outpatient hospital laboratory non-critical … lab non... · 82482 assay rbc cholinesterase $9.99...

Effective Date: 01/01/2015

Updated: 01/05/2015

ATTENTION: The procedure codes with established rates effective

for dates of service starting July 1, 2013, through June 30, 2014 reflect

a reduction in rates of 11.48% for SFY12, an increase of .5% for SFY13,

a decrease of 2.2% for FY14 and increase of 3% for FY15. Codes with no established

rate pay at a percentage of billed charges per administrative rule and the same

percentage for SFY12 reductions and SFY13 and SFY14 increases

will be applied.

The rates represented are not reflective of applicable

cost share and other payment adjustments.

CODE PROCEDURE FEE

80047 Metabolic panel ionized ca $11.40

80048 Basic metabolic panel $11.01

80050 GENERAL HEALTH SCREEN PANEL $48.65

80051 Electrolyte panel $9.12

80053 Comprehen metabolic panel $13.75

80055 OBSTETRIC PROFILE $10.78

80061 LIPID PROFILE $17.42

80069 Renal function panel $11.30

80074 Acute hepatitis panel $61.10

80076 Hepatic function panel $10.62

80150 AMIKACIN $19.60

80156 Assay carbamazepine total $18.94

80157 Assay carbamazepine free $17.43

80158 CYCLOSPORINE $23.48

80162 Assay of digoxin total $17.27

80164 Assay dipropylacetic acd tot $17.62

80168 ETHOSUXIMIDE $21.68

80170 Assay of gentamicin $20.38

80173 Assay of haloperidol $19.15

80176 Assay of lidocaine $19.10

80178 Assay of lithium $8.59

80184 Assay of phenobarbital $14.90

80185 Assay of phenytoin total $17.05

80186 Assay of phenytoin free $17.07

80188 Assay of primidone $21.58

80190 Assay of procainamide $21.79

80192 Assay of procainamide $21.79

80194 Assay of quinidine $18.36

80195 Assay of sirolimus $18.04

80197 Assay of tacrolimus $17.85

80198 Assay of theophylline $18.41

80200 Assay of tobramycin $20.96

80201 Assay of topiramate $15.51

80202 Assay of vancomycin $17.62

80299 Quantitative assay drug $17.81

80400 ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY $34.40

80402 ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY $78.69

80406 ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE $55.45

OUTPATIENT HOSPITAL LABORATORY

NON-CRITICAL ACCESS

Rates displayed below do not reflect rates for codes billed containing modifiers.

For information on how modifiers will affect payment see ARSD § 67:16:02:03.02.

