2019 clinical diagnostic laboratory fee schedule cpt codes ... clinical lab fee schedule (2).pdf ·...

2019 Clinical Diagnostic Laboratory Fee Schedule

CPT codes, descriptions and other data only are copyright 2016 American Medical Association. All rights reserved.

CPT is a registered trademark of the American Medical Association (AMA).

Effective 04/01/19 - 03/31/20

New Procedure Codes for 2019 are effective as of 01/01/19

HCPCS Modifier SHORTDESC WV Medicaid

36415 Routine venipuncture 3.00

78267 Breath tst attain/anal c-14 9.95

78268 Breath test analysis c-14 84.97

80047 Metabolic panel ionized ca 12.36

80047 QW Metabolic panel ionized ca 12.36

80048 Metabolic panel total ca 8.46

80048 QW Metabolic panel total ca 9.40

80050 General health panel 45.12

80051 Electrolyte panel 7.01

80051 QW Electrolyte panel 7.79

80053 Comprehen metabolic panel 10.57

80053 QW Comprehen metabolic panel 11.74

80055 Obstetric panel 47.81

80061 Lipid panel 13.39

80061 QW Lipid panel 14.88

80069 Renal function panel 8.69

80069 QW Renal function panel 9.65

80074 Acute hepatitis panel 47.64

80076 Hepatic function panel 8.17

80081 Obstetric panel 74.86

80150 Assay of amikacin 15.08

80155 Drug assay caffeine 34.71

80156 Assay carbamazepine total 14.56

80157 Assay carbamazepine free 13.26

80158 Drug assay cyclosporine 18.05

80159 Drug assay clozapine 18.50

80162 Assay of digoxin total 13.28

80163 Assay of digoxin free 13.28

80164 Assay dipropylacetic acd tot 13.55

80165 Dipropylacetic acid free 13.55

80168 Assay of ethosuximide 16.34

80169 Drug assay everolimus 13.73

80170 Assay of gentamicin 16.38

80171 Drug screen quant gabapentin 19.50

80173 Assay of haloperidol 14.56

80175 Drug screen quan lamotrigine 13.26

80176 Assay of lidocaine 14.69

80177 Drug scrn quan levetiracetam 13.26

80178 Assay of lithium 6.62

80178 QW Assay of lithium 7.34

80180 Drug scrn quan mycophenolate 18.05

80183 Drug scrn quant oxcarbazepin 13.26

80184 Assay of phenobarbital 13.77

80185 Assay of phenytoin total 13.26

80186 Assay of phenytoin free 13.76

80188 Assay of primidone 16.60

80190 Assay of procainamide 54.00

1

34




Effective 04/01/19 - 03/31/20



80192 Assay of procainamide 16.75

80194 Assay of quinidine 14.60

80195 Assay of sirolimus 13.73

80197 Assay of tacrolimus 13.73

80198 Assay of theophylline 14.14

80199 Drug screen quant tiagabine 24.40

80200 Assay of tobramycin 16.13

80201 Assay of topiramate 11.92

80202 Assay of vancomycin 13.55

80203 Drug screen quant zonisamide 13.26

80299 Quantitative assay drug 16.78

80305 Drug test prsmv dir opt obs 11.34

80306 Drug test prsmv instrmnt 15.43

80307 Drug test prsmv chem anlyzr 58.19

80400 Acth stimulation panel 32.62



80408 Aldosterone suppression eval 125.50

80410 Calcitonin stimul panel 26.79

80412 Crh stimulation panel 721.46

80414 Testosterone response 51.63

80415 Estradiol response panel 55.88

80416 Renin stimulation panel 188.39

80417 Renin stimulation panel 43.99

80418 Pituitary evaluation panel 579.46

80420 Dexamethasone panel 145.69

80422 Glucagon tolerance panel 46.07

80424 Glucagon tolerance panel 50.50

80426 Gonadotropin hormone panel 148.41

80428 Growth hormone panel 66.71

80430 Growth hormone panel 116.40

80432 Insulin suppression panel 149.05

80434 Insulin tolerance panel 256.53

80435 Insulin tolerance panel 103.01

80436 Metyrapone panel 91.16

80438 Trh stimulation panel 50.41

80439 Trh stimulation panel 67.21

80500 Clinical pathology consultation; limited, without review of patient's history and medical records16.10

80502 Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records52.44

81000 Urinalysis nonauto w/scope 3.62

81001 Urinalysis auto w/scope 3.17

81002 Urinalysis nonauto w/o scope 3.13

81002 Urinalysis nonauto w/o scope 3.13

81003 Urinalysis auto w/o scope 2.24

81003 QW Urinalysis auto w/o scope 2.49

81005 Urinalysis 2.17

81007 Urine screen for bacteria 26.98

2

34




Effective 04/01/19 - 03/31/20



81007 QW Urine screen for bacteria 26.98

81015 Microscopic exam of urine 3.05

81020 Urinalysis glass test 4.23

81025 Urine pregnancy test 7.75

81050 Urinalysis volume measure 3.28

81099 Unlisted Urinalysis test procedure Unlisted/Manual

81105 Hpa-1 genotyping 122.22








81120 Idh1 common variants 173.93

81121 Idh2 common variants 266.21

81161 Dmd dup/delet analysis 251.10

81162 Brca1&2 gen full seq dup/del 1,824.88

81163 Brca1&2 gene full seq alys 421.20

81164 Brca1&2 gen ful dup/del alys 525.81

81165 Brca1 gene full seq alys 254.59

81166 Brca1 gene full dup/del alys 271.22

81167 Brca2 gene full dup/del alys 254.59

81170 Abl1 gene 270.00

81171 Aff2 gene detc abnor alleles 123.30

81172 Aff2 gene charac alleles 247.35

81173 Ar gene full gene sequence 271.22

81174 Ar gene known famil variant 166.68

81175 Asxl1 full gene sequence 608.85

81176 Asxl1 gene target seq alys 241.89

81177 Atn1 gene detc abnor alleles 123.30

81178 Atxn1 gene detc abnor allele 123.30




81182 Atxn8os gen detc abnor allel 123.30

81183 Atxn10 gene detc abnor allel 123.30

81184 Cacna1a gen detc abnor allel 123.30

81185 Cacna1a gene full gene seq 761.64

81186 Cacna1a gen known famil vrnt 166.68

81187 Cnbp gene detc abnor allele 123.30

81188 Cstb gene detc abnor allele 123.30

81189 Cstb gene full gene sequence 247.35

81190 Cstb gene known famil vrnt 166.68

81200 Aspa gene 42.53

81201 Apc gene full sequence 702.00

81202 Apc gene known fam variants 252.00

3

34




Effective 04/01/19 - 03/31/20



81203 Apc gene dup/delet variants 180.00

81204 Ar gene charac alleles 123.30

81205 Bckdhb gene 85.49

81206 Bcr/abl1 gene major bp 163.96

81207 Bcr/abl1 gene minor bp 144.84

81208 Bcr/abl1 gene other bp 193.16

81209 Blm gene 35.38

81210 Braf gene 157.86

81212 Brca1&2 185&5385&6174 vrnt 396.00

81215 Brca1 gene known famil vrnt 337.73

81216 Brca2 gene full seq alys 166.61

81217 Brca2 gene known famil vrnt 337.73

81218 Cebpa gene full sequence 241.89

81220 Cftr gene com variants 500.94

81221 Cftr gene known fam variants 87.50

81222 Cftr gene dup/delet variants 391.56

81223 Cftr gene full sequence 449.10

81233 Btk gene common variants 157.86

81234 Dmpk gene detc abnor allele 123.30

81235 Egfr gene com variants 292.12

81236 Ezh2 gene full gene sequence 254.59

81238 F9 full gene sequence 540.00

81239 Dmpk gene charac alleles 247.35

81240 F2 gene 59.12

81241 F5 gene 66.03

81242 Fancc gene 32.96

81243 Fmr1 gene detection 51.34

81244 Fmr1 gene charac alleles 40.40

81245 Flt3 gene 148.96

81246 Flt3 gene analysis 74.70

81247 G6pd gene alys cmn variant 157.33

81248 G6pd known familial variant 337.73

81249 G6pd full gene sequence 540.00

81252 Gjb2 gene full sequence 91.01

81253 Gjb2 gene known fam variants 55.37

81254 Gjb6 gene com variants 31.50

81255 Hexa gene 46.31

81256 Hfe gene 65.36

81257 Hba1/hba2 gene 92.03

81258 Hba1/hba2 gene fam vrnt 337.73

81259 Hba1/hba2 full gene sequence 540.00

81261 Igh gene rearrange amp meth 197.99

81262 Igh gene rearrang dir probe 61.70

81263 Igh vari regional mutation 294.52

81264 Igk rearrangeabn clonal pop 155.46

81265 Str markers specimen anal 215.05

81266 Str markers spec anal addl 274.33

4

34




Effective 04/01/19 - 03/31/20



81267 Chimerism anal no cell selec 207.46

81268 Chimerism anal w/cell select 260.78

81269 Hba1/hba2 gene dup/del vrnts 182.16

81270 Jak2 gene 91.67

81271 Htt gene detc abnor alleles 123.30

81272 Kit gene targeted seq analys 296.56

