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The inclusion of a rate on this table does not guarantee that a service is covered. Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical
80184 phenobarbital $14.2880185 phentoin: total $16.5180186 phentoin; free $17.1580188 primidone $20.3080190 procainamide $20.8780192 procainamide: with antibodies $20.8780194 quinidine $18.1880195 sirolimus $17.0980197 tacrolimus $17.0980198 theophylline $17.6380200 tobramycin $20.0880201 topiramate $14.8680202 vancomycin $16.7080299 quantitation of drug, not elsewhere specified $17.0680300 drug screen non tlc devices $18.1280301 drug screen class list a $18.1280302 drug screen prsmptv 1 class $22.3780303 drug screen one/mult class $22.9080304 drug screen one/mult class $22.3780320 drug screen quantalcohols $13.4780321 alcohols biomarkers 1or 2 $13.4780322 alcohols biomarkers 3/more $13.4780323 alkaloids nos $37.4180324 drug screen amphetamines 1/2 $19.3780325 amphetamines 3or 4 $19.3780326 amphetamines 5 or more $19.3780327 anabolic steroid 1 or 2 $32.1680328 anabolic steroid 3 or more $32.1680329 analgesics non-opioid 1 or 2 $25.2280330 analgesics non-opioid 3-5 $25.2280331 analgesics non-opioid 6/more $25.2280332 antidepressants class 1 or 2 $22.3780333 antidepressants class 3-5 $22.3780334 antidepressants class 6/more $22.3780335 antidepressant tricyclic 1/2 $20.3080336 antidepressant tricyclic 3-5 $20.3080337 tricyclic & cyclicals 6/more $20.3080338 antidepressant not specified $22.3780339 antiepileptics nos 1-3 $18.0480340 antiepileptics nos 4-6 $18.0480341 antiepileptics nos 7/more $18.0480342 antipsychotics nos 1-3 $22.9080343 antipsychotics nos 4-6 $22.9080344 antipsychotics nos 7/more $22.9080345 drug screening barbiturates $14.2880346 benzodiazepines1-12 $23.0480347 benzodiazepines 13 or more $23.04
86806 lymphocytotoxicity assay, visual xm; w/o titration $59.3086807 serum screening for cytotoxic pra; standard method $49.3086808 serum screening for cytotoxic pra; quick method $36.9986812 tissue typing hla typing a,b, or c single antigen $32.1586813 tissue typing hla typing a,b, &/or c mult antigens $72.2686816 hla typing; dr/dq, single antigen $34.7186817 hla typing; dr/dq, multiple antigens $80.2186821 tissue typing lympnocyte culture mixed (mlc) $70.3486822 tissue typing lymphocyte culture primed (plc) $45.5486825 human leukocyte antigen (hla) crossmatch, non‐cytotoxic (eg, using $102.6086826 human leukocyte antigen (hla) crossmatch, non‐cytotoxic (eg, using $34.2086828 antibody to human leukocyte antigens (hla), solid phase assays (eg, $48.5186829 antibody to human leukocyte antigens (hla), solid phase assays (eg, $36.3986830 antibody to human leukocyte antigens (hla), solid phase assays (eg, $98.2586831 antibody to human leukocyte antigens (hla), solid phase assays (eg, $84.2286832 antibody to human leukocyte antigens (hla), solid phase assays (eg, $154.4186833 antibody to human leukocyte antigens (hla), solid phase assays (eg, $140.3786834 antibody to human leukocyte antigens (hla), solid phase assays (eg, $435.1586835 antibody to human leukocyte antigens (hla), solid phase assays (eg, $393.0486850 antibody screen, rbc, each serum technique $14.5186860 antibody elution, each elution $14.2086870 antibody id, each panel for each serum technique $25.6386880 coombs test; direct, each antiserum $6.6986885 antihuman globulin test indirect, qualitative each antiserum $7.1286886 coombs test, indirect titer, each antiserum $6.4586900 blood typing; abo $3.7186901 blood typing; rh (d) $3.7186902 blood typing; antigen testing of donor blood using reagent serum, e $4.8086904 blood typing; antigen screening, per unit screened $11.8486905 blood typing; rbc antigens, each $4.7686906 blood typing; rh phenotyping, complete $9.6686940 hemolysins/agglutinins, auto, screen, each $10.2286941 hemolysins/ agglutinins, each; incubated $15.0987003 animal innoculation small animal w/observation and $20.9787015 concentration (any type), for infectious agents $8.3287040 culture, bacterial; blood, with isolation and presumptive identificatio $12.8687045 culture, bacterial; feces, with isolation and preliminary examination $11.7587046 culture, bacterial; stool, additional pathogens, isolation and prelimin $11.7587070 culture, bacterial; any other source except urine, blood or stool, wit $10.7387071 culture, bacterial; quantitative, aerobic with isolation and presumpt $11.7587073 culture, bacterial; quantitative, anaerobic with isolation and presum $11.7587075 culture, bacterial; any source, anaerobic with isolation and presump $11.7987076 culture, bacterial; anaerobic isolate, additional methods required fo $10.0687077 culture, bacterial; aerobic isolate, additional methods required for d $10.0687081 culture, presumptive, pathogenic organisms, screening only; $7.1887084 culture w colony estimation from density chart inc $10.7387086 culture, bacterial; quantitative colony count, urine $10.05