CODE PROCEDURE FEE

80408 ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE IN $163.23

80410 Calcitonin stimul panel $97.32

80412 CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL $404.64

80414 CHORIONIC GONADOTROPHIN STIMULATION PANEL; TESTOSTERONE $67.16

80415 CHORIONIC GONADOTROPHIN STIMULATION PANEL; ESTRADIOL RE $72.69

80416 Renin stimulation panel $171.66

80417 Renin stimulation panel $57.22

80418 COMBINED RAPID ANTERIOR PITUITARY EVALUATION PANEL $737.75

80420 DEXAMETHASONE SUPPRESSION PANEL, 48 HOUR $85.68

80422 GLUCAGON TOLERANCE PANEL; FOR INSULINOMA $59.94

80424 GLUCAGON TOLERANCE PANEL; FOR PHEOCHROMOCYTOMA $65.69

80426 GONADOTROPIN RELEASING HORMONE STIMULATION PANEL $193.08

80428 GROWTH HORMONE STIMULATION PANEL (EG, ARGININE INFUSION $86.73

80430 GROWTH HORMONE SUPPRESSION PANEL (GLUCOSE ADMINISTRATIO $102.03

80432 INSULIN-INDUCED C-PEPTIDE SUPPRESSION PANEL $175.67

80434 INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY $111.52

80435 INSULIN TOLERANCE PANEL; FOR GROWTH HORMONE DEFICIENCY $133.92

80436 METYRAPONE PANEL $110.56

80438 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; $65.53

80439 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; $87.38

80500 CLINICAL PATHOLOGY CONSULTATION; LIMITED, WITHOUT REVIE $14.31

80502 CLINICAL PATHOLOGY CONSULTATION; COMPREHENSIVE, FOR A C $50.89

81000 Urinalysis nonauto w/scope $3.83

81001 Urinalysis auto w/scope $3.83

81002 ROUTINE URINALYSIS W/O MICRO $3.11

81003 Urinalysis auto w/o scope $2.72

81005 URINALYSIS CHEMICAL QUALITATIVE $2.25

81007 URINALYSIS BACTERIURIA SCREEN, BY NON-CULTURE TECHNIQUE $3.12

81015 MICROSCOPIC URINE EXAM $3.68

81020 Urinalysis glass test $4.52

81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHOD $8.70

81050 Urinalysis volume measure $3.63

81229 Cytogen m array copy no&snp $998.67

81511 Ftl cgen abnor four anal $112.71

82009 ACETONE,QUALITATIVE $5.49

82010 ACETONE BLOOD $11.18

82013 ACETLCHOLINESTERASE $14.53

82016 Acylcarnitines qual $18.03

82017 Acylcarnitines quant $7.52

82024 Assay of acth $50.23

82030 Assay of adp & amp $35.50

82040 Assay of serum albumin $6.01

82042 Assay of urine albumin $6.28

82043 Microalbumin quantitative $7.53

82044 Microalbumin semiquant $5.55

82045 Albumin ischemia modified $44.64

82075 Assay of breath ethanol $15.68

82085 ALDOLASE, KINETIC ULTRAVIOLET $12.63

82088 Assay of aldosterone $53.00

82103 Alpha-1-antitrypsin total $17.47

82104 Alpha-1-antitrypsin pheno $18.80

82105 Alpha-fetoprotein serum $21.81

82106 Alpha-fetoprotein amniotic $21.81

82107 AFP-L3 FRACTION ISOFORM & TOTAL AFP $84.69

82108 Assay of aluminum $33.15

82120 Amines vaginal fluid qual $3.04

82127 Amino acid single qual $18.03

82128 Amino acids mult qual $18.03

82131 Amino acids single quant $7.52

82135 Assay aminolevulinic acid $21.41

82136 Amino acids quant 2-5 $7.52

CODE PROCEDURE FEE

82139 Amino acids quan 6 or more $7.52

82140 AMMONIA BLOOD $18.96

82143 AMINIOTIC FLUID SCAN $9.46

82150 AMYLASE BLOOD QUANTITATIVE $8.43

82154 ANDROSTANEDIOL GLUCURONIDE $37.50

82157 ANDROSTENEDIONE RIA $38.08

82160 Assay of androsterone $32.53

82163 ANGIOTENSIN II,RIA $28.25

82164 ANGIOTENSIN-CONVERTING ENZYME $18.98

82172 Assay of apolipoprotein $20.15

82175 ARSENIC $24.68

82180 ASCORBIC ACID BLOOD $12.86

82190 ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE $19.39

82207 FECAL OCCULT BLOOD TEST $3.07

82232 Assay of beta-2 protein $21.04

82239 Bile acids total $9.60

82240 Bile acids cholylglycine $34.56

82247 Bilirubin total $6.09

82248 Bilirubin direct $6.23

82252 BILIRUBIN,FECES,QUALITATIVE $5.51

82261 Assay of biotinidase $7.14

82270 Occult blood feces $3.07

82271 Occult blood other sources $3.33

82272 Occult bld feces 1-3 tests $3.33

82274 Assay test for blood fecal $20.91

82286 BRADYKININ $7.40

82300 Assay of cadmium $30.10

82306 Vitamin d 25 hydroxy $38.50

82308 CALCITONIN,RIA $31.75

82310 Assay of calcium $6.25

82330 Assay of calcium $17.77

82331 CALCIUM AFTER CALCIUM INFUSION TEST $6.73

82340 Assay of calcium in urine $5.66

82355 Calculus analysis qual $13.51

82360 Calculus assay quant $16.75

82365 Calculus spectroscopy $16.77

82370 X-ray assay calculus $16.30

82373 Assay c-d transfer measure $23.74

82374 Assay blood carbon dioxide $5.93

82375 Assay carboxyhb quant $14.68

82376 Assay carboxyhb qual $7.79

82378 CARCINOEMBRYONIC ANTIGEN (CEA) $24.68

82379 Assay of carnitine $7.52

82380 Assay of carotene $12.00

82382 Assay urine catecholamines $22.36

82383 Assay blood catecholamines $32.59

82384 Assay three catecholamines $32.85

82387 Assay of cathepsin-d $9.96

82390 Assay of ceruloplasmin $13.96

82397 CHEMILUMINESCENT ASSAY $18.38

82415 Assay of chloramphenicol $16.48

82435 Assay of blood chloride $5.57

82436 Assay of urine chloride $6.10

82438 Assay other fluid chlorides $5.93

82441 CHLORINATED HYDROCARBONS,SCREEN $7.81

82465 Assay bld/serum cholesterol $5.28

82480 Assay serum cholinesterase $10.25

82482 Assay rbc cholinesterase $9.99

82485 Assay chondroitin sulfate $7.40

82486 CHROMATOGRAPHY $23.49

82487 CHROMATOGRAPHY,PAPER,1-DIMENSIONAL $7.40

CODE PROCEDURE FEE

82488 CHROMATOGRAPHY,PAPER,2-DIMENSIONAL $7.40

82489 CHROMATOGRAPHY,THIN LAYER $7.40

82491 Chromotography quant sing $23.49

82492 Chromotography quant mult $23.49

82495 Assay of chromium $26.38

82507 Assay of citrate $7.40

82523 Collagen crosslinks $24.31

82525 Assay of copper $16.14

82528 Assay of corticosterone $7.40

82530 Cortisol free $21.74

82533 CORTISOL;RIA,PLASMA $16.85

82540 Assay of creatine $5.61

82541 Column chromotography qual $23.49

82542 Column chromotography quant $23.49

82543 Column chromotograph/isotope $23.49

82544 Column chromotograph/isotope $23.49

82550 Assay of ck (cpk) $8.74

82552 Assay of cpk in blood $17.42

82553 Creatine mb fraction $15.01

82554 Creatine isoforms $15.44

82565 Assay of creatinine $6.21

82570 Assay of urine creatinine $6.28

82575 CREATININE,CLEARANCE * $12.55

82585 Assay of cryofibrinogen $11.15

82595 Assay of cryoglobulin $8.17

82600 Assay of cyanide $25.23