81274 Htt gene charac alleles 247.35

81275 Kras gene variants exon 2 173.93

81276 Kras gene addl variants 173.93

81284 Fxn gene detc abnor alleles 123.30

81285 Fxn gene charac alleles 247.35

81286 Fxn gene full gene sequence 247.35

81288 Mlh1 gene 173.09

81289 Fxn gene known famil variant 166.68

81290 Mcoln1 gene 35.38

81291 Mthfr gene 58.81

81292 Mlh1 gene full seq 607.86

81293 Mlh1 gene known variants 297.90

81294 Mlh1 gene dup/delete variant 182.16

81295 Msh2 gene full seq 343.53

81296 Msh2 gene known variants 303.96

81297 Msh2 gene dup/delete variant 191.97

81298 Msh6 gene full seq 577.67

81299 Msh6 gene known variants 277.20

81300 Msh6 gene dup/delete variant 214.20

81301 Microsatellite instability 313.70

81305 Myd88 gene p.leu265pro vrnt 157.86

81310 Npm1 gene 221.87

81312 Pabpn1 gene detc abnor allel 123.30

81314 Pdgfra gene 296.56

81315 Pml/raralpha com breakpoints 207.32

81316 Pml/raralpha 1 breakpoint 207.32

81317 Pms2 gene full seq analysis 608.85

81318 Pms2 known familial variants 297.90

81319 Pms2 gene dup/delet variants 183.15

81321 Pten gene full sequence 540.00

81322 Pten gene known fam variant 42.80

81323 Pten gene dup/delet variant 270.00

81324 Pmp22 gene dup/delet 682.52

81325 Pmp22 gene full sequence 692.62

81326 Pmp22 gene known fam variant 42.80

81329 Smn1 gene dos/deletion alys 123.30

81331 Snrpn/ube3a gene 45.96

81332 Serpina1 gene 43.65

81333 Tgfbi gene common variants 123.30

81334 Runx1 gene targeted seq alys 593.12

81336 Smn1 gene full gene sequence 271.22

5

34




Effective 04/01/19 - 03/31/20



81337 Smn1 gen nown famil seq vrnt 166.68

81340 Trb@ gene rearrange amplify 208.92

81341 Trb@ gene rearrange dirprobe 49.59

81342 Trg gene rearrangement anal 201.49

81343 Ppp2r2b gen detc abnor allel 123.30

81344 Tbp gene detc abnor alleles 123.30

81361 Hbb gene com variants 157.33

81362 Hbb gene known fam variant 337.73

81363 Hbb gene dup/del variants 182.16

81364 Hbb full gene sequence 292.12

81370 Hla i & ii typing lr 402.12

81371 Hla i & ii type verify lr 364.07

81372 Hla i typing complete lr 363.23

81373 Hla i typing 1 locus lr 114.69

81374 Hla i typing 1 antigen lr 72.75

81375 Hla ii typing ag equiv lr 220.74

81376 Hla ii typing 1 locus lr 122.22

81377 Hla ii type 1 ag equiv lr 91.81

81378 Hla i & ii typing hr 345.56

81379 Hla i typing complete hr 335.39

81380 Hla i typing 1 locus hr 177.25

81381 Hla i typing 1 allele hr 152.91

81382 Hla ii typing 1 loc hr 123.68

81383 Hla ii typing 1 allele hr 109.13

81400 Mopath procedure level 1 57.56







81410 Aortic dysfunction/dilation 453.60

81411 Aortic dysfunction/dilation 1,215.17

81412 Ashkenazi jewish assoc dis 2,203.70

81420 Fetal chrmoml aneuploidy 683.15

81432 Hrdtry brst ca-rlatd dsordrs 679.05

81433 Hrdtry brst ca-rlatd dsordrs 438.93

81434 Hereditary retinal disorders 538.12

81435 Hereditary colon ca dsordrs 584.90

81436 Hereditary colon ca dsordrs 584.90

81437 Heredtry nurondcrn tum dsrdr 438.93

81438 Heredtry nurondcrn tum dsrdr 438.93

81442 Noonan spectrum disorders 1,929.24

81479 Unlisted molecular pathology procedure Unlisted/Manual

81507 Fetal aneuploidy trisom risk 715.50

81519 Oncology breast mrna 3,485.70

81539 Oncology prostate prob score 684.00

6

34




Effective 04/01/19 - 03/31/20



81541 Onc prostate mrna 46 genes 3,485.70

81595 Cardiology hrt trnspl mrna 2,916.00

81596 Nfct ds chrnc hcv 6 assays 64.97

81599 Unlisted multianalyte assay with algorithmic analysis Unlisted/Manual

82009 Test for acetone/ketones 4.52

82010 Acetone assay 8.17

82010 QW Acetone assay 9.08

82013 Acetylcholinesterase assay 11.17

82016 Acylcarnitines qual 14.84

82017 Acylcarnitines quant 16.87

82024 Assay of acth 38.62

82030 Assay of adp & amp 25.80

82040 Assay of serum albumin 4.95

82040 QW Assay of serum albumin 5.50

82042 Other source albumin quan ea 7.00

82043 Ur albumin quantitative 5.78

82043 QW Ur albumin quantitative 6.43

82044 Ur albumin semiquantitative 5.61

82044 QW Ur albumin semiquantitative 5.61

82045 Albumin ischemia modified 33.94

82075 Assay of breath ethanol 27.00

82085 Assay of aldolase 9.71

82088 Assay of aldosterone 40.75

82103 Alpha-1-antitrypsin total 13.44

82104 Alpha-1-antitrypsin pheno 14.46

82105 Alpha-fetoprotein serum 16.78

82106 Alpha-fetoprotein amniotic 16.78

82107 Alpha-fetoprotein l3 64.41

82108 Assay of aluminum 25.48

82120 Amines vaginal fluid qual 5.39

82120 QW Amines vaginal fluid qual 5.39

82127 Amino acid single qual 13.87

82128 Amino acids mult qual 13.87

82131 Amino acids single quant 20.68

82135 Assay aminolevulinic acid 16.45

82136 Amino acids quant 2-5 17.65

82139 Amino acids quan 6 or more 16.87

82140 Assay of ammonia 14.57

82143 Amniotic fluid scan 8.42

82150 Assay of amylase 6.48

82150 QW Assay of amylase 7.20

82154 Androstanediol glucuronide 28.84

82157 Assay of androstenedione 29.28

82160 Assay of androsterone 25.00

82163 Assay of angiotensin ii 20.52

82164 Angiotensin i enzyme test 14.60

82172 Assay of apolipoprotein 18.98

7

34




Effective 04/01/19 - 03/31/20



82175 Assay of arsenic 18.97

82180 Assay of ascorbic acid 9.88

82190 Atomic absorption 14.90

82232 Assay of beta-2 protein 16.17

82239 Bile acids total 17.13

82240 Bile acids cholylglycine 26.58

82247 Bilirubin total 5.01

82247 QW Bilirubin total 5.57

82248 Bilirubin direct 5.01

82252 Fecal bilirubin test 4.55

82261 Assay of biotinidase 16.87

82270 Occult blood feces 3.94

82271 Occult blood other sources 4.79

82271 QW Occult blood other sources 4.79

82272 Occult bld feces 1-3 tests 3.81

82274 Assay test for blood fecal 15.90

82274 QW Assay test for blood fecal 17.68

82286 Assay of bradykinin 5.16

82300 Assay of cadmium 23.15

82306 Vitamin d 25 hydroxy 29.60

82308 Assay of calcitonin 26.79

82310 Assay of calcium 5.16

82310 QW Assay of calcium 5.73

82330 Assay of calcium 13.68

82330 QW Assay of calcium 15.19

82331 Calcium infusion test 12.01

82340 Assay of calcium in urine 6.03

82355 Calculus analysis qual 11.57

82360 Calculus assay quant 12.87

82365 Calculus spectroscopy 12.90

82370 X-ray assay calculus 12.53

82373 Assay c-d transfer measure 18.05

82374 Assay blood carbon dioxide 4.89

82374 QW Assay blood carbon dioxide 5.43

82375 Assay carboxyhb quant 12.32

82376 Assay carboxyhb qual 12.66

82378 Carcinoembryonic antigen 18.96

82379 Assay of carnitine 16.87

82380 Assay of carotene 9.23

82382 Assay urine catecholamines 24.57

82383 Assay blood catecholamines 26.17

82384 Assay three catecholamines 25.25

82387 Assay of cathepsin-d 18.05

82390 Assay of ceruloplasmin 10.74

82397 Chemiluminescent assay 14.12

82415 Assay of chloramphenicol 12.67

82435 Assay of blood chloride 4.60

8

34




Effective 04/01/19 - 03/31/20



82435 QW Assay of blood chloride 5.11

82436 Assay of urine chloride 5.18

82438 Assay other fluid chlorides 4.89

82441 Test for chlorohydrocarbons 6.00

82465 Assay bld/serum cholesterol 4.36

82465 QW Assay bld/serum cholesterol 4.83

82480 Assay serum cholinesterase 7.88

82482 Assay rbc cholinesterase 8.83

82485 Assay chondroitin sulfate 20.66

82495 Assay of chromium 20.28

82507 Assay of citrate 27.80

82523 Collagen crosslinks 18.68

82523 QW Collagen crosslinks 20.76

82525 Assay of copper 12.41

82528 Assay of corticosterone 22.52

82530 Cortisol free 16.71

82533 Total cortisol 16.30

82540 Assay of creatine 4.64

82542 Col chromotography qual/quan 21.68

