Mercy Family Practice SC

Fee Schedule 2017

CPT4FreqPriceCodeText
994971203.12Advanced Directive (paperwork)
82043313.65Albumin; urine, microalbumin, quantitative
95117718.48Allergy Shots
G04391186.73Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
G04381277.20Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
206101119.78Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)
3641514712.50Collection of venous blood by venipuncture
82570212.22Creatinine; other source
96110117.55Developmental screening, with interpretation and report, per standardized instrument form
99324193.23Domiciliary or rest home visit for an established patient: a problem focused history; a problem focused examination; and straightforward medical decision making.
993351153.33Domiciliary or rest home visit for an established patient: an expanded problem focused interval history; an expanded problem focused examination; medical decision.
9933614216.07Domiciliary or rest home visit for an established patient: a detailed interval history; a detailed examination; medical decision making of moderate complexity.
993261228.30Domiciliary or rest home visit: a detailed history; a detailed examination; and medical decision making of moderate complexity.
93000741.15Electrocardiogram (EKG), least 12 leads; with interpretation and report
114201201.67Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less
932241176.40External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation
93225152.63External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)
82963215.00G6PD lab test
8294817.20Glucometer for Diabetes Mellitus (average glucose over 2 months)
830371222.92Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use
90632183.08Hepatitis A vaccine, adult dosage, for intramuscular use
90746199.52Hepatitis B – ENGERIX, Immunization,
86703220.83HIV lab test
993481139.23Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low comple
904711542.52Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
G0008442.52Immunization Influenza (Medicare)
90674520.26Influenza quad Flucelvax
906882720.26Influenza quadrivalent Fluzone
90662155.62Influenza vaccine High Dose (Fluzone HD) >65 yo
90656820.67Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
906581420.26Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Q2038320.08Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluzone)
G04023253.40Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment
J1040138.32Injection, methylprednisolone acetate, 80 mg
J330133.00Injection, triamcinolone acetonide, not otherwise specified, 10 mg
20550295.00Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
99366271.32Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional
55024525.00No Show
993071577.12Nursing home follow-up exam 10 min
9930868118.88Nursing home follow-up exam 15 min
993092156.72Nursing home follow-up exam 25 min
993041159.50Nursing home Initial exam 25 min
993051227.17Nursing home Initial exam 35 min
993062287.92Nursing home Initial exam 45 min
9920226122.22Office visit new patient: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making.
992035175.77Office visit new patient: A detailed history; A detailed examination; Medical decision making of low complexity.
9920424269.00Office visit new patient:: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity.
992051334.80Office visit new patient: A comprehensive history; A comprehensive examination; Medical decision making of high complexity.
99211134.77Office visit for the evaluation and management of an established patient: minimal. typically, 5 minutes.
99212274.05Office visit for the evaluation and management of an established patient: a problem focused history; a problem focused examination; straightforward medical decision making.
9921336121.92Office visit for the evaluation and management of an established patient: an expanded problem focused history; an expanded problem focused examination; medical decision making.
99214110130.00Office visit, established
992154241.40Office visit for the evaluation and management of an established patient: a comprehensive history; a comprehensive examination; medical decision making of high complexity.
G0009242.52Pneumococcal vaccine, Medicare administration fee
906703193.79Pneumococcal 13 Prevnar13 (Pfizer)
907325108.00Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
993951165.57Preventative exams established 18 to 39 yrs old
993965180.25Preventative exams established 40 to 64 yrs old
993852189.40Preventative exams New 18 to 39 yrs old
993972203.12Preventative exams established 65+ yrs old
993863219.92Preventative exams New 40 to 64 yrs old
993871282.72Preventative exams New 65+ yrs old
69210185.48Removal impacted cerumen (separate procedure), one or both ears
Q0091178.43PAP smear
86580113.85PPD Skin test; tuberculosis, intradermal
90715265.95Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap)
96372157.28Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
8100335.10Urinalysis
8100127.25Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

1500 Heritage Rd Suite A/ De Pere, WI 54115
Hours M-F 8am - 4pm
Phone 920-347-1990 . Fax 920-347-1991