82607 CYANOCOBALAMIN;RIA $19.60

82608 CYANOCOBALAMIN UNSATURATED BIND CAP $18.63

82610 Cystatin c $14.55

82615 CYSTINE,URINE,QUALITATIVE $10.62

82626 DEHDROEPIANDROSTERONE,RIA $7.21

82627 DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) $28.91

82633 DESOXYCORTICOSTERONE,11-RIA $40.28

82634 DESOXYCORTISOL,11-(COMPOND S),RIA $38.08

82638 Assay of dibucaine number $15.92

82652 Vit d 1 25-dihydroxy $50.05

82656 Pancreatic elastase fecal $15.17

82657 Enzyme cell activity $23.49

82658 Enzyme cell activity ra $23.49

82664 ELECTROPHORETIC TECHNIQUE,NOS $44.68

82668 Assay of erythropoietin $24.44

82670 Assay of estradiol $36.34

82671 Assay of estrogens $42.01

82672 Assay of estrogen $20.02

82677 Assay of estriol $31.46

82679 Assay of estrone $32.47

82693 Assay of ethylene glycol $19.38

82696 Assay of etiocholanolone $30.68

82705 Fats/lipids feces qual $3.64

82710 Fats/lipids feces quant $21.84

82715 Assay of fecal fat $22.39

82725 Assay of blood fatty acids $18.34

82726 Long chain fatty acids $23.49

82728 Assay of ferritin $17.72

82731 Assay of fetal fibronectin $19.60

82735 Assay of fluoride $24.12

82746 Assay of folic acid serum $19.13

82747 Assay of folic acid rbc $21.43

82757 Assay of semen fructose $22.56

82759 Assay of rbc galactokinase $29.57

82760 Assay of galactose $14.56

CODE PROCEDURE FEE

82775 GALACTOSE-1-PO4 URIDYL TRANSFERASE $29.00

82776 GALACTOSE-1-PHOSPHATE URIDYL SCREEN $11.54

82784 Assay iga/igd/igg/igm each $12.10

82785 Assay of gammaglobulin ige $21.42

82787 Igg 1 2 3 or 4 each $23.42

82800 GASES,BLOOD,LH,ARTERIA OR RENOUS $11.02

82803 Blood gases any combination $25.93

82805 Blood gases w/o2 saturation $35.16

82810 Blood gases o2 sat only $8.67

82820 HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN SATU $12.35

82930 Gastric analy w/ph ea spec $6.74

82938 GASTRIN (SERUM) AFTER SECRETIN STIMULATION (EG, FOR GAS $23.02

82941 GASTRIN,RIA $22.94

82943 GLUCAGON,RIA $4.28

82945 Glucose other fluid $4.80

82946 GLUCAGON TOLERANCE TEST $19.60

82947 Assay glucose blood quant $4.76

82948 GLUCOSE,BLOOD,STICK TEST $3.83

82950 GLUCOSE,POST GLUCOSE TEST $5.76

82951 GLUCOSE TOLERANCE TEST,3 SPECIMENS $16.75

82952 GLUCOSE TOLERANCE TEST,E/ADDITIONAL $2.69

82955 Assay of g6pd enzyme $12.61

82960 G6PD SCREEN $7.88

82962 GLUCOSE, BLOOD, BY GLUCOSE MONITORING DEVICE(S) CLEARED $2.27

82963 Assay of glucosidase $27.95

82965 Assay of gdh enzyme $10.05

82977 GAMMA-GLUTAMYL TRANSPEPTIDASE (GGT) $9.37

82978 Assay of glutathione $19.61

82979 Assay rbc glutathione $9.46

82985 Assay of glycated protein $19.60

83001 Assay of gonadotropin (fsh) $24.17

83002 Assay of gonadotropin (lh) $24.09

83003 Assay growth hormone (hgh) $21.69

83009 H pylori (c-13) blood $88.57

83010 Assay of haptoglobin quant $16.35

83012 Assay of haptoglobins $22.36

83013 H pylori (c-13) breath $88.57

83014 H pylori drug admin/collect $10.22

83015 HEAVY METAL SCREEN, CHEMICAL $24.50

83018 Quantitative screen metals $28.57

83020 ELECTROPHORESIS HEMOGLOBIN $4.97

83021 Hemoglobin chromotography $23.49

83026 Hemoglobin copper sulfate $2.86

83030 Fetal hemoglobin chemical $10.76

83033 Fetal hemoglobin assay qual $7.76

83036 HEMOGLOBIN, GLYCOSYLATED $11.84

83037 Glycosylated hb home device $12.23

83045 HEMOGLOBIN,METHEMOGLOBIN,QUALITATIVE $6.01

83050 HEMOGLOBIN,METHEMOGLOBIN,QUANT. $4.77

83051 Assay of plasma hemoglobin $9.50

83060 HEMOGLOBIN,SULFHEMOGLOBIN,QUANT. $10.76

83065 Assay of hemoglobin heat $7.40

83068 HEMOGLOBIN,UNSTABLE,SCREEN $11.02

83069 Assay of urine hemoglobin $2.86

83070 Assay of hemosiderin qual $4.28

83080 Assay of b hexosaminidase $7.52

83088 Assay of histamine $34.23

83090 Assay of homocystine $22.18

83150 Assay of homovanillic acid $25.16

83491 Assay of corticosteroids 17 $22.78

83497 Assay of 5-hiaa $16.77

CODE PROCEDURE FEE

83498 Assay of progesterone 17-d $21.68

83499 Assay of progesterone 20- $32.78

83500 Assay free hydroxyproline $29.45

83505 Assay total hydroxyproline $31.61

83516 Immunoassay nonantibody $15.01

83518 Immunoassay dipstick $11.03

83519 Immunoassay, nonantibody $18.60

83520 IMMUNOASSAY, ANALYTE; NOT OTHERWISE SPECIFIED $16.84

83525 INSULIN,RIA $14.88

83527 INSULIN; FREE $16.85

83528 Assay of intrinsic factor $20.69

83540 Assay of iron $7.89

83550 IBC-SERUM-CHEMICAL * $10.87

83570 Assay of idh enzyme $10.13

83582 Assay of ketogenic steroids $18.44

83586 Assay 17- ketosteroids $16.65

83593 Fractionation ketosteroids $34.20

83605 Assay of lactic acid $13.89

83615 LDH-BLOOD-KINETIC ULTRAVIOLET * $7.86

83625 Assay of ldh enzymes $16.65

83630 Lactoferrin fecal (qual) $25.81

83631 Lactoferrin fecal (quant) $25.81

83632 LACTOGEN,PLACENTAL(HPL),RIA $26.28

83633 LACTOSE,URINE;QUALITATIVE $2.86

83655 Assay of lead $15.73

83661 L/s ratio fetal lung $28.59

83662 Foam stability fetal lung $25.01

83663 Fluoro polarize fetal lung $24.87

83664 Lamellar bdy fetal lung $24.87

83670 Assay of lap enzyme $11.92

83690 Assay of lipase $8.96

83695 Assay of lipoprotein(a) $17.03

83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 $44.64

83700 Lipopro bld electrophoretic $32.28

83701 Lipoprotein bld hr fraction $32.63

83704 Lipoprotein bld by nmr $41.49

83718 Assay of lipoprotein $11.26

83719 Assay of blood lipoprotein $15.13

83721 Assay of blood lipoprotein $12.40

83727 Assay of lrh hormone $22.36

83735 Assay of magnesium $8.71

83775 Assay malate dehydrogenase $9.59

83785 MANGANE-BLOOD OR URINE $23.81

83788 Mass spectrometry qual $23.49

83789 Mass spectrometry quant $23.49

83825 Assay of mercury $21.15

83835 Assay of metanephrines $20.02

83857 Assay of methemalbumin $14.78

83861 Microfluid analy tears $20.39

83864 MUCOPOLYSACCHARIDES-ACID-BLOOD $27.40

83872 MUCIN,SYNOVIAL FLUID (ROPE TEST) $7.62

83873 Assay of csf protein $22.38

83874 Assay of myoglobin $16.79

83876 Assay myeloperoxidase $41.90

83880 Assay of natriuretic peptide $44.64

83883 Assay nephelometry not spec $14.08

83885 Assay of nickel $31.87

83915 Assay of nucleotidase $14.50

83916 OLIGOCLONAL IMMUNE GLOBULIN $26.15