87088 culture, bacterial; with isolation and presumptive identification of is $10.0887101 culture, fungi (mold or yeast) isolation, with presumptive identificat $9.6087102 culture fungi isolation other source $10.4787103 blood culture for fungi $11.2487106 culture, fungi, definitive identification, each organism; yeast $12.8687107 culture, fungi, definitive identification, each organism; mold $12.8687109 culture mycoplasm any source $19.1887110 culture, chlamydia, any source $24.4187116 culture, tubercle or other acid‐fast bacilli (eg, tb, afb, mycobacteria) $13.4787118 culture, mycobacterial, definitive identification, each isolate $13.6387140 culture, typing; immunofluorescent method, each antiserum $6.9587143 culture, typing; gas liquid chromatography (glc) or high pressure liqu $15.6187147 culture, typing; immunologic method, other than immunofluoresenc $6.4587149 culture, typing; identification by nucleic acid probe $24.9987150 culture, typing; identification by nucleic acid (dna or rna) probe, amp $31.3287152 culture, typing; identification by pulse field gel typing $6.5287153 culture, typing; identification by nucleic acid sequencing method, ea $75.5887158 culture typing other methods $6.5287164 26 darkfield examination $14.9087164 darkfield examination $7.8987166 dark field exam any source w/o collection $14.0787168 macroscopic examination; arthropod $4.7587169 macroscopic examination; parasite $4.7587172 pinworm exam (eg, cellophane tape prep) $4.7587176 homogenization, tissue, for culture $7.3387177 ova and parasites $11.0887181 susceptibility studies, antimicrobial agent; agar dilution method, per $5.9287184 susceptibility studies, antimicrobial agent; disk method, per plate (1 $8.5887185 susceptibility studies, antimicrobial agent; enzyme detection (eg, be $5.9287186 susceptibility studies, antimicrobial agent; microdilution or agar dilu $10.7787187 susceptibility studies, antimicrobial agent; microdilution or agar dilu $12.9287188 susceptibility studies, antimicrobial agent; macrobroth dilution meth $8.2787190 susceptibility studies, antimicrobial agent; mycobacteria, proportion $7.0587197 serum bactericidal titer $18.7287205 smear, primary source with interpretation; gram or giemsa stain for $5.3187206 smear, primary source with interpretation; fluorescent and/or acid f $6.6987207 26 smear, primary source with interpretation; special stain for inclusion $15.1787207 smear, primary source with interpretation; special stain for inclusion $7.4787209 smear, primary source with interpretation; complex special stain (eg $22.3987210 smear, primary source with interpretation; wet mount for infectious $4.7587220 tissue examination by koh slide of samples from skin, hair, or nails fo $5.3187230 tissue culture lymphocyte $24.6187250 virus isolation; inoculation of embryonated eggs, or small animal, inc $20.3087252 virus isolation; tissue culture inoculation, observation, and presump $20.3087253 virus isolation; tissue culture, additional studies or definitive $20.3087254 virus isolation; shell vial, includes identification with immunofluores $20.3087255 virus isolation; including identification by non‐immunologic method, $30.45
87260 infectious agent antigen detection by immunofluorescent technique $14.2887265 infectious agent antigen detection by direct fluorescent antibody tec $14.2887267 infectious agent antigen detection by immunofluorescent technique $14.2887269 infectious agent antigen detection by immunofluorescent technique $14.2887270 infectious agent antigen detection by direct fluorescent antibody tec $14.2887271 infectious agent antigen detection by immunofluorescent technique $14.2887272 infectious agent antigen detection by direct fluorescent antibody tec $14.2887273 infectious agent antigen detection by immunofluorescent technique $14.2887274 infectious agent antigen detection by immunofluorescent technique $14.2887275 infectious agent antigen detection by immunofluorescent technique $14.2887276 infectious agent antigen detection by direct fluorescent antibody tec $14.2887277 infectious agent antigen detection by immunofluorescent technique $14.2887278 infectious agent antigen detection by direct fluorescent antibody tec $14.2887279 infectious agent antigen detection by immunofluorescent technique $14.2887280 infectious agent antigen detection by direct fluorescent antibody tec $14.2887281 infectious agent