82550 Assay of ck (cpk) 6.51

82550 QW Assay of ck (cpk) 7.24

82552 Assay of cpk in blood 13.39

82553 Creatine mb fraction 11.55

82554 Creatine isoforms 11.87

82565 Assay of creatinine 5.12

82565 QW Assay of creatinine 5.70

82570 Assay of urine creatinine 5.18

82570 QW Assay of urine creatinine 5.75

82575 Creatinine clearance test 9.46

82585 Assay of cryofibrinogen 12.73

82595 Assay of cryoglobulin 6.46

82600 Assay of cyanide 19.40

82607 Vitamin b-12 15.08

82608 B-12 binding capacity 14.32

82610 Cystatin c 16.67

82615 Test for urine cystines 8.60

82626 Dehydroepiandrosterone 25.27

82627 Dehydroepiandrosterone 22.24

82633 Desoxycorticosterone 30.99

82634 Deoxycortisol 29.28

82638 Assay of dibucaine number 12.25

82642 Dihydrotestosterone 29.28

82652 Vit d 1 25-dihydroxy 38.50

82656 Pancreatic elastase fecal 11.53

82657 Enzyme cell activity 19.95

82658 Enzyme cell activity ra 39.63

82664 Electrophoretic test 55.35

9

34




Effective 04/01/19 - 03/31/20



82668 Assay of erythropoietin 18.79

82670 Assay of estradiol 27.94

82671 Assay of estrogens 32.30

82672 Assay of estrogen 21.70

82677 Assay of estriol 24.18

82679 Assay of estrone 24.96

82679 QW Assay of estrone 27.73

82693 Assay of ethylene glycol 14.90

82696 Assay of etiocholanolone 23.62

82705 Fats/lipids feces qual 5.09

82710 Fats/lipids feces quant 16.80

82715 Assay of fecal fat 20.67

82725 Assay of blood fatty acids 16.89

82726 Long chain fatty acids 18.05

82728 Assay of ferritin 13.64

82731 Assay of fetal fibronectin 64.41

82735 Assay of fluoride 18.54

82746 Assay of folic acid serum 14.71

82747 Assay of folic acid rbc 17.33

82757 Assay of semen fructose 17.33

82759 Assay of rbc galactokinase 21.48

82760 Assay of galactose 11.20

82775 Assay galactose transferase 21.07

82776 Galactose transferase test 10.57

82784 Assay iga/igd/igg/igm each 9.31

82785 Assay of ige 16.46

82787 Igg 1 2 3 or 4 each 8.02

82800 Blood ph 9.90

82803 Blood gases any combination 23.46

82805 Blood gases w/o2 saturation 70.89

82810 Blood gases o2 sat only 8.79

82820 Hemoglobin-oxygen affinity 12.01

82930 Gastric analy w/ph ea spec 6.04

82938 Gastrin test 17.69

82941 Assay of gastrin 17.63

82943 Assay of glucagon 14.29

82945 Glucose other fluid 3.93

82946 Glucagon tolerance test 15.99

82947 Assay glucose blood quant 3.93

82947 QW Assay glucose blood quant 4.37

82948 Reagent strip/blood glucose 4.54

82950 Glucose test 4.74

82950 QW Glucose test 5.27

82951 Glucose tolerance test (gtt) 12.87

82951 QW Glucose tolerance test (gtt) 14.30

82952 Gtt-added samples 3.92

82952 QW Gtt-added samples 4.36

10

34




Effective 04/01/19 - 03/31/20



82955 Assay of g6pd enzyme 9.69

82960 Test for g6pd enzyme 6.05

82962 Glucose blood test 2.95

82963 Assay of glucosidase 21.48

82965 Assay of gdh enzyme 11.84

82977 Assay of ggt 7.20

82977 QW Assay of ggt 8.00

82978 Assay of glutathione 14.26

82979 Assay rbc glutathione 9.44

82985 Assay of glycated protein 15.08

82985 QW Assay of glycated protein 16.75

83001 Assay of gonadotropin (fsh) 18.59

83001 QW Assay of gonadotropin (fsh) 20.65

83002 Assay of gonadotropin (lh) 18.51

83002 QW Assay of gonadotropin (lh) 20.57

83003 Assay growth hormone (hgh) 16.67

83009 H pylori (c-13) blood 67.36

83010 Assay of haptoglobin quant 12.57

83012 Assay of haptoglobins 24.20

83013 H pylori (c-13) breath 67.36

83014 H pylori drug admin 7.86

83015 Heavy metal qual any anal 18.85

83018 Heavy metal quant each nes 21.97

83020 26 Hemoglobin electrophoresis 11.68

83020 Hemoglobin electrophoresis 12.87

83021 Hemoglobin chromotography 18.05

83026 Hemoglobin copper sulfate 3.61

83030 Fetal hemoglobin chemical 9.67

83033 Fetal hemoglobin assay qual 7.20

83036 Glycosylated hemoglobin test 9.71

83036 QW Glycosylated hemoglobin test 10.79

83037 Glycosylated hb home device 9.71

83037 QW Glycosylated hb home device 10.79

83045 Blood methemoglobin test 5.84

83050 Blood methemoglobin assay 7.38

83051 Assay of plasma hemoglobin 7.31

83060 Blood sulfhemoglobin assay 8.27

83065 Assay of hemoglobin heat 8.10

83068 Hemoglobin stability screen 8.52

83069 Assay of urine hemoglobin 3.95

83070 Assay of hemosiderin qual 4.74

83080 Assay of b hexosaminidase 16.87

83088 Assay of histamine 29.53

83090 Assay of homocystine 16.87

83150 Assay of homovanillic acid 20.17

83491 Assay of corticosteroids 17 17.52

83497 Assay of 5-hiaa 12.90

11

34




Effective 04/01/19 - 03/31/20



83498 Assay of progesterone 17-d 27.17

83500 Assay free hydroxyproline 22.65

83505 Assay total hydroxyproline 24.31

83516 Immunoassay nonantibody 11.53

83518 Immunoassay dipstick 8.68

83519 Ria nonantibody 16.56

83520 Immunoassay quant nos nonab 15.54

83525 Assay of insulin 11.43

83527 Assay of insulin 12.95

83528 Assay of intrinsic factor 17.84

83540 Assay of iron 6.47

83550 Iron binding test 8.74

83570 Assay of idh enzyme 8.85

83582 Assay of ketogenic steroids 14.18

83586 Assay 17- ketosteroids 12.80

83593 Fractionation ketosteroids 26.30

83605 Assay of lactic acid 10.68

83605 QW Assay of lactic acid 11.87

83615 Lactate (ld) (ldh) enzyme 6.04

83625 Assay of ldh enzymes 12.80

83630 Lactoferrin fecal (qual) 19.63

83631 Lactoferrin fecal (quant) 19.63

83632 Placental lactogen 20.22

83633 Test urine for lactose 10.13

83655 Assay of lead 12.11

83655 QW Assay of lead 13.46

83661 L/s ratio fetal lung 21.99

83662 Foam stability fetal lung 18.91

83663 Fluoro polarize fetal lung 18.91

83664 Lamellar bdy fetal lung 18.91

83670 Assay of lap enzyme 9.16

83690 Assay of lipase 6.89

83695 Assay of lipoprotein(a) 12.95

83698 Assay lipoprotein pla2 41.68

83700 Lipopro bld electrophoretic 11.26

83701 Lipoprotein bld hr fraction 30.47

83704 Lipoprotein bld quan part 31.55

83718 Assay of lipoprotein 8.19

83718 QW Assay of lipoprotein 9.11

83719 Assay of blood lipoprotein 11.64

83721 Assay of blood lipoprotein 9.54

83721 QW Assay of blood lipoprotein 10.60

83727 Assay of lrh hormone 17.19

83735 Assay of magnesium 6.70

83775 Assay malate dehydrogenase 7.37

83785 Assay of manganese 24.60

83789 Mass spectrometry qual/quan 21.70

12

34




Effective 04/01/19 - 03/31/20



83825 Assay of mercury 16.25

83835 Assay of metanephrines 16.94

83857 Assay of methemalbumin 10.74

83861 Microfluid analy tears 20.23

83864 Mucopolysaccharides 25.65

83872 Assay synovial fluid mucin 5.86

83873 Assay of csf protein 17.21

83874 Assay of myoglobin 12.92

83876 Assay myeloperoxidase 45.77

83880 Assay of natriuretic peptide 35.33

83880 QW Assay of natriuretic peptide 37.71

83883 Assay nephelometry not spec 13.60

83885 Assay of nickel 24.51

83915 Assay of nucleotidase 11.15

83916 Oligoclonal bands 24.65

83918 Organic acids total quant 21.24

83919 Organic acids qual each 16.45

83921 Organic acid single quant 19.09

83930 Assay of blood osmolality 6.62

83935 Assay of urine osmolality 6.81

83937 Assay of osteocalcin 29.84

83945 Assay of oxalate 13.01

83950 Oncoprotein her-2/neu 64.41

83951 Oncoprotein dcp 64.41

83970 Assay of parathormone 41.27

83986 Assay ph body fluid nos 3.58

83986 QW Assay ph body fluid nos 3.98

83992 Assay for phencyclidine 18.15

83993 Assay for calprotectin fecal 19.63

84030 Assay of blood pku 5.50

84035 Assay of phenylketones 3.66

84060 Assay acid phosphatase 7.39

84066 Assay prostate phosphatase 9.66

84075 Assay alkaline phosphatase 5.18

84075 QW Assay alkaline phosphatase 5.75

