THE UNIVERSITY OF TEXASHEALTHSCIENCECENTER AT TYLER

UNIVERSITY HEALTH CLINIC - UT TYLER EMPLOYEE

Name: [f pt name] Unit # : [f pt unit num]ENCOUNTER # [f z encounter acct]

Address: [f pt addr1]Service Date: [f appt date]Account # : [f pt acct num]

City/St: [f pt csz]Primary Ins: [f pt ins name1]Provider: [f appt doctor name]

Home Phone # [f pt home ph]Secondary Ins: [f pt ins name2]Referring: [q ADM.REFPHY]

Prim Co-Pay: [q ADM.ADIPPA]Auth # : [f pt auth num1]

Spec Co-Pay: [q ADM.ADISPA]APPT Time: [f appt start time]

NOTES: ______FACULTY______STAFF______

HCPCS / X / Physician Visits / Charge / HCPCS / X / Clinic Laboratory / Charge
New / 36415 / Venipuncture, routine / $ 5.00
99201 / O/P New Pt., Level I / $ 30.00 / 82947 / Glucose, finger stick / No Charge
99202 / O/P New Pt., Level II / $ 30.00 / 86308 / Mono Spot / No Charge
99203 / O/P New Pt., Level III / $ 30.00 / Q0091 / Pap Smear Screening (to UTHCT) / No Charge
99204 / O/P New Pt., Level IV / $ 30.00 / 81025 / Pregnancy Quickview- Urine / No Charge
99205 / O/P New Pt., Level V / $ 30.00 / 87880 / Rapid Strep / No Charge
Established / 81002 / Urinalysis, Dipstick / No Charge
99211 / O/P Estab. Pt., Level I / $ 30.00 / 87804 / Flu / No Charge
99212 / O/P Estab. Pt., Level II / $ 30.00 / TX Dept of Health Lab / Charge
99213 / O/P Estab. Pt., Level III / $ 30.00 / 86592 / Syphilis RPR / No charge
99214 / O/P Estab. Pt., Level IV / $ 30.00 / 87801 / Inf agent detection, DNA/RNA / $ 8.00
99215 / O/P Estab. Pt., Level V / $ 30.00 / including Chylmd & Gonorrhea
Modifier-25 / 99000 / Specimen transfer Phys to Lab / No Charge
Radiology / Charge*
71010TC / Chest, 1 view / $ 56.00 / OE / X / UTHCT Laboratory / Charge
73110TC / Wrist; complete, min of 3 views / $ 61.00 / xxxxx / Pap smear liq base / $ 29.00
73130TC / Hand; minimum of 3 views / $ 60.00 / xxxxx / **Phys Interp(Lab Charge Only) / $ 35.00
73140TC / Finger(s), minimum of 2 views / $ 55.00 / CBC / CBC / $ 10.00
73562TC / Knee; minimum of 3 views / $ 63.00 / CMP / CMP / $ 14.00
73630TC / Foot; complete, min of 3 views / $ 60.00 / CST / Culture, Throat / $ 22.00
*Chg includes $30.00 Interp fee / CSU / Urine Culture / $ 11.00
HCPCS / Injections/Vaccinations / Charge / CSW / Culture, Wound / $ 50.00
(See Vac/Drug/Med below) / EBVEA / Epstein-Barr antibody / $ 17.00
90772 / Therap/Proph/Dx Inj; SQ, IM / No Charge / EBVIGM / EBV AB to VCA / $ 23.00
90471 / Immunization admin, single / No Charge / ESR / Sed Rate / $ 5.00
90472 / Immunization admin, 2+ / No Charge / FSH / FSH / $ 24.00
95115 / Immunotherapy, one injection / No Charge / GLUR / Glucose (Lab) / $ 5.00
95117 / Immunotherapy inj; 2 or more / No Charge / GLYCO / Glycohemoglobin / $ 13.00
86580 / TB intradermal test / No Charge / HBSAG / Hepatitis B surface AG screen / $ 13.00
HBSAB / Hepatitis B Antibody titer / $ 14.00
HCPCS / Vaccine/Drug/Medication / Charge / HCGQN / HCG, Quanitative Serum / $ 11.00
J0696 / Ceftruaxine Sod, per 250 MG / $ 11.00 / HCVAB / Hepatitis C virus AB / $ 18.00
90649 / H Papilloma Vaccine per dose / $ 231.00 / HEPAT / Hepatic function / $ 11.00
90632 / Hep A Vaccine, Adult, IM / $ 62.00 / HERCUL / Herpes Culture (Ref) / $ 130.00
90746 / Hep B Vaccine, Adult, IM / $ 53.00 / HSV2 / HSV2 IGG / $ 25.00
90636 / Hap A / Hep B (Twinrix) / $ 84.00 / HIV / HIV AB Scr+Reflex Blot (REF) / $ 11.00
90658 / Influenza Vaccine, IM / $ 12.00 / HPV / HPV / $ 45.00
J1055 / Medroxyprogesterone Ace.150 mg / $ 50.00 / IRON / Iron / $ 8.00
90733 / Meningococcal Vaccine, SC / $ 92.00 / LH / LH / $ 24.00
J1030 / Methylprednisolone Ace. 40 mg / $ 4.00 / LIPID / Lipid panel / $ 17.00
90707 / MMR Vaccine, SC / $ 46.00 / MUMIG / Mumps titer IgG / $ 17.00
90713 / Poliovirus, IPV, SC / $ 25.00 / PROLAC / Prolactin / $ 25.00
90718 / TD Vaccine, IM / $ 17.00 / PSA / PSA / $ 24.00
90715 / Tdap Vaccine, > 7 yrs, IM / $ 38.00 / RUBEOL / Measles titer IgG / $ 17.00
90703 / Tetanus Vaccine / $ 20.00 / RUBIGG / Rubella, AB / $ 19.00
T4TOT / T4-Thyroxine / $ 9.00
HCPCS / Clinical Procedures / Charge / TSH / TSH ultra sensitive / $ 22.00
94010 / Breathing Capacity Testing / $ 112.00 / TU / T3 uptake / $ 8.00
93005 / EKG Tracing Only / $ 15.00 / UA / UA, auto, w/o microscope / $ 3.00
114XX / Excision of Ben Lesion 1cm / $ 25.00 / URACID / Uric Acid, Serum / $ 6.00
116XX / Excision of Malig Lesion 1 cm / $ 160.00 / VZIGG / Varicella ZosterAB IGG / $ 11.00
10060 / I&D of Abscess / $ 98.00 / WET / Wet Mount, KOH, Inf / $ 6.00
58300 / Insert IUD / $ 117.00 / Other:
94640 / Nebulizer Treatment / $ 10.00
69210 / Removal impacted cerumen / $ 48.00 / UT Tyler
58301 / Removal IUD / $ 125.00 / 14-Jul-09
Other:

PHYSICIAN / NURSE PRACTITIONER SIGNATURE______