83918 Organic acids total quant $15.86

83919 Organic acids qual each $16.39

CODE PROCEDURE FEE

83921 Organic acid single quant $16.39

83930 Assay of blood osmolality $7.92

83935 Assay of urine osmolality $7.92

83937 Assay of osteocalcin $38.83

83945 Assay of oxalate $16.75

83950 Oncoprotein her-2/neu $84.69

83951 Oncoprotein dcp $86.83

83970 PARATHORMONE,RIA $53.68

83986 Assay of body fluid acidity $4.35

83987 Exhaled breath condensate $21.40

83992 PHENCYCLIDINE (PCP) $19.11

83993 Assay for calprotectin fecal $25.81

84030 Assay of blood pku $4.50

84035 Assay of phenylketones $4.28

84060 ACID PHOSPATASE-BLOOD * $9.60

84061 Phosphatase forensic exam $10.17

84066 PHOSPHATASE,ACID,BLD, PROST FRAC RIA $12.56

84075 ALKALINE PHOSPHATASE-BLOOD * $6.28

84078 PHOSPHATASE,HEAT STABLE $9.60

84080 ALKALINE PHOSPHATASE-FRACTIONATED $19.24

84081 Assay phosphatidylglycerol $21.50

84085 Assay of rbc pg6d enzyme $8.77

84087 PHOSPHOHEXOSE ISOMERASE $13.43

84100 Assay of phosphorus $5.76

84105 Assay of urine phosphorus $6.28

84106 PORPHOBILINOGEN-URINE-QUALITATIVE $3.64

84110 Assay of porphobilinogen $7.92

84112 Placenta alpha micro ig c/v $79.51

84119 PORPHYRINS,COPRO-,URINE;QUALITATIVE $11.20

84120 Assay of urine porphyrins $19.14

84126 Assay of feces porphyrins $33.13

84132 Assay of serum potassium $5.57

84133 Assay of urine potassium $5.21

84134 Assay of prealbumin $7.22

84135 Assay of pregnanediol $24.88

84138 Assay of pregnanetriol $24.62

84140 Assay of pregnenolone $10.52

84143 Assay of 17-hydroxypregneno $10.52

84144 Assay of progesterone $27.13

84145 Procalcitonin (pct) $30.79

84146 Assay of prolactin $25.21

84150 PROSTAGLANDIN,ANY ONE,RIA $7.40

84152 Assay of psa complexed $24.18

84153 Assay of psa total $23.92

84154 Assay of psa free $23.92

84155 Assay of protein serum $4.44

84156 Assay of protein urine $4.49

84157 Assay of protein other $4.49

84160 Assay of protein any source $4.28

84163 Pappa serum $19.79

84165 Protein e-phoresis serum $13.96

84166 Protein e-phoresis/urine/csf $23.46

84181 PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, $18.46

84182 Protein western blot test $18.46

84202 PROTOPORPHYRIN,RBC,QUANTITATIVE $18.66

84203 PROTOPORPHYRIN,SCREEN $7.40

84206 PROINSULIN,RIA $21.90

84207 Assay of vitamin b-6 $36.53

84210 Assay of pyruvate $11.97

84220 Assay of pyruvate kinase $11.97

84228 Assay of quinine $7.40

CODE PROCEDURE FEE

84233 Assay of estrogen $88.63

84234 Assay of progesterone $89.27

84235 Assay of endocrine hormone $68.05

84238 Assay nonendocrine receptor $47.56

84244 RENIN(RIA) $28.61


84255 Assay of selenium $33.20

84260 Assay of serotonin $40.28

84270 Assay of sex hormone globul $28.26

84275 Assay of sialic acid $17.47

84285 Assay of silica $30.63

84295 Assay of serum sodium $5.84

84300 Assay of urine sodium $5.90

84302 Assay of sweat sodium $5.95

84305 Assay of somatomedin $24.99

84307 Assay of somatostatin $22.74

84311 SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED $9.09

84315 SPECIF GRAVITY-EXCLUDING URINE $3.04

84375 Chromatogram assay sugars $25.49

84376 Sugars single qual $3.04

84377 Sugars multiple qual $3.04

84378 Sugars single quant $14.98

84379 Sugars multiple quant $14.98

84392 Assay of urine sulfate $5.76

84402 Assay of free testosterone $33.12

84403 Assay of total testosterone $33.58


84430 Assay of thiocyanate $11.14

84431 Thromboxane urine $17.45

84432 Assay of thyroglobulin $20.42

84436 Assay of total thyroxine $7.09

84437 Assay of neonatal thyroxine $8.29

84439 Assay of free thyroxine $9.00

84442 Assay of thyroid activity $11.84

84443 THYROID STIMULATING HORMONE,RIA $21.84

84445 Assay of tsi globulin $66.14

84446 Assay of vitamin e $18.44

84449 Assay of transcortin $23.40

84450 SGOT-TIMED KINETIC UV METHOD * $6.27

84460 SGPT-TIMED KINETIC UV METHOD * $6.89

84466 Assay of transferrin $16.61

84478 Assay of triglycerides $7.48

84479 Assay of thyroid (t3 or t4) $8.42

84480 Assay triiodothyronine (t3) $18.47

84481 TRIODOTHYRONINE, FT-3 RIA UNBOUND T3 $22.03

84482 T3 reverse $20.50

84484 Assay of troponin quant $8.70

84485 TRIPSIN-DUODENAL FLUID $9.76

84488 TRYPSIN-FECES-QUALITATIVE 24-HR $7.56

84490 Assay of feces for trypsin $9.90

84510 Assay of tyrosine $13.53

84512 Assay of troponin qual $10.01

84520 Assay of urea nitrogen $4.78

84525 BUN-STICK TEST * $2.86

84540 Assay of urine/urea-n $5.76

84545 UREA NITROGEN-URINE-CLEARANCE $8.58

84550 Assay of blood/uric acid $5.49

84560 Assay of urine/uric acid $5.76

84577 Assay of feces/urobilinogen $16.23

84578 UROBILINOGEN-URINE-QUALITATIVE $3.64

84580 Assay of urine urobilinogen $9.23

CODE PROCEDURE FEE

84583 Assay of urine urobilinogen $6.10

84585 Assay of urine vma $20.16

84586 Assay of vip $45.95

84588 Assay of vasopressin $44.15

84590 Assay of vitamin a $14.88

84591 Assay of nos vitamin $15.25

84597 Assay of vitamin k $17.83

84600 Assay of volatiles $10.48

84620 XYLOSE-TOLERANCE TEST-BLOOD $15.41

84630 Assay of zinc $14.82

84681 Assay of c-peptide $27.06

84702 GONADOTROPIN, CHORIONIC; QUANTITATIVE $19.58

84703 GONADOTROPIN, CHORIONIC; QUALITATIVE $9.77

84704 Hcg free betachain test $19.79

84830 OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR $13.06

85002 BLEEDING TIME;IVY $5.46

85004 Automated diff wbc count $8.50

85007 BLOOD COUNT;DIFFERENTIAL WBC COUNT $4.18

85008 BLOOD COUNT; MANUAL BLOOD SMEAR EXAMINATION WITHOUT DIF $4.18

85009 DIFFERENTIAL WBC COUNT,BUFFY COAT $4.51

85013 Spun microhematocrit $2.86

85014 BLOOD COUNT HEMATOCRIT $2.86

85018 BLOOD COUNT,HEMOGLOBIN,COLORIMETRIC $2.86

85025 BLOOD COUNT; HEMOGRAM AND PLATELET COUNT, AUTOMATED, AN $10.11

85027 Complete cbc automated $8.42

85032 Manual cell count each $5.27

85041 BLOOD COUNT, RED BLOOD CELL (RBC) $3.65

85044 BLOOD COUNT,RETICULOCYTE COUNT $5.21

85045 BLOOD COUNT RETICULOCYTE COUNT, FLOW CYTOMETRY $4.86

85046 Reticyte/hgb concentrate $7.26

85048 BLOOD COUNT,WHITE BLOOD CELL (WBC) $3.04

85049 Automated platelet count $5.49

85055 Reticulated platelet assay $23.79

85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WI $9.67