84078 Assay alkaline phosphatase 7.43

84080 Assay alkaline phosphatases 14.79

84081 Assay phosphatidylglycerol 16.52

84085 Assay of rbc pg6d enzyme 9.44

84087 Assay phosphohexose enzymes 10.32

84100 Assay of phosphorus 4.74

84105 Assay of urine phosphorus 5.20

84106 Test for porphobilinogen 5.24

84110 Assay of porphobilinogen 8.44

84112 Placenta alpha micro ig c/v 88.30

84119 Test urine for porphyrins 12.02

84120 Assay of urine porphyrins 14.72

13

34




Effective 04/01/19 - 03/31/20



84126 Assay of feces porphyrins 35.20

84132 Assay of serum potassium 4.60

84132 QW Assay of serum potassium 5.11

84133 Assay of urine potassium 4.31

84134 Assay of prealbumin 14.59

84135 Assay of pregnanediol 19.14

84138 Assay of pregnanetriol 18.95

84140 Assay of pregnenolone 20.67

84143 Assay of 17-hydroxypregneno 22.81

84144 Assay of progesterone 20.86

84146 Assay of prolactin 19.38

84150 Assay of prostaglandin 37.59

84152 Assay of psa complexed 18.40

84153 Assay of psa total 18.40

84154 Assay of psa free 18.40

84155 Assay of protein serum 3.66

84155 QW Assay of protein serum 4.08

84156 Assay of protein urine 3.66

84157 Assay of protein other 3.66

84157 QW Assay of protein other 4.08

84160 Assay of protein any source 5.18

84163 Pappa serum 15.06

84165 26 Protein e-phoresis serum 11.68

84165 Protein e-phoresis serum 10.74

84166 26 Protein e-phoresis/urine/csf 11.68

84166 Protein e-phoresis/urine/csf 17.83

84181 26 Western blot test 11.68

84181 Western blot test 17.03

84182 26 Protein western blot test 11.68

84182 Protein western blot test 26.29

84202 Assay RBC protoporphyrin 14.35

84203 Test RBC protoporphyrin 8.77

84206 Assay of proinsulin 24.02

84207 Assay of vitamin b-6 28.10

84210 Assay of pyruvate 13.03

84220 Assay of pyruvate kinase 9.44

84228 Assay of quinine 11.64

84233 Assay of estrogen 79.09

84234 Assay of progesterone 64.88

84235 Assay of endocrine hormone 64.11

84238 Assay nonendocrine receptor 36.57

84244 Assay of renin 22.00


84255 Assay of selenium 25.53

84260 Assay of serotonin 30.99

84270 Assay of sex hormone globul 21.74

84275 Assay of sialic acid 13.44

14

34




Effective 04/01/19 - 03/31/20



84285 Assay of silica 23.54

84295 Assay of serum sodium 4.82

84295 QW Assay of serum sodium 5.35

84300 Assay of urine sodium 4.86

84302 Assay of sweat sodium 4.86

84305 Assay of somatomedin 21.27

84307 Assay of somatostatin 18.28

84311 Spectrophotometry 7.29

84315 Body fluid specific gravity 2.95

84375 Chromatogram assay sugars 35.10

84376 Sugars single qual 5.50

84377 Sugars multiple qual 5.50

84378 Sugars single quant 11.53

84379 Sugars multiple quant 11.53

84392 Assay of urine sulfate 4.94

84402 Assay of free testosterone 25.47

84403 Assay of total testosterone 25.81

84410 Testosterone bioavailable 51.28


84430 Assay of thiocyanate 11.64

84432 Assay of thyroglobulin 16.06

84436 Assay of total thyroxine 6.87

84437 Assay of neonatal thyroxine 6.46

84439 Assay of free thyroxine 9.02

84442 Assay of thyroid activity 14.79

84443 Assay thyroid stim hormone 16.80

84443 QW Assay thyroid stim hormone 18.68

84445 Assay of tsi globulin 50.86

84446 Assay of vitamin e 14.18

84449 Assay of transcortin 18.00

84450 Transferase (AST) (SGOT) 5.18

84450 QW Transferase (AST) (SGOT) 5.75

84460 Alanine amino (ALT) (SGPT) 5.30

84460 QW Alanine amino (ALT) (SGPT) 5.89

84466 Assay of transferrin 12.76

84478 Assay of triglycerides 5.74

84478 QW Assay of triglycerides 6.38

84479 Assay of thyroid (t3 or t4) 6.46

84480 Assay triiodothyronine (t3) 14.18

84481 Free assay (FT-3) 16.94

84482 T3 reverse 15.76

84484 Assay of troponin quant 11.22

84485 Assay duodenal fluid trypsin 7.20

84488 Test feces for trypsin 7.30

84490 Assay of feces for trypsin 8.94

84510 Assay of tyrosine 10.40

84512 Assay of troponin qual 9.08

15

34




Effective 04/01/19 - 03/31/20



84520 Assay of urea nitrogen 3.95

84520 QW Assay of urea nitrogen 4.39

84525 Urea nitrogen semi-quant 4.62

84540 Assay of urine/urea-n 5.00

84545 Urea-N clearance test 6.62

84550 Assay of blood/uric acid 4.52

84550 QW Assay of blood/uric acid 5.02

84560 Assay of urine/uric acid 4.74

84577 Assay of feces/urobilinogen 16.80

84578 Test urine urobilinogen 4.02

84580 Assay of urine urobilinogen 8.60

84583 Assay of urine urobilinogen 5.45

84585 Assay of urine vma 15.50

84586 Assay of vip 35.33

84588 Assay of vasopressin 33.94

84590 Assay of vitamin a 11.61

84591 Assay of nos vitamin 15.35

84597 Assay of vitamin k 13.72

84600 Assay of volatiles 16.08

84620 Xylose tolerance test 11.84

84630 Assay of zinc 11.39

84681 Assay of c-peptide 20.82

84702 Chorionic gonadotropin test 15.06

84703 Chorionic gonadotropin assay 7.52

84703 QW Chorionic gonadotropin assay 8.36

84704 Hcg free betachain test 15.06

84830 Ovulation tests 11.43

84999 Unlisted chemistry procedure Unlisted/Manual

85002 Bleeding time test 4.51

85004 Automated diff wbc count 6.46

85007 Bl smear w/diff wbc count 3.44

85008 Bl smear w/o diff wbc count 3.44

85009 Manual diff wbc count b-coat 4.56

85013 Spun microhematocrit 6.30

85014 Hematocrit 2.37

85014 QW Hematocrit 2.64

85018 Hemoglobin 2.37

85018 QW Hemoglobin 2.64

85025 Complete cbc w/auto diff wbc 7.77

85027 Complete cbc automated 6.46

85032 Manual cell count each 4.31

85041 Automated rbc count 3.02

85044 Manual reticulocyte count 4.31

85045 Automated reticulocyte count 4.00

85046 Reticyte/hgb concentrate 5.57

85048 Automated leukocyte count 2.54

85049 Automated platelet count 4.47

16

34




Effective 04/01/19 - 03/31/20



85055 Reticulated platelet assay 32.17

85060 Blood smear, peripheral, interpretation by physician with written report15.89

85097 Bone marrow, smear interpretation 45.79

85130 Chromogenic substrate assay 11.89

85170 Blood clot retraction 14.67

85175 Blood clot lysis time 18.33

85210 Clot factor ii prothrom spec 12.99

85220 Blooc clot factor v test 17.65

85230 Clot factor vii proconvertin 17.90

85240 Clot factor viii ahg 1 stage 17.90

85244 Clot factor viii reltd antgn 20.42

85245 Clot factor viii vw ristoctn 22.94

85246 Clot factor viii vw antigen 22.94

85247 Clot factor viii multimetric 22.94

85250 Clot factor ix ptc/chrstmas 19.04

85260 Clot factor x stuart-power 17.90

85270 Clot factor xi pta 17.90

85280 Clot factor xii hageman 19.35

85290 Clot factor xiii fibrin stab 16.34

85291 Clot factor xiii fibrin scrn 8.89

85292 Clot factor fletcher fact 18.94

85293 Clot factor wght kininogen 18.94

85300 Antithrombin iii activity 11.85

85301 Antithrombin iii antigen 10.81

85302 Clot inhibit prot c antigen 12.02

85303 Clot inhibit prot c activity 13.83

85305 Clot inhibit prot s total 11.61

85306 Clot inhibit prot s free 15.33

85307 Assay activated protein c 15.33

85335 Factor inhibitor test 12.87

85337 Thrombomodulin 15.54

85345 Coagulation time lee & white 4.31

85347 Coagulation time activated 4.26

85348 Coagulation time otr method 4.04

85360 Euglobulin lysis 8.41

85362 Fibrin degradation products 6.89

85366 Fibrinogen test 72.41

85370 Fibrinogen test 11.36

85378 Fibrin degrade semiquant 8.75

85379 Fibrin degradation quant 10.18

85380 Fibrin degradj d-dimer 10.18

85384 Fibrinogen activity 8.75

85385 Fibrinogen antigen 13.01

85390 26 Fibrinolysins screen i&r 24.06

85390 Fibrinolysins screen i&r 13.93

85396 Coagulation/fibrinolysis assay, whole blood, including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day13.08

