-3 $ 175.00
96101 WAIS - IV $ 175.00
96111 WIAT-III $ 175.00
96111 ABAS - II $ 92.00
96111 ASDS $ 92.00
96111 BASC - II $ 92.00
96111 BAYLEY $ 175.00
96111 CARS - 2 $ 92.00
96111 KABC $ 175.00
96111 LEITER $ 175.00
96111 STANFORD - BINET - 5 $ 175.00
96111 WOODCOCK JOHNSON - III $ 171.00
96111 WRAT - 4 $ 171.00
96118 BVRT $ 175.00
96118 HALSTEAD -REITAN $ 750.00
96118 WMS IV $ 227.00
96118 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 REVIEW OF RECORDS $ 112.00
99199 REVIEW RECORDS $ 56.00
99243 TP EXAM $ 217.00
99244 CARDIAC EXAM $ 217.00
99244 INTERNAL MED FOR CA $ 217.00
99244 INTERNAL MED EXAM $ 217.00
99244 NEURO EXAM $ 217.00
99244 ORTHOPEDIC EXAM $ 217.00
99244 OTO EXAM $ 217.00
99244 CARDIAC PED $ 217.00
99244 PEDIATRIC EXAM $ 217.00
99244 PULMONARY EXAM $ 217.00
99244 P.M. EXAM $ 217.00
99244 PEDIATRIC NEURO $ 217.00
99244 PED 16 + $ 217.00
99244 TREATING PHYSICIAN $ 217.00
Table 1
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