85097 BONE MARROW SMEAR AND/OR CELL BLOCK; SMEAR INTERPRETATI $37.41

85130 CHROMOGENIC SUBSTRATE ASSAY $9.00

85170 CLOT RETRACTION $2.86

85175 CLOT LYSIS TIME $5.51

85210 Clot factor ii prothrom spec $17.87

85220 Blooc clot factor v test $22.95

85230 Clot factor vii proconvertin $23.29

85240 Clot factor viii ahg 1 stage $23.29

85244 Clot factor viii reltd antgn $26.55

85245 Clot factor viii vw ristoctn $29.85

85246 Clot factor viii vw antigen $29.85

85247 Clot factor viii multimetric $29.85

85250 Clot factor ix ptc/chrstmas $24.76

85260 Clot factor x stuart-power $23.29

85270 Clot factor xi pta $23.29

85280 Clot factor xii hageman $26.63

85290 Clot factor xiii fibrin stab $21.25

85291 Clot factor xiii fibrin scrn $11.56

85292 Clot factor fletcher fact $24.63

85293 Clot factor wght kininogen $24.63

85300 Antithrombin iii activity $15.86

85301 Antithrombin iii antigen $14.07

85302 Clot inhibit prot c antigen $15.63

85303 Clot inhibit prot c activity $18.19

85305 Clot inhibit prot s total $15.08

85306 Clot inhibit prot s free $14.99

85307 Assay activated protein c $15.49

CODE PROCEDURE FEE

85335 FACTOR INHIBITOR TEST $15.86

85337 THROMBOMODULIN $13.56

85345 Coagulation time lee & white $4.06

85347 Coagulation time activated $5.15

85348 Coagulation time otr method $4.51

85360 EUGLOBULIN $10.93

85362 FIBRIN DEGRADATION;AGGLUTINATION $8.96

85366 FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP)(FSP); P $7.40

85370 FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP)(FSP); Q $14.77

85378 Fibrin degrade semiquant $9.28

85379 Fibrin degradation quant $10.32

85380 Fibrin degradj d-dimer $10.65

85384 Fibrinogen activity $11.05

85385 Fibrinogen antigen $11.05

85390 Fibrinolysins screen i&r $6.26

85396 Clotting assay whole blood $14.92

85397 Clotting funct activity $30.94

85400 FIBRINOLYTIC MECHANISMS-PLASMIN $12.18

85410 FIBRINULYTIC MECHANISMS-ANTIPLASMIN $10.61

85415 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVA $22.36

85420 FIBRINOLYTIC MECHANISMS-PLASMINOGEN $8.50

85421 FIBRINOLYTIC MECHANISMS; PLASMINOGEN, ANTIGENIC ASSAY $13.25

85441 Heinz bodies direct $5.10

85445 Heinz bodies induced $8.86

85460 Hemoglobin fetal $10.06

85461 Hemoglobin fetal $8.63

85475 Hemolysin acid $11.54

85520 HEPARIN ASSAY $17.03

85525 Heparin neutralization $15.42

85530 HEPARIN-PROOTAMINE TOLRANCE TEST $18.44

85536 Iron stain peripheral blood $8.50

85540 LEUKOCYTE ALKALINE PHOSPHATE $7.92

85547 MECHANICAL FRAGILITY,RBC $11.18

85549 MURAMIDASE,SERUM $24.39

85555 OSMOTIC FRAGILITY,RBC $8.69

85557 OSMOTIC FRAGILITY,RBC;INCUBATED,QUAN $17.38

85576 PLATELET, AGGREGATION (IN VITRO), ANY AGENT $18.34

85597 PLATELET NEUTRALIZATION $19.59

85598 Hexagnal phosph pltlt neutrl $18.98

85610 PROTHROMBIN TIME $4.76

85611 PROTHROMBIN TIME; SUBSTITUTION, PLASMA FRACTIONS, EACH $4.78

85612 PROTHROMBIN TIME;RUSSELL VIPER VENOM $13.16

85613 Russell viper venom diluted $13.16

85635 REPTILASE TEST $12.22

85651 Rbc sed rate nonautomated $4.31

85652 Rbc sed rate automated $3.27

85660 SICKLE CELL TEST $7.18

85670 Thrombin time plasma $7.51

85675 Thrombin time titer $8.91

85705 THROMBOPLASTIN INHIBITION; TISSUE $7.41

85730 Thromboplastin time partial $7.81

85732 Thromboplastin time partial $8.42

85810 BLOOD VISCOSITY EXAMINATION $12.19

86000 Agglutinins febrile antigen $9.08

86001 Allergen specific igg $5.87

86003 ALLERGEN SPECIFIC IGE; QUANTITATIVE, EACH PANEL OF UP T $5.81

86005 ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREE $9.10

86021 ANTIBODY IDENTIFICATION,LEUKOCYTE $16.33

86022 ANTIBODY IDENTIFICATION,PLATELET $16.29

86023 ANTIBODY IDENTIFICATION; PLATELET ASSOCIATED IMMUNOGLO $14.78

86038 ANTI NUCLEAR ANTIBODIES (ANA) RIA $15.72

CODE PROCEDURE FEE

86039 ANTINUCLEAR ANTIBODIES (ANA); TITER $13.51

86060 Antistreptolysin o titer $9.49

86063 Antistreptolysin o screen $5.24

86077 Phys blood bank serv xmatch $38.52

86078 Phys blood bank serv reactj $38.78

86079 Phys blood bank serv authrj $38.78

86140 C-REACTIVE PROTEIN $4.71

86141 C-reactive protein hs $17.03

86146 Beta-2 glycoprotein antibody $21.09

86147 Cardiolipin antibody ea ig $20.42

86148 Anti-phospholipid antibody $20.90

86155 CHEMOTAXIS ASSAY $15.85

86156 Cold agglutinin screen $7.70

86157 Cold agglutinin titer $7.70

86160 Complement antigen $14.47

86161 COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT $14.47

86162 Complement total (ch50) $26.43

86171 Complement fixation each $13.03

86185 COUNTERELECTROPHORESIS,E/ANTIGEN $11.64

86200 Ccp antibody $17.03

86215 Deoxyribonuclease antibody $17.24

86225 Dna antibody native $17.87

86226 Dna antibody single strand $15.74

86235 EXTRACTABLE NUCLEAR ANTIGEN,ANTIBODY $23.32

86243 FC RECEPTOR ASSAY $7.40

86255 Fluorescent antibody screen $15.68

86256 Fluorescent antibody titer $13.51

86277 GROWTH HORMONE,HUMAN(HGH)ANTIBDY RIA $20.47

86280 HEMAGGLUTINATION INHIBITION $10.64

86294 Immunoassay tumor qual $25.80

86300 Immunoassay tumor ca 15-3 $27.36

86301 Immunoassay tumor ca 19-9 $27.36

86304 Immunoassay tumor ca 125 $27.36

86305 Human epididymis protein 4 $28.05

86308 Heterophile antibody screen $6.73

86309 Heterophile antibody titer $8.43

86310 Heterophile antibody absrbj $9.59

86316 Immunoassay tumor other $27.07

86317 Immunoassay infectious agent $19.50

86318 Immunoassay infectious agent $16.84

86320 IMMUNDELETROPHORESIS-SERUM $18.02

86325 IMMUIOELECTROPHORESIS-URINE $17.39

86327 IMMUNOELECTROPHORESIS; CROSSED (2 DIMENSIONAL ASSAY) $20.87

86329 Immunodiffusion nes $18.26

86331 IMMUNODIFFUSION;GEL DIFFUSION QUAL $16.50

86332 IMMUNE COMPLEX ASSAY C1Q BINDING CELL $31.70

86334 Immunofix e-phoresis serum $18.02

86335 Immunfix e-phorsis/urine/csf $38.59

86336 Inhibin A $17.03

86337 INSULIN ANTIBODIES, RIA $27.95

86340 INTRINSIC FACTOR ANTIBODIES, RIA $19.60

86341 ISLET CELL ANTIBODY $25.73

86343 LEUKOCYTE HISTAMINE RELEASE TEST $16.21

86344 LEUKOCYTE PHAGOCYTOSIS $10.39

86352 Cell function assay w/stim $91.57

86353 LYMPHOCYTE TRANSFORMATION $63.76

86355 B cells total count $49.60

86356 Mononuclear cell antigen $23.79