85400 Fibrinolytic plasmin 7.70

17

34




Effective 04/01/19 - 03/31/20



85410 Fibrinolytic antiplasmin 7.70

85415 Fibrinolytic plasminogen 17.19



85441 Heinz bodies direct 4.20

85445 Heinz bodies induced 6.81

85460 Hemoglobin fetal 7.73

85461 Hemoglobin fetal 8.42

85475 Hemolysin acid 8.87

85520 Heparin assay 13.10

85525 Heparin neutralization 11.84

85530 Heparin-protamine tolerance 13.10

85536 Iron stain peripheral blood 6.46

85540 Wbc alkaline phosphatase 8.60

85547 RBC mechanical fragility 8.60

85549 Muramidase 18.75

85555 RBC osmotic fragility 6.72

85557 RBC osmotic fragility 13.36

85576 26 Blood platelet aggregation 11.68

85576 Blood platelet aggregation 22.42

85576 QW Blood platelet aggregation 23.87

85597 Phospholipid pltlt neutraliz 17.97

85598 Hexagnal phosph pltlt neutrl 17.97

85610 Prothrombin time 3.93

85610 QW Prothrombin time 4.37

85611 Prothrombin test 3.94

85612 Viper venom prothrombin time 15.74

85613 Russell viper venom diluted 9.58

85635 Reptilase test 9.85

85651 Rbc sed rate nonautomated 3.84

85652 Rbc sed rate automated 2.70

85660 RBC sickle cell test 5.51

85670 Thrombin time plasma 5.77

85675 Thrombin time titer 6.85

85705 Thromboplastin inhibition 9.63

85730 Thromboplastin time partial 6.00

85732 Thromboplastin time partial 6.46

85810 Blood viscosity examination 11.67

85999 Unlisted hematology and coagulation procedure Unlisted/Manual

86000 Agglutinins febrile antigen 6.98

86001 Allergen specific igg 7.04

86003 Allergen specific IgE 5.22

86005 Allergen specific IgE 7.97

86008 Allg spec ige recomb ea 17.94

86021 WBC antibody identification 15.06

86022 Platelet antibodies 18.37

86023 Immunoglobulin assay 12.46

18

34




Effective 04/01/19 - 03/31/20



86038 Antinuclear antibodies 12.09

86039 Antinuclear antibodies (ANA) 11.16

86060 Antistreptolysin o titer 7.30

86063 Antistreptolysin o screen 5.77

86077 Blood bank physician services; difficult cross match and/or evaluation of irregular anitbody(s), interpretation and written report35.05

86078 Blood bank physician services; investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report35.05

86079 Blood bank physician services; authorization for deviation from standard blood banking procedures (eg, use of outdated blood, transfusion of Rh incompatible units), with written report34.81