86357 Nk cells total count $49.60

86359 T cells total count $49.06

86360 T cell absolute count/ratio $58.00

CODE PROCEDURE FEE

86361 T cell absolute count $23.53

86367 Stem cells total count $49.60

86376 Microsomal antibody each $18.93

86378 MIGRATION INHIBITORY FACTOR TEST $27.09

86382 Neutralization test viral $21.98

86384 NITROBLUE TETRAZOLIUM DYE TEST (NTD) $14.82

86403 Particle agglut antbdy scrn $13.25

86406 Particle agglut antbdy titr $13.84

86430 Rheumatoid factor test qual $7.40

86431 Rheumatoid factor quant $7.40

86480 Tb test, cell immun measure $75.93

86481 Tb ag response t-cell susp $92.49

86485 Skin test candida $7.41

86486 Skin test nos antigen $3.41

86490 SENSITIVITY TEST-COCCIDIOIDOMYCOCCIS $6.87

86510 SENSITIVITY TEST-HISTOPLASMOSIS $7.37

86580 SENSITIVITY TEST-TUBERCULOSIS $5.17

86590 Streptokinase antibody $14.34

86592 SYPHILIS,QUALITATIVE $5.17

86593 SYPHILIS,QUANTITATIVE $5.34

86602 ANTIBODY; ACTINOMYCES $13.23

86603 Adenovirus antibody $14.29

86606 ANTIBODY; ASPIRGILLUS $7.41

86609 Bacterium antibody $16.76

86611 Bartonella antibody $13.38

86612 Blastomyces antibody $14.29

86615 ANTIBODY; BORDETELLA $17.16

86617 Lyme disease antibody $20.14

86618 ANTIBODY; BORELLIA BUFGDORFERI (LYME DISEASE) $22.69

86619 ANTIBODY; BORRELIA (RELAPSING FEVER) $17.40

86622 Brucella antibody $10.42

86625 Campylobacter antibody $17.06

86628 Candida antibody $7.41

86631 Chlamydia antibody $13.51

86632 Chlamydia igm antibody $13.51

86635 Coccidioides antibody $14.29

86638 ANTIBODY; COXIELLA BRUNETII (Q FEVER) $14.29

86641 ANTIBODY; CRYPTOCOCCUS $18.34

86644 ANTIBODY; CYTOMEGALOVIRUS (CMV) $18.71

86645 Cmv antibody igm $13.51

86648 ANTIBODY; DIPTHERIA $19.78

86651 Encephalitis californ antbdy $13.51

86652 Encephaltis east eqne anbdy $13.51

86653 Encephaltis st louis antbody $13.51

86654 Encephaltis west eqne antbdy $13.51

86658 Enterovirus antibody $14.29

86663 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA) $13.51

86664 Epstein-barr nuclear antigen $13.51

86665 Epstein-barr capsid vca $13.51

86666 Ehrlichia antibody $13.38

86668 ANTIBODY; FRANCISELLA TULARENSIS $9.24

86671 Fungus nes antibody $14.29

86674 Giardia lamblia antibody $13.51

86677 Helicobacter pylori antibody $18.87

86682 Helminth antibody $13.17

86684 Hemophilus influenza antibdy $18.34

86687 Htlv-i antibody $10.92

86688 Htlv-ii antibody $12.71

86689 Htlv/hiv confirmj antibody $25.17

86692 Hepatitis delta agent antbdy $22.69

86694 Herpes simplex nes antbdy $18.71

CODE PROCEDURE FEE

86695 Herpes simplex type 1 test $13.51

86696 Herpes simplex type 2 test $18.71

86698 Histoplasma antibody $14.29

86701 Hiv-1antibody $11.56

86702 Hiv-2 antibody $12.71

86703 Hiv-1/hiv-2 1 result antbdy $12.71

86704 Hep b core antibody total $15.68

86705 Hep b core antibody igm $15.31

86706 Hep b surface antibody $13.96

86707 Hepatitis be antibody $15.04

86708 Hepatitis a total antibody $16.11

86709 Hepatitis a igm antibody $14.64

86710 Influenza virus antibody $13.51

86711 John cunningham antibody $17.77

86713 Legionella antibody $13.51

86717 Leishmania antibody $13.51

86720 Leptospira antibody $17.16

86723 Listeria monocytogenes $17.16

86727 Lymph choriomeningitis ab $14.29

86729 Lympho venereum antibody $13.51

86732 Mucormycosis antibody $7.41

86735 Mumps antibody $13.51

86738 Mycoplasma antibody $17.23

86741 ANTIBODY; NEISSERIA MENINGITIDIS $17.16

86744 Nocardia antibody $17.16

86747 Parvovirus antibody $19.55

86750 Malaria antibody $17.16

86753 Protozoa antibody nos $13.17

86756 Respiratory virus antibody $13.51

86757 Rickettsia antibody $23.89

86759 Rotavirus antibody $17.16

86762 Rubella antibody $18.71

86765 Rubeola antibody $13.51

86768 Salmonella antibody $17.16

86771 Shigella antibody $17.16

86774 Tetanus antibody $19.24

86777 Toxoplasma antibody $18.71

86778 Toxoplasma antibody igm $13.51

86780 Treponema pallidum $17.85

86784 Trichinella antibody $7.41

86787 Varicella-zoster antibody $13.51

86788 West nile virus ab igm $13.51

86789 WEST NILE VIRUS $18.93

86790 Virus antibody nos $13.51

86793 Yersinia antibody $17.16

86800 THYROGLOBULIN ANTIBODY, RIA $20.69

86803 Hepatitis c ab test $18.57

86804 Hep c ab test confirm $20.14

86805 LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH WITH TITRAT $68.01

86806 LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH WITHOUT TIT $61.89

86807 SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY $51.47

86808 SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY $38.61

86812 Hla typing a b or c $33.56

86813 Hla typing a b or c $75.41

86816 Hla typing dr/dq $36.23

86817 Hla typing dr/dq $83.74

86821 Lymphocyte culture mixed $73.44

86822 Lymphocyte culture primed $47.54

86880 Coombs test direct $6.99

86885 Coombs test indirect qual $7.44

86886 Coombs test indirect titer $6.73

CODE PROCEDURE FEE

86900 Blood typing serologic abo $3.62

86901 Blood typing serologic rh(d) $7.24

86902 Blood type antigen donor ea $4.71

86904 Blood typing patient serum $12.37

86905 Blood typing rbc antigens $4.63

86906 Bld typing serologic rh phnt $10.67

86940 Hemolysins/agglutinins auto $7.71

86941 HEMOLYSINS AND AGGLUTININS, AUTO, SCREEN, EACH; INCUBAT $12.53

87003 ANIMAL INOCULATION $21.89

87015 Specimen infect agnt concntj $8.68

87040 CULTURE,BACTERIAL;BLOOD $11.84

87045 Feces culture aerobic bact $4.71

87046 Stool cultr aerobic bact ea $5.07

87070 Culture othr specimn aerobic $11.20

87071 Culture aerobic quant other $5.03

87073 Culture bacteria anaerobic $5.03

87075 Cultr bacteria except blood $11.84

87076 Culture anaerobe ident each $12.20

87077 Culture aerobic identify $10.62

87081 CULTURE,BACTERIAL,SCREENING $5.34

87084 CULTURE PRESUM PATHOGENIC ORGANISMS $11.20

87086 Urine culture/colony count $10.02

87088 CULTURE,URINE;IDENTIFICATION $7.92

87101 CULTURE,FUNGI,ISOLATION;SKIN $10.03

87102 CULTURE,FUNGI,ISOLATION;OTHER SOURCE $5.77

87103 CULTURE, FUNGI, ISOLATION BLOOD $11.19

87106 Fungi identification yeast $5.77

87107 Fungi identification mold $6.16

87109 Mycoplasma $20.01

87110 CULTURE, CHLAMYDIA $25.43

87116 CULTURE,ACID-FAST BACILLI,ISOLATION $14.05

87118 CULTURE,DEFINITIVE IDENTIFICATION $14.24

87140 Culture type immunofluoresc $7.26

87143 Culture typing glc/hplc $16.30

87147 Culture type immunologic $6.73

87149 Culture type, nucleic acid $24.76

87150 Dna/rna amplified probe $47.31

87152 Culture type pulse field gel $6.88

87153 Dna/rna sequencing $155.49

87158 Culture typing added method $6.81

87164 DARK FIELD EXAMINATION $11.14

87166 DARK FIELD EXAM,W/O COLLECTION $2.03

87168 Macroscopic exam arthropod $5.03

87169 Macroscopic exam parasite $5.03

87172 Pinworm exam $5.03

87176 ENDOTOXIN,BACTERIAL;HOMOGENIZATION $7.65

87177 OVA AND PARASITES,DIRECT SMEARS $11.58

87181 Microbe susceptible diffuse $5.76

87184 Microbe susceptible disk $8.97

87185 Microbe susceptible enzyme $5.83

87186 Microbe susceptible mic $11.23

87187 Microbe susceptible mlc $13.49

87188 Microbe suscept macrobroth $8.63

87190 Microbe suscept mycobacteri $7.35

87197 Bactericidal level serum $19.54

87205 Smear gram stain $5.17

87206 Smear fluorescent/acid stai $6.99

87207 Smear special stain $7.79

87209 Smear complex stain $22.19

87210 Smear wet mount saline/ink $4.71

87220 TISSUE EXAMINATION FOR FUNGI (KOH) $5.21

CODE PROCEDURE FEE

87230 Assay toxin or antitoxin $25.67

87250 Virus inoculate eggs/animal $26.90

87252 Virus inoculation tissue $35.88

87253 Virus inoculate tissue addl $27.79

87254 Virus inoculation shell via $25.71

87255 Genet virus isolate hsv $44.52

87260 Adenovirus ag if $14.81

87265 Pertussis ag if $15.61

87267 Enterovirus antibody dfa $15.77

87269 Giardia ag if $15.77

87270 Chlamydia trachomatis ag if $15.61

87271 Cytomegalovirus dfa $15.77

87272 Cryptosporidium ag if $15.61

87273 Herpes simplex 2 ag if $15.77

87274 Herpes simplex 1 ag if $16.16

87275 Influenza b ag if $14.81

87276 Influenza a ag if $15.61

87277 Legionella micdadei ag if $15.77

87278 Legion pneumophilia ag if $15.61

87279 Parainfluenza ag if $14.81

87280 Respiratory syncytial ag if $14.81

87281 Pneumocystis carinii ag if $15.77

87283 Rubeola ag if $15.77

87285 Treponema pallidum ag if $15.61

87290 Varicella zoster ag if $16.16

87299 Antibody detection nos if $15.77

87300 Ag detection polyval if $15.77

87301 Adenovirus ag eia $15.61

87305 Aspergillus ag eia $15.77

87320 Chylmd trach ag eia $15.77

87324 Clostridium ag eia $15.61

87327 Cryptococcus neoform ag eia $15.77

87328 Cryptosporidium ag eia $15.61

87329 Giardia ag eia $15.77

87332 Cytomegalovirus ag eia $15.61

87335 E coli 0157 ag eia $15.61

87336 Entamoeb hist dispr ag eia $15.77

87337 Entamoeb hist group ag eia $15.77

87338 Hpylori stool eia $15.77

87339 H pylori ag eia $15.77

87340 Hepatitis b surface ag eia $12.58

87341 Hepatitis b surface ag eia $12.72

87350 Hepatitis be ag eia $14.98

87380 Hepatitis delta ag eia $21.35

87385 Histoplasma capsul ag eia $15.61

87389 Hiv-1 ag w/hiv-1 & hiv-2 ab $27.03

87390 Hiv-1 ag eia $23.20

87391 Hiv-2 ag eia $22.94

87400 Influenza a/b ag eia $15.77

87420 Resp syncytial ag eia $15.61

87425 Rotavirus ag eia $15.61

87427 Shiga-like toxin ag eia $15.77

87430 Strep a ag eia $15.77

87449 Ag detect nos eia mult $15.61

87450 Ag detect nos eia single $12.47

87451 Ag detect polyval eia mult $12.60

87470 Bartonella dna dir probe $26.08

87471 Bartonella dna amp probe $45.65

87472 Bartonella dna quant $55.71

87475 Lyme dis dna dir probe $26.08

87476 Lyme dis dna amp probe $45.65

CODE PROCEDURE FEE

87477 Lyme dis dna quant $55.71

87480 Candida dna dir probe $26.08

87481 Candida dna amp probe $45.65

87482 Candida dna quant $54.29

87485 Chylmd pneum dna dir probe $26.08

87486 Chylmd pneum dna amp probe $45.65

87487 Chylmd pneum dna quant $55.71

87490 Chylmd trach dna dir probe $24.76

87491 Chylmd trach dna amp probe $43.32

87492 Chylmd trach dna quant $45.47

87493 C diff amplified probe $45.14

87495 Cytomeg dna dir probe $26.08

87496 Cytomeg dna amp probe $45.65

87497 Cytomeg dna quant $55.71

87498 Enterovirus dna amp probe $46.15

87500 Vanomycin dna amp probe $46.15

87501 Influenza dna amp prob 1+ $63.34

87502 Influenza dna amp probe $105.03

87503 Influenza dna amp prob addl $25.64

87510 Gardner vag dna dir probe $26.08

87511 Gardner vag dna amp probe $45.65

87512 Gardner vag dna quant $54.29

87515 Hepatitis b dna dir probe $26.08

87516 Hepatitis b dna amp probe $45.65

87517 Hepatitis b dna quant $55.71

87520 Hepatitis c rna dir probe $26.08

87521 Hepatitis c rna amp probe $45.65

87522 Hepatitis c rna quant $55.71

87525 Hepatitis g dna dir probe $26.08

87526 Hepatitis g dna amp probe $45.65

87527 Hepatitis g dna quant $54.29

87528 Hsv dna dir probe $26.08

87529 Hsv dna amp probe $45.65

87530 Hsv dna quant $55.71

87531 Hhv-6 dna dir probe $26.08

87532 Hhv-6 dna amp probe $45.65

87533 Hhv-6 dna quant $54.29

87534 Hiv-1 dna dir probe $26.08

87535 Hiv-1 dna amp probe $45.65

87536 Hiv-1 dna quant $110.66

87537 Hiv-2 dna dir probe $26.08

87538 Hiv-2 dna amp probe $45.65

87539 Hiv-2 dna quant $55.71

87540 Legion pneumo dna dir prob $26.08

87541 Legion pneumo dna amp prob $45.65

87542 Legion pneumo dna quant $54.29

87550 Mycobacteria dna dir probe $26.08

87551 Mycobacteria dna amp probe $45.65

87552 Mycobacteria dna quant $55.71

87555 M.tuberculo dna dir probe $26.08

87556 M.tuberculo dna amp probe $45.65

87557 M.tuberculo dna quant $55.71

87560 M.avium-intra dna dir prob $26.08

87561 M.avium-intra dna amp prob $45.65

87562 M.avium-intra dna quant $55.71

87580 M.pneumon dna dir probe $26.08

87581 M.pneumon dna amp probe $45.65

87582 M.pneumon dna quant $54.29

87590 N.gonorrhoeae dna dir prob $24.76

87591 N.gonorrhoeae dna amp prob $40.18

87592 N.gonorrhoeae dna quant $55.71

CODE PROCEDURE FEE

87631 Resp virus 3-5 targets $158.35



87640 Staph a dna amp probe $46.15

87641 Mr-staph dna amp probe $46.15

87650 Strep a dna dir probe $26.08

87651 Strep a dna amp probe $45.65

87652 Strep a dna quant $54.29

87653 Strep b dna amp probe $46.15

87660 Trichomonas vagin dir probe $26.37

87797 Detect agent nos dna dir $24.76