86140 C-reactive protein 5.18

86141 C-reactive protein hs 12.95

86146 Beta-2 glycoprotein antibody 25.45

86147 Cardiolipin antibody ea ig 25.45

86148 Anti-phospholipid antibody 16.07

86152 Cell enumeration & id 245.70

86153 26 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required22.20

86155 Chemotaxis assay 15.98

86156 Cold agglutinin screen 7.26

86157 Cold agglutinin titer 8.06

86160 Complement antigen 12.00

86161 Complement/function activity 12.00

86162 Complement total (ch50) 20.32

86171 Complement fixation each 10.01

86200 Ccp antibody 12.95

86215 Deoxyribonuclease antibody 13.25

86225 Dna antibody native 13.74

86226 Dna antibody single strand 12.11

86235 Nuclear antigen antibody 17.94

86255 26 Fluorescent antibody screen 11.68

86255 Fluorescent antibody screen 12.05

86256 26 Fluorescent antibody titer 11.68

86256 Fluorescent antibody titer 12.05

86277 Growth hormone antibody 15.74

86280 Hemagglutination inhibition 8.19

86294 Immunoassay tumor qual 23.01

86294 QW Immunoassay tumor qual 23.01

86300 Immunoassay tumor ca 15-3 20.82

86301 Immunoassay tumor ca 19-9 20.82

86304 Immunoassay tumor ca 125 20.82

86308 Heterophile antibody screen 5.18

86308 QW Heterophile antibody screen 5.75

86309 Heterophile antibody titer 6.46

86310 Heterophile antibody absrbj 7.37

86316 Immunoassay tumor other 20.82

86317 Immunoassay infectious agent 14.99

86318 Immunoassay infectious agent 16.28

86318 QW Immunoassay infectious agent 16.28

86320 26 Serum immunoelectrophoresis 11.68

86320 Serum immunoelectrophoresis 26.93

19

34




Effective 04/01/19 - 03/31/20



86325 26 Other immunoelectrophoresis 11.68

86325 Other immunoelectrophoresis 22.37

86327 26 Immunoelectrophoresis assay 14.25

86327 Immunoelectrophoresis assay 26.93

86329 Immunodiffusion nes 14.05

86331 Immunodiffusion ouchterlony 11.98

86332 Immune complex assay 24.37

86334 26 Immunofix e-phoresis serum 11.68

86334 Immunofix e-phoresis serum 22.35

86335 26 Immunfix e-phorsis/urine/csf 11.68

86335 Immunfix e-phorsis/urine/csf 29.35

86336 Inhibin A 15.59

86337 Insulin antibodies 21.41

86340 Intrinsic factor antibody 15.08

86341 Islet cell antibody 21.21

86343 Leukocyte histamine release 12.46

86344 Leukocyte phagocytosis 9.35

86353 Lymphocyte transformation 49.02

86355 B cells total count 37.73

86356 Mononuclear cell antigen 26.78

86357 Nk cells total count 37.73

86359 T cells total count 37.73

86360 T cell absolute count/ratio 46.98

86361 T cell absolute count 26.78

86367 Stem cells total count 70.00

86376 Microsomal antibody each 14.55

86382 Neutralization test viral 16.91

86384 Nitroblue tetrazolium dye 12.25

86386 Nuclear matrix protein 22 19.60

86403 Particle agglut antbdy scrn 10.39

86406 Particle agglut antbdy titr 10.64

86430 Rheumatoid factor test qual 5.67

86431 Rheumatoid factor quant 5.67

86480 Tb test cell immun measure 61.98

86481 Tb ag response t-cell susp 90.00

86485 Skin test; candida 5.56

86486 Skin test; unlisted antigen, each 2.97

86490 Skin test; coccidioidomycosis 52.02

86510 Skin test; histoplasmosis 3.78

86580 Skin test; tuberculosis, intradermal 4.81

86590 Streptokinase antibody 12.28

86592 Syphilis test non-trep qual 4.74

86593 Syphilis test non-trep quant 4.90

86602 Antinomyces antibody 11.30

86603 Adenovirus antibody 14.30

86606 Aspergillus antibody 16.73

86609 Bacterium antibody 14.31

20

34




Effective 04/01/19 - 03/31/20



86611 Bartonella antibody 11.30

86612 Blastomyces antibody 14.34

86615 Bordetella antibody 14.65

86617 Lyme disease antibody 17.22

86618 QW Lyme disease antibody 18.92

86618 Lyme disease antibody 18.92

86619 Borrelia antibody 14.87

86622 Brucella antibody 9.93

86625 Campylobacter antibody 14.58

86628 Candida antibody 13.34

86631 Chlamydia antibody 13.14

86632 Chlamydia igm antibody 14.09

86635 Coccidioides antibody 12.75

86638 Q fever antibody 13.47

86641 Cryptococcus antibody 16.01

86644 CMV antibody 15.99

86645 Cmv antibody igm 18.72

86648 Diphtheria antibody 16.89

86651 Encephalitis californ antbdy 14.65

86652 Encephaltis east eqne anbdy 14.65

86653 Encephaltis st louis antbody 14.65

86654 Encephaltis west eqne antbdy 14.65

86658 Enterovirus antibody 14.47

86663 Epstein-barr antibody 14.58

86664 Epstein-barr nuclear antigen 16.99

86665 Epstein-barr capsid vca 20.16

86666 Ehrlichia antibody 11.30

86668 Francisella tularensis 12.74

86671 Fungus nes antibody 13.62

86674 Giardia lamblia antibody 16.35

86677 Helicobacter pylori antibody 16.12

86682 Helminth antibody 14.45

86684 Hemophilus influenza antibdy 17.60

86687 Htlv-i antibody 9.32

86688 Htlv-ii antibody 15.56

86689 Htlv/hiv confirmj antibody 21.51

86692 Hepatitis delta agent antbdy 19.07

86694 Herpes simplex nes antbdy 15.99

86695 Herpes simplex type 1 test 14.65

86696 Herpes simplex type 2 test 21.51

86698 Histoplasma antibody 13.89

86701 QW Hiv-1antibody 9.87

86701 Hiv-1antibody 9.87

86702 Hiv-2 antibody 15.02

86703 QW Hiv-1/hiv-2 1 result antbdy 15.23

86703 Hiv-1/hiv-2 1 result antbdy 15.23

86704 Hep b core antibody total 13.39

21

34




Effective 04/01/19 - 03/31/20



86705 Hep b core antibody igm 13.09

86706 Hep b surface antibody 11.93

86707 Hepatitis be antibody 12.85

86708 Hepatitis a total antibody 13.76

86709 Hepatitis a igm antibody 12.51

86710 Influenza virus antibody 15.06

86711 John cunningham antibody 15.99

86713 Legionella antibody 17.00

86717 Leishmania antibody 13.61

86720 Leptospira antibody 14.65

86723 Listeria monocytogenes 14.65

86727 Lymph choriomeningitis ab 14.30

86732 Mucormycosis antibody 14.65

86735 Mumps antibody 14.50

86738 Mycoplasma antibody 14.71

86741 Neisseria meningitidis 14.65

86744 Nocardia antibody 14.65

86747 Parvovirus antibody 16.70

86750 Malaria antibody 14.65

86753 Protozoa antibody nos 13.76

86756 Respiratory virus antibody 14.32

86757 Rickettsia antibody 21.51

86759 Rotavirus antibody 16.41

86762 Rubella antibody 15.99

86765 Rubeola antibody 14.31

86768 Salmonella antibody 14.65

86771 Shigella antibody 22.03

86774 Tetanus antibody 16.44

86777 Toxoplasma antibody 15.99

86778 Toxoplasma antibody igm 16.00

86780 Treponema pallidum 14.71

86784 Trichinella antibody 13.96

86787 Varicella-zoster antibody 14.31

86788 West nile virus ab igm 18.72

86789 West nile virus antibody 15.99

86790 Virus antibody nos 14.31

86793 Yersinia antibody 14.65

86794 Zika virus igm antibody 18.72

86800 Thyroglobulin antibody 17.68

86803 Hepatitis c ab test 15.85

86804 Hep c ab test confirm 17.22

86805 Lymphocytotoxicity assay 170.56

86806 Lymphocytotoxicity assay 52.88

86807 Cytotoxic antibody screening 70.79

86808 Cytotoxic antibody screening 32.98

86812 Hla typing a b or c 28.67

86813 Hla typing a b or c 64.44

22

34




Effective 04/01/19 - 03/31/20



86816 Hla typing dr/dq 30.95

86817 Hla typing dr/dq 95.53

86821 Lymphocyte culture mixed 40.63

86825 Hla x-math non-cytotoxic 98.54

86826 Hla x-match noncytotoxc addl 32.88

86828 Hla class i&ii antibody qual 57.77

86829 Hla class i/ii antibody qual 57.77

86830 Hla class i phenotype qual 89.71

86831 Hla class ii phenotype qual 76.90

86832 Hla class i high defin qual 291.38

86833 Hla class ii high defin qual 293.22

86834 Hla class i semiquant panel 397.29

86835 Hla class ii semiquant panel 358.85

86849 Unlisted immunology procedure Unlisted/Manual

86850 Rbc antibody screen 8.79

86860 Antibody elution, (RBC), each elution 26.96

86870 Antibody identification, RBC antibodies, each panel for each serum technique22.58

86880 Coombs test direct 5.99

86885 Coombs test indirect qual 6.36

86886 Coombs test indirect titer 5.75

86890 Autologous blood or component, collection processing and storage; predeposited44.32

86891 Autologous blood or component, collection processing and storage; intra-or postoperative salvage19.18

86900 Blood typing abo 3.32

86901 Blood typing rh (d) 3.32

86902 Blood type antigen donor ea 5.72

86904 Blood typing patient serum 14.71

86905 Blood typing rbc antigens 4.26

86906 Blood typing rh phenotype 8.61

86920 Compatibility test each unit; immediate spin technique 21.45

86921 Compatibility test each unit; incubation technique 21.45

86922 Compatibility test each unit; antiglobulin technique 21.45

86923 Compatibility test each unit; electronic 11.62

86927 Fresh frozen plasma, thawing, each unit 8.78

86930 Frozen blood, each unit; freezing (includes preparation) 21.45

86931 Frozen blood, each unit; thawing 32.36

86932 Frozen blood, each unit; freezing (includes preparation) and thawing42.89

86940 Hemolysins/agglutinins auto 9.12

86941 Hemolysins/agglutinins 13.46

86945 Irradiation of blood product, each unit 10.54

86950 Leukocyte transfusion 28.58

86960 Volume reduction of blood or blood products (eg, red blood cells or platelets), each unit11.62

86965 Pooling of platelets or other blood products 14.43

86970 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with chemical agents or drugs, each14.43

86971 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each17.56

86972 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; by density gradient separation14.43

86975 Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each14.43

86976 Pretreatment of serum for use in RBC antibody identification; by dilution14.43

23

34




Effective 04/01/19 - 03/31/20



86977 Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors, each14.43

86978 Pretreatment of serum for use in RBC antibody identification; by differential red cell absorption using patient RBCs or RBCs of known phenotype, each absorption17.56