87798 Detect agent nos dna amp $46.15

87799 Detect agent nos dna quant $55.71

87800 Detect agnt mult dna direc $49.52

87801 Detect agnt mult dna ampli $92.30

87802 Strep b assay w/optic $15.77

87803 Clostridium toxin a w/optic $15.77

87804 Influenza assay w/optic $15.77

87807 Rsv assay w/optic $15.77

87808 TRICHOMONAS VAGINALIS $15.77

87809 Adenovirus assay w/optic $15.77

87810 Chylmd trach assay w/optic $15.61

87850 N. gonorrhoeae assay w/optic $15.61

87880 Strep a assay w/optic $15.77

87899 Agent nos assay w/optic $15.61

87900 Phenotype infect agent drug $175.69

87902 Genotype dna/rna hep c $317.78

87903 Phenotype dna hiv w/culture $658.66

87904 Phenotype dna hiv w/clt add $34.28

87905 Sialidase enzyme assay $16.09

87906 Genotype dna hiv reverse t $158.89

87910 Genotype cytomegalovirus $317.78

87912 Genotype dna hepatitis b $317.78

88104 Cytopath fl nongyn smears $18.82

88106 Cytopath fl nongyn filter $58.87

88108 Cytopath concentrate tech $18.82

88112 Cytopath cell enhance tech $79.68

88120 Cytp urne 3-5 probes ea spec $382.65

88121 Cytp urine 3-5 probes cmptr $329.84

88125 CYTOPATHOLOGY,FORENSIC $17.88

88130 CYTOLOGY SMEAR-BUCCAL $20.71

88140 CYTOLOGY SMEAR-WBC-FOR CHROMOSOMS $10.78

88141 Cytopath c/v interpret $13.74

88142 Cytopath c/v thin layer $20.80

88143 Cytopath c/v thin layer redo $13.74

88147 Cytopath c/v automated $13.74

88148 Cytopath c/v auto rescreen $13.74

88150 Cytopath c/v manual $13.74

88152 Cytopath c/v auto redo $13.74

88153 Cytopath c/v redo $13.74

88154 Cytopath c/v select $13.74

88155 Cytopath c/v index add-on $7.79

88160 Cytopath smear other source $14.12



88164 Cytopath tbs c/v manual $12.81

88165 Cytopath tbs c/v redo $13.74

88166 Cytopath tbs c/v auto redo $13.74

88167 Cytopath tbs c/v select $13.74

88172 EVALUATION OF FINE NEEDLE ASPIRATE WITH OR WITHOUT PREP $42.64

88173 Cytopath eval fna report $112.23

CODE PROCEDURE FEE

88174 Cytopath c/v auto in fluid $28.09

88175 Cytopath c/v auto fluid redo $34.83

88177 Cytp fna eval ea addl $22.28

88182 FLOW CYTOMETRY; CELL CYCLE OR DNA ANALYSIS $82.53

88184 Flowcytometry/ tc 1 marker $60.05

88185 Flowcytometry/tc add-on $35.70

88187 Flowcytometry/read 2-8 $54.36

88188 Flowcytometry/read 9-15 $67.23

88189 Flowcytometry/read 16 & > $82.80

88199 UNLISTED CYTOPATHOLOGY PROCEDURE $26.32

88230 Tissue culture lymphocyte $160.33

88233 Tissue culture skin/biopsy $183.04

88235 Tissue culture placenta $191.52

88237 Tissue culture bone marrow $164.27

88239 Tissue culture tumor $191.88

88240 Cell cryopreserve/storage $13.14

88241 Frozen cell preparation $13.14

88245 Chromosome analysis 20-25 $193.60


88249 Chromosome analysis 100 $225.23





88267 Chromosome analys placenta $233.81

88269 Chromosome analys amniotic $216.31

88271 Cytogenetics dna probe $3.07

88272 Cytogenetics 3-5 $34.82

88273 Cytogenetics 10-30 $42.24

88274 Cytogenetics 25-99 $45.27

88275 Cytogenetics 100-300 $52.23

88280 CHROMOSOME ANALYSIS,KARYOTYPING $32.63

88283 CHROMOSOME ANALYSIS ADDITIONAL SPECIALIZED BANDING TECH $89.21

88285 Chromosome count additional $26.15

88289 Chromosome study additional $47.38

88291 Cyto/molecular report $4.86

88300 Surgical path gross $11.30

88302 SURGICAL PATH-GROSS AND MICRO $14.12

88304 SURGICAL PATH-GROSS AND MICRO $13.47

88305 LEVEL IV - SURGICAL PATHOLOGY, GROSS & MICRO EXAM $13.47

88307 COMPLEX EX.MULT.TISSUES-SLIDES $13.47

88309 COMP.DIAG.EXAM. $18.82

88311 DECALCIFICATION PROCEDURE $14.12

88312 SPEC.STAINS;GROUP 1 FOR MICROORGAN. $75.65

88313 SPECIAL STAINS GROUP II $53.09

88314 Histochemical stains add-on $11.30

88319 DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY ENZYME CONSTIT $65.50

88321 SURGICAL PATH-CONSULT $18.82

88323 CONS.&RPT.REF.MATERIALS PREP.SLIDES $110.86

88325 SURGICAL PATH-CONSULT-COMPREHENSIVE $159.01

88329 Path consult introp $32.94

88331 Path consult intraop 1 bloc $74.82

88332 Path consult intraop, addl $14.12

88333 Intraop cyto path consult 1 $73.01

88334 Intraop cyto path consult, 2 $44.53

88342 Immunohisto antibody stain $85.19

88346 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY $80.42

88347 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY INDIRECT METHOD $59.69

88348 ELECTRON MICROSCOPY:DIAGNOSTIC $112.93

88355 Analysis skeletal muscle $156.80

88356 Analysis nerve $220.35

CODE PROCEDURE FEE

88358 Analysis tumor $62.50

88360 Tumor immunohistochem/manual $93.75

88361 Immunohistochemistry, tumor $114.40

88362 NERVE TEASING PREPARATIONS $244.28

88365 TISSUE IN SITU HYBRIDIZATION, INTERPRETATION AND REPORT $133.96

88367 Insitu hybridization auto $213.47

88368 Insitu hybridization manual $178.81

88371 Protein western blot tissue $28.28

88372 PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERP $25.15

88380 Microdissection laser $147.45

88381 Microdissection manual $130.40

88720 Bilirubin total transcut $6.30

88738 Hgb quant transcutaneous $6.77

88740 Transcutaneous carboxyhb $6.77

88741 Transcutaneous methb $6.77

89049 Chct for mal hyperthermia $187.17

89050 BODY FLUID CELL COUNT $4.71

89051 BODY FLUID CELL COUNT W/DIFF $5.97

89055 Leukocyte assessment fecal $5.23

89060 Exam synovial fluid crystals $9.29

89125 FAT STAIN,FECES,URINE,SPUTUM $3.73

89160 MEAT FIBERS, FECES $4.46

89190 NASAL SMEAR FOR EOSINOPHILS $5.76

89220 Sputum specimen collection $11.05

89230 Collect sweat for test $2.20

NOTE: Fee schedules are subject to review and amendment under

the provisions of § 67:16:01:28. A provider may request that the

department review a particular reimbursement rate for possible

adjustment or request the inclusion or exclusion of a particular code

from the list. When reviewing the requests, the department shall review

paid claims information, Medicare fee schedules, national coding lists,

and documentation submitted by the provider or the associated medical

professional organization to determine whether a change is warranted.

outpatient hospital laboratory non-critical … lab non... · 82482 assay rbc cholinesterase $9.99...

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