86985 Splitting of blood or blood products, each unit 22.13

86999 Unlisted transfusion medicine procedure Unlisted/Manual

87003 Small animal inoculation 18.71

87015 Specimen infect agnt concntj 7.42

87040 Blood culture for bacteria 11.47

87045 Feces culture aerobic bact 10.49

87046 Stool cultr aerobic bact ea 10.49

87070 Culture othr specimn aerobic 9.58

87071 Culture aerobic quant other 10.49

87073 Culture bacteria anaerobic 10.49

87075 Cultr bacteria except blood 10.52

87076 Culture anaerobe ident each 8.97

87077 QW Culture aerobic identify 8.97

87077 Culture aerobic identify 8.97

87081 Culture screen only 7.36

87084 Culture of specimen by kit 24.36

87086 Urine culture/colony count 8.96

87088 Urine bacteria culture 8.99

87101 Skin fungi culture 8.56

87102 Fungus isolation culture 9.34

87103 Blood fungus culture 18.41

87106 Fungi identification yeast 11.47

87107 Fungi identification mold 11.47

87109 Mycoplasma 17.10

87110 Chlamydia culture 21.77

87116 Mycobacteria culture 12.01

87118 Mycobacteric identification 13.15

87140 Culture type immunofluoresc 6.19

87143 Culture typing glc/hplc 13.91

87147 Culture type immunologic 5.75

87149 Dna/rna direct probe 22.28

87150 Dna/rna amplified probe 39.00

87152 Culture type pulse field gel 6.97

87153 Dna/rna sequencing 128.18

87158 Culture typing added method 6.97

87164 26 Dark field examination 11.93

87164 Dark field examination 11.93

87166 Dark field examination 12.56

87168 Macroscopic exam arthropod 4.74

87169 Macroscopic exam parasite 4.74

87172 Pinworm exam 4.74

87176 Tissue homogenization cultr 6.53

87177 Ova and parasites smears 9.89

87181 Microbe susceptible diffuse 5.27

87184 Microbe susceptible disk 7.66

24

34




Effective 04/01/19 - 03/31/20



87185 Microbe susceptible enzyme 5.27

87186 Microbe susceptible mic 9.60

87187 Microbe susceptible mlc 36.15

87188 Microbe suscept macrobroth 7.38

87190 Microbe suscept mycobacteri 6.58

87197 Bactericidal level serum 16.70

87205 Smear gram stain 4.74

87206 Smear fluorescent/acid stai 5.99

87207 26 Smear special stain 6.66

87207 Smear special stain 6.66

87209 Smear complex stain 19.97

87210 QW Smear wet mount saline/ink 5.24

87210 Smear wet mount saline/ink 5.24

87220 Tissue exam for fungi 4.74

87230 Assay toxin or antitoxin 21.93

87250 Virus inoculate eggs/animal 21.74

87252 Virus inoculation tissue 28.96

87253 Virus inoculate tissue addl 22.45

87254 Virus inoculation shell via 21.74

87255 Genet virus isolate hsv 37.63

87260 Adenovirus ag if 13.32

87265 Pertussis ag if 13.32

87267 Enterovirus antibody dfa 13.32

87269 Giardia ag if 13.32

87270 Chlamydia trachomatis ag if 13.32

87271 Cytomegalovirus dfa 13.32

87272 Cryptosporidium ag if 13.32

87273 Herpes simplex 2 ag if 13.32

87274 Herpes simplex 1 ag if 13.32

87275 Influenza b ag if 13.32

87276 Influenza a ag if 14.46

87278 Legion pneumophilia ag if 14.04

87279 Parainfluenza ag if 14.79

87280 Respiratory syncytial ag if 13.32

87281 Pneumocystis carinii ag if 13.32

87283 Rubeola ag if 54.72

87285 Treponema pallidum ag if 13.32

87290 Varicella zoster ag if 13.32

87299 Antibody detection nos if 14.49

87300 Ag detection polyval if 13.32

87301 Adenovirus ag eia 13.32

87305 Aspergillus ag eia 13.32

87320 Chylmd trach ag eia 13.50

87324 Clostridium ag eia 13.32

87327 Cryptococcus neoform ag eia 13.32

87328 Cryptosporidium ag eia 13.32

87329 Giardia ag eia 13.32

25

34




Effective 04/01/19 - 03/31/20



87332 Cytomegalovirus ag eia 13.32

87335 E coli 0157 ag eia 13.32

87336 Entamoeb hist dispr ag eia 14.40

87337 Entamoeb hist group ag eia 13.32

87338 Hpylori stool eia 15.98

87339 H pylori ag eia 14.40

87340 Hepatitis b surface ag eia 11.48

87341 Hepatitis b surface ag eia 11.48

87350 Hepatitis be ag eia 12.81

87380 Hepatitis delta ag eia 18.23

87385 Histoplasma capsul ag eia 13.32

87389 Hiv-1 ag w/hiv-1 & hiv-2 ab 26.76

87390 Hiv-1 ag eia 21.65

87391 Hiv-2 ag eia 19.71

87400 Influenza a/b ag eia 13.32

87420 Resp syncytial ag eia 13.32

87425 Rotavirus ag eia 13.32

87427 Shiga-like toxin ag eia 13.32

87430 Strep a ag eia 15.13

87449 QW Ag detect nos eia mult 13.32

87449 Ag detect nos eia mult 13.32

87450 Ag detect nos eia single 10.66

87451 Ag detect polyval eia mult 10.66

87471 Bartonella dna amp probe 39.00

87472 Bartonella dna quant 47.59

87475 Lyme dis dna dir probe 22.28

87476 Lyme dis dna amp probe 39.00

87480 Candida dna dir probe 22.28

87481 Candida dna amp probe 39.00

87482 Candida dna quant 50.17

87483 Cns dna amp probe type 12-25 463.10

87485 Chylmd pneum dna dir probe 22.28

87486 Chylmd pneum dna amp probe 39.00

87487 Chylmd pneum dna quant 47.59

87490 Chylmd trach dna dir probe 22.28

87491 Chylmd trach dna amp probe 39.00

87492 Chylmd trach dna quant 48.12

87493 C diff amplified probe 39.00

87495 Cytomeg dna dir probe 27.03

87496 Cytomeg dna amp probe 39.00

87497 Cytomeg dna quant 47.59

87498 Enterovirus probe&revrs trns 39.00

87500 Vanomycin dna amp probe 39.00

87501 Influenza dna amp prob 1+ 57.02

87502 Influenza dna amp probe 94.55

87503 Influenza dna amp prob addl 26.30

87505 Nfct agent detection gi 142.54

26

34




Effective 04/01/19 - 03/31/20



87506 Iadna-dna/rna probe tq 6-11 237.14

87507 Iadna-dna/rna probe tq 12-25 463.10

87510 Gardner vag dna dir probe 22.28

87511 Gardner vag dna amp probe 39.00

87512 Gardner vag dna quant 46.40

87516 Hepatitis b dna amp probe 39.00

87517 Hepatitis b dna quant 47.59

87520 Hepatitis c rna dir probe 28.10

87521 Hepatitis c probe&rvrs trnsc 39.00

87522 Hepatitis c revrs trnscrpj 47.59

87525 Hepatitis g dna dir probe 26.82

87526 Hepatitis g dna amp probe 39.00

87527 Hepatitis g dna quant 46.40

87528 Hsv dna dir probe 22.28

87529 Hsv dna amp probe 39.00

87530 Hsv dna quant 47.59

87531 Hhv-6 dna dir probe 52.20

87532 Hhv-6 dna amp probe 39.00

87533 Hhv-6 dna quant 46.40

87534 Hiv-1 dna dir probe 22.28

87535 Hiv-1 probe&reverse trnscrpj 39.00

87536 Hiv-1 quant&revrse trnscrpj 94.55

87537 Hiv-2 dna dir probe 22.28

87538 Hiv-2 probe&revrse trnscripj 39.00

87539 Hiv-2 quant&revrse trnscripj 52.76

87540 Legion pneumo dna dir prob 22.28

87541 Legion pneumo dna amp prob 39.00

87542 Legion pneumo dna quant 46.40

87550 Mycobacteria dna dir probe 22.28

87551 Mycobacteria dna amp probe 43.42

87552 Mycobacteria dna quant 47.59

87555 M.tuberculo dna dir probe 24.19

87556 M.tuberculo dna amp probe 39.00

87557 M.tuberculo dna quant 47.59

87560 M.avium-intra dna dir prob 24.56

87561 M.avium-intra dna amp prob 39.00

87562 M.avium-intra dna quant 47.59

87580 M.pneumon dna dir probe 22.28

87581 M.pneumon dna amp probe 39.00

87582 M.pneumon dna quant 272.36

87590 N.gonorrhoeae dna dir prob 24.19

87591 N.gonorrhoeae dna amp prob 39.00

87592 N.gonorrhoeae dna quant 47.59

87623 Hpv low-risk types 39.00

87624 Hpv high-risk types 39.00

87625 Hpv types 16 & 18 only 39.00

87631 Resp virus 3-11 targets 142.54

27

34




Effective 04/01/19 - 03/31/20





87634 Rsv dna/rna amp probe 77.99

87640 Staph a dna amp probe 39.00

87641 Mr-staph dna amp probe 39.00

87650 Strep a dna dir probe 22.28

87651 Strep a dna amp probe 39.00

87652 Strep a dna quant 46.40

87653 Strep b dna amp probe 39.00

87660 Trichomonas vagin dir probe 22.28

87661 Trichomonas vaginalis amplif 39.00

87662 Zika virus dna/rna amp probe 57.02

87797 Detect agent nos dna dir 27.03

87798 Detect agent nos dna amp 39.00

87799 Detect agent nos dna quant 47.59

87800 Detect agnt mult dna direc 44.58

87801 Detect agnt mult dna ampli 77.99

87802 Strep b assay w/optic 13.32

87803 Clostridium toxin a w/optic 14.40

87804 QW Influenza assay w/optic 14.90

87804 Influenza assay w/optic 14.90

87806 Hiv antigen w/hiv antibodies 29.49

87807 QW Rsv assay w/optic 13.32

87807 Rsv assay w/optic 13.32

87808 QW Trichomonas assay w/optic 13.76

87808 Trichomonas assay w/optic 13.76

87809 QW Adenovirus assay w/optic 19.58

87809 Adenovirus assay w/optic 19.58

87810 Chylmd trach assay w/optic 31.76

87850 N. gonorrhoeae assay w/optic 22.10

87880 QW Strep a assay w/optic 14.88

87880 Strep a assay w/optic 14.88

87899 QW Agent nos assay w/optic 14.46

87899 Agent nos assay w/optic 14.46

87900 Phenotype infect agent drug 144.83

87901 Genotype dna hiv reverse t 286.06

87902 Genotype dna/rna hep c 286.06

87903 Phenotype dna hiv w/culture 542.95

87904 Phenotype dna hiv w/clt add 28.96

87906 Genotype dna/rna hiv 143.03

87910 Genotype cytomegalovirus 286.06

87912 Genotype dna hepatitis b 286.06

87999 Unlisted microbiology procedure Unlisted/Manual

88104 26 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation43.77

88104 TC Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation43.77

88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation43.77

88106 26 Cytopathology, fluids, washings or brushings, except cervical or vaginal; simple filter method with interpretation38.58

28

34




Effective 04/01/19 - 03/31/20



88106 TC Cytopathology, fluids, washings or brushings, except cervical or vaginal; simple filter method with interpretation38.58

88106 Cytopathology, fluids, washings or brushings, except cervical or vaginal; simple filter method with interpretation38.58

88108 26 Cytopathology, concentration technique, smears and interpretation36.71

88108 TC Cytopathology, concentration technique, smears and interpretation36.71

88108 Cytopathology, concentration technique, smears and interpretation36.71

88112 26 Cytopathology, selective cellular enhancement technique with interpretation, except cervical or vaginal41.52

88112 TC Cytopathology, selective cellular enhancement technique with interpretation, except cervical or vaginal41.52

88112 Cytopathology, selective cellular enhancement technique with interpretation, except cervical or vaginal41.52

88120 26 Cytopathology, in situ hybridization (eg, FISH) 372.58

88120 TC Cytopathology, in situ hybridization (eg, FISH) 372.58

88120 Cytopathology, in situ hybridization (eg, FISH) 372.58

88121 26 Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology310.53

88121 TC Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology310.53

88121 Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology310.53

88125 26 Cytopathology, forensic (eg, sperm) 16.42

88125 TC Cytopathology, forensic (eg, sperm) 16.42

88125 Cytopathology, forensic (eg, sperm) 16.42

88130 Sex chromatin identification 19.97

88140 Sex chromatin identification 8.87

88141 Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician20.11

88142 Cytopath c/v thin layer 22.51

88143 Cytopath c/v thin layer redo 22.51

88147 Cytopath c/v automated 45.50

88148 Cytopath c/v auto rescreen 16.88

88150 Cytopath c/v manual 13.19

88152 Cytopath c/v auto redo 24.88

88153 Cytopath c/v redo 21.63

88155 Cytopath c/v index add-on 13.19

88160 26 Cytopathology, smears, any other source; screening and interpretation43.61

88160 TC Cytopathology, smears, any other source; screening and interpretation43.61

88160 Cytopathology, smears, any other source; screening and interpretation43.61

88161 26 Cytopathology, smears, any other source; preparation, screening and interpretation39.73

88161 TC Cytopathology, smears, any other source; preparation, screening and interpretation39.73

88161 Cytopathology, smears, any other source; preparation, screening and interpretation39.73

88162 26 Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains58.60

88162 TC Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains58.60

88162 Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains58.60

88164 Cytopath tbs c/v manual 13.19

88165 Cytopath tbs c/v redo 38.00

88166 Cytopath tbs c/v auto redo 13.19

88167 Cytopath tbs c/v select 13.19

88172 26 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s)35.63

88172 TC Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s)35.63

88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s)35.63

88173 26 Cytopathology, evaluation of fine needle aspirate; interpretation and report93.87

88173 TC Cytopathology, evaluation of fine needle aspirate; interpretation and report93.87

88173 Cytopathology, evaluation of fine needle aspirate; interpretation and report93.87

29

34




Effective 04/01/19 - 03/31/20



88174 Cytopath c/v auto in fluid 23.74

88175 Cytopath c/v auto fluid redo 29.44

88177 26 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (list sperately in addition to code for primary procedure)18.98

88177 TC Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (list sperately in addition to code for primary procedure)18.98

88177 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (list sperately in addition to code for primary procedure)18.98

88182 Flow cytometry, cell cycle or DNA analysis 78.56

88182 26 Flow cytometry, cell cycle or DNA analysis 78.56

88182 TC Flow cytometry, cell cycle or DNA analysis 78.56

88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker38.84

88185 each additional marker (List separately in addition to code for first marker)17.37

88187 Flow cytometry, interpretation; 2 to 8 markers 29.73

88188 Flow cytometry, interpretation; 9 to 15 markers 41.56

88189 Flow cytometry, interpretation; 16 or more markers 55.74

88199 Unlisted cytopathology procedure Unlisted/Manual

88199 26 Unlisted cytopathology procedure Unlisted/Manual

88199 TC Unlisted cytopathology procedure Unlisted/Manual

88230 Tissue culture lymphocyte 129.44

88233 Tissue culture skin/biopsy 156.37

88235 Tissue culture placenta 163.63

88237 Tissue culture bone marrow 140.34

88239 Tissue culture tumor 163.91

88240 Cell cryopreserve/storage 11.76

88241 Frozen cell preparation 11.22

88245 Chromosome analysis 20-25 192.42


88249 Chromosome analysis 100 192.42





88267 Chromosome analys placenta 199.76

88269 Chromosome analys amniotic 184.81

88271 Cytogenetics dna probe 23.80

88272 Cytogenetics 3-5 36.63



88275 Cytogenetics 100-300 46.07

88280 Chromosome karyotype study 30.12

88283 Chromosome banding study 76.22

88285 Chromosome count additional 24.22

88289 Chromosome study additional 38.26

88291 Cytogenetics and molecular cytogenetics, interpretation and report20.77

88299 Unlisted cytogenetic study Unlisted/Manual

88300 Level I-Surgical pathology, gross examination only 10.02

88300 26 Level I-Surgical pathology, gross examination only 10.02

88300 TC Level I-Surgical pathology, gross examination only 10.02

88302 Level II- Surgical pathology, gross and microscopic examination 18.53

30

34




Effective 04/01/19 - 03/31/20



88302 26 Level II- Surgical pathology, gross and microscopic examination 18.53

88302 TC Level II- Surgical pathology, gross and microscopic examination 18.53

88304 TC Level III- Surgical pathology, gross and microscopic examination24.49

88304 Level III- Surgical pathology, gross and microscopic examination24.49

88304 26 Level III- Surgical pathology, gross and microscopic examination24.49

88305 TC Level IV- Surgical pathology, gross and microscopic examination42.12

88305 Level IV- Surgical pathology, gross and microscopic examination42.12

88305 26 Level IV- Surgical pathology, gross and microscopic examination42.12

88307 Level V- Surgical pathology, gross and microscopic examination158.06

88307 26 Level V- Surgical pathology, gross and microscopic examination158.06

88307 TC Level V- Surgical pathology, gross and microscopic examination158.06

88309 Level VI- Surgical pathology, gross and microscopic examination241.13

88309 26 Level VI- Surgical pathology, gross and microscopic examination241.13

88309 TC Level VI- Surgical pathology, gross and microscopic examination241.13

88311 Decalcification procedure (List separately in addition to code for surgical pathology examination)13.71

88311 26 Decalcification procedure (List separately in addition to code for surgical pathology examination)13.71

88311 TC Decalcification procedure (List separately in addition to code for surgical pathology examination)13.71

88312 TC Special stains (List separately in addition to code for primary service); Group I for microorganisms, each58.03

88312 Special stains (List separately in addition to code for primary service); Group I for microorganisms, each58.03

88312 26 Special stains (List separately in addition to code for primary service); Group I for microorganisms, each58.03

88313 Group II, all other, except immunocytochemistry and immunoperoxidase stains, each41.71

88313 26 Group II, all other, except immunocytochemistry and immunoperoxidase stains, each41.71

88313 TC Group II, all other, except immunocytochemistry and immunoperoxidase stains, each41.71

88314 histochemical staining with frozen section(s) 50.84

88314 26 histochemical staining with frozen section(s) 50.84

88314 TC histochemical staining with frozen section(s) 50.84

88319 Determinative histochemistry or cytochemistry to identify enzyme constituents, each52.69

88319 26 Determinative histochemistry or cytochemistry to identify enzyme constituents, each52.69

88319 TC Determinative histochemistry or cytochemistry to identify enzyme constituents, each52.69

88321 Consultation and report on referred slides prepared elsewhere 64.76

88323 Consultation and report on referred material requiring preparation of slides76.10

88323 26 Consultation and report on referred material requiring preparation of slides76.10

88323 TC Consultation and report on referred material requiring preparation of slides76.10

88325 Consultation, comprehensive, with review of records and specimens, with report on referred material116.59

88329 Pathology consultation during surgery 32.41

88331 Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen60.13

88331 26 Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen60.13

88331 TC Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen60.13

88332 Pathology consultation during surgery; each additional tissue block with frozen section(s)32.61

88332 26 Pathology consultation during surgery; each additional tissue block with frozen section(s)32.61

88332 TC Pathology consultation during surgery; each additional tissue block with frozen section(s)32.61

88333 Pathology consultation during surgery; cytologic examination, initial site55.66

88333 26 Pathology consultation during surgery; cytologic examination, initial site55.66

88333 TC Pathology consultation during surgery; cytologic examination, initial site55.66

88334 Pathology consultation during surgery; cytologic examination, each additional site34.40

88334 26 Pathology consultation during surgery; cytologic examination, each additional site34.40

88334 TC Pathology consultation during surgery; cytologic examination, each additional site34.40

31

34




Effective 04/01/19 - 03/31/20



88341 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure55.32

88341 26 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure55.32

88341 TC Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure55.32

88342 Immunohistochemistry (including tissue immunoperoxidase), each antibody65.50

88342 26 Immunohistochemistry (including tissue immunoperoxidase), each antibody65.50

88342 TC Immunohistochemistry (including tissue immunoperoxidase), each antibody65.50

88344 Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure103.70

88344 26 Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure103.70

88344 TC Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure103.70

88346 Immunofluorescence, per specimen; initial single antibody stain procedure56.50

88346 26 Immunofluorescence, per specimen; initial single antibody stain procedure56.50

88346 TC Immunofluorescence, per specimen; initial single antibody stain procedure56.50

88348 Electron microscopy; diagnostic 205.89

88348 26 Electron microscopy; diagnostic 205.89

88348 TC Electron microscopy; diagnostic 205.89

88350 Immunofluorescence, per specimen; each additional single antibody stain procedure43.54

88350 26 Immunofluorescence, per specimen; each additional single antibody stain procedure43.54

88350 TC Immunofluorescence, per specimen; each additional single antibody stain procedure43.54

88355 Morphometric analysis; skeletal muscle 81.26

88355 26 Morphometric analysis; skeletal muscle 81.26

88355 TC Morphometric analysis; skeletal muscle 81.26

88356 Morphometric analysis; nerve 136.07

88356 26 Morphometric analysis; nerve 136.07

88356 TC Morphometric analysis; nerve 136.07

88358 Morphometric analysis; tumor 57.77

88358 26 Morphometric analysis; tumor 57.77

88358 TC Morphometric analysis; tumor 57.77

88360 Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody; manual79.99

88360 26 Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody; manual79.99

88360 TC Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody; manual79.99

88361 Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody; using computer-assisted technology86.99

88361 26 Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody; using computer-assisted technology86.99

88361 TC Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody; using computer-assisted technology86.99

88362 Nerve teasing preparations 127.79

88362 26 Nerve teasing preparations 127.79

88362 TC Nerve teasing preparations 127.79

88363 Examination and selection of retrieved archival (ie, previously diagnosed) tissue (s) for molecular analysis (eg, KRAS mutational analysis)15.07

88364 In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure78.78

88364 26 In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure78.78

88364 TC In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure78.78

88365 In situ hybridization, each probe 106.84

88365 26 In situ hybridization, each probe 106.84

88365 TC In situ hybridization, each probe 106.84

88366 In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure155.92

88366 26 In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure155.92

88366 TC In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure155.92

88367 Morphmetric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; using computer-assisted technology64.24

32

34




Effective 04/01/19 - 03/31/20



88367 26 Morphmetric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; using computer-assisted technology64.24

88367 TC Morphmetric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; using computer-assisted technology64.24

88368 Morphmetric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; manual72.71

88368 26 Morphmetric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; manual72.71

88368 TC Morphmetric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; manual72.71

88369 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each additional single probe stain procedure65.39

88369 26 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each additional single probe stain procedure65.39

88369 TC Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each additional single probe stain procedure65.39

88371 26 Protein western blot tissue 24.70

88371 Protein western blot tissue 24.70

88372 26 Protein analysis w/probe 25.27

88372 Protein analysis w/probe 25.27

88373 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure47.19

88373 26 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure47.19

88373 TC Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure47.19

88374 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure202.12

88374 26 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure202.12

88374 TC Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure202.12

88377 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure241.16

88377 26 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure241.16

88377 TC Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure241.16

88380 Microdissection; laser capture 82.89

88380 26 Microdissection; laser capture 82.89

88380 TC Microdissection; laser capture 82.89

88381 Microdissection; manual 72.62

88381 26 Microdissection; manual 72.62

88381 TC Microdissection; manual 72.62

88387 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); each tissue preparation (eg, a single lymph node)22.16

88387 26 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); each tissue preparation (eg, a single lymph node)22.16

88387 TC Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); each tissue preparation (eg, a single lymph node)22.16

88388 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies; in conjuction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure)21.41

88388 26 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies; in conjuction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure)21.41

88388 TC Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies; in conjuction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure)21.41

88399 Unlisted surgical pathology procedure Unlisted/Manual

88399 26 Unlisted surgical pathology procedure Unlisted/Manual

88399 TC Unlisted surgical pathology procedure Unlisted/Manual

88720 Bilirubin total transcut 5.57

88738 Hgb quant transcutaneous 5.57

88740 Transcutaneous carboxyhb 8.43

88741 Transcutaneous methb 8.43

88749 Unlisted in vivo (eg, transcutaneous) laboratory serviceUnlisted/Manual

89049 Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report145.83

89050 Body fluid cell count 5.25

89051 Body fluid cell count 6.12

89055 Leukocyte assessment fecal 4.74

89060 26 Exam synovial fluid crystals 7.95

89060 Exam synovial fluid crystals 7.95

33

34




Effective 04/01/19 - 03/31/20



89125 Specimen fat stain 5.29

89160 Exam feces for meat fibers 4.37

89190 Nasal smear for eosinophils 5.27

89220 Sputum, obtaining specimen, aerosol induced technique (separate procedure)9.51

89230 Sweat collection by iontophoresis 2.15

89240 Unlisted miscellaneous pathology test Unlisted/Manual

89310 Semen analysis w/count 9.57

0008M Onc breast risk score 3,099.02

0009M Fetal aneuploidy trisom risk 541.89

G0480 Drug test def 1-7 classes 102.99



G0483 Drug test def 22+ classes 222.23

G0659 Drug test def simple all cl 64.65

P7001 Culture, bacterial, urine; quantitative, sensitivity study 15.00

P9612 Catheterize for urine spec 2.70

34

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