antigen detection by immunofluorescent technique $14.2887283 infectious agent antigen detection by immunofluorescent technique $14.2887285 infectious agent antigen detection by direct fluorescent antibody tec $14.2887290 infectious agent antigen detection by direct fluorescent antibody tec $14.2887299 infectious agent antigen detection by immunofluorescent technique $14.2887300 infectious agent antigen detection by immunofluorescent technique $14.2887301 infectious agent antigen detection by enzyme immunoassay techniq $14.2887305 infectious agent antigen detection by enzyme immunoassay techniq $14.2887320 infectious agent antigen detection by enzyme immunoassay techniq $14.2887324 infectious agent antigen detection by enzyme immunoassay techniq $14.2887327 infectious agent antigen detection by enzyme immunoassay techniq $14.2887328 infectious agent antigen detection by enzyme immunoassay techniq $14.2887329 infectious agent antigen detection by enzyme immunoassay techniq $14.2887332 infectious agent antigen detection by enzyme immunoassay techniq $14.2887335 infectious agent antigen detection by enzyme immunoassay techniq $14.2887336 infectious agent antigen detection by enzyme immunoassay techniq $14.2887337 infectious agent antigen detection by enzyme immunoassay techniq $14.2887338 infectious agent antigen detection by enzyme immunoassay techniq $17.9287339 infectious agent antigen detection by enzyme immunoassay techniq $14.2887340 infectious agent antigen detection by enzyme immunoassay techniq $11.5987341 infectious agent antigen detection by enzyme immunoassay techniq $11.5987350 infectious agent antigen detection by enzyme immunoassay techniq $13.7987380 infectious agent antigen detection by enzyme immunoassay techniq $20.4687385 infectious agent antigen detection by enzyme immunoassay techniq $14.2887389 infectious agent antigen detection by enzyme immunoassay techniq $29.9287390 infectious agent antigen detection by enzyme immunoassay techniq $21.9887391 infectious agent antigen detection by enzyme immunoassay techniq $21.9887400 infectious agent antigen detection by enzyme immunoassay techniq $14.2887420 infectious agent antigen detection by enzyme immunoassay techniq $14.2887425 infectious agent antigen detection by enzyme immunoassay techniq $14.2887427 infectious agent antigen detection by enzyme immunoassay techniq $14.2887430 infectious agent antigen detection by enzyme immunoassay techniq $14.28
87449 infectious agent antigen detection by enzyme immunoassay techniq $14.2887450 infectious agent antigen detection by enzyme immunoassay techniq $9.5387451 infectious agent antigen detection by enzyme immunoassay techniq $9.5387470 infectious agent detection by nucleic acid (dna or rna); bartonella he $24.9987471 infectious agent detection by nucleic acid (dna or rna); bartonella he $30.5687472 infectious agent detection by nucleic acid (dna or rna); bartonella he $40.5887475 infectious agent detection by nucleic acid (dna or rna); borrelia burg $24.9987476 infectious agent detection by nucleic acid (dna or rna); borrelia burg $30.5687477 infectious agent detection by nucleic acid (dna or rna); borrelia burg $40.5887480 infectious agent detection by nucleic acid (dna or rna); candida spec $24.9987481 infectious agent detection by nucleic acid (dna or rna); candida spec $30.5687482 infectious agent detection by nucleic acid (dna or rna); candida spec $40.5887485 infectious agent detection by nucleic acid (dna or rna); chlamydia pn $24.9987486 infectious agent detection by nucleic acid (dna or rna); chlamydia pn $30.5687487 infectious agent detection by nucleic acid (dna or rna); chlamydia pn $40.5887490 infectious agent detection by nucleic acid (dna or rna); chlamydia tra $24.9987491 infectious agent detection by nucleic acid (dna or rna); chlamydia tra $30.5687492 infectious agent detection by nucleic acid (dna or rna); chlamydia tra $40.5887493 clostridium difficile, toxin gene(s), amplified probe technique $31.3287495 infectious agent detection by nucleic acid (dna or rna); cytomegalov $24.9987496 infectious agent detection by nucleic acid (dna or rna); cytomegalov $30.5687497 infectious agent detection by nucleic acid (dna or rna); cytomegalov $40.5887498 infectious agent detection by nucleic acid (dna or rna); enterovirus, $30.5687500 infectious agent detection by nucleic acid (dna or rna); vancomycin r $30.5687501 infectious agent detection by nucleic acid (dna or rna); infuenza viru $35.9587502 infectious agent detection by nucleic acid (dna or rna); infuenza viru $66.7287503 infectious agent detection by nucleic acid (dna or rna); infuenza viru $11.5787505 nfct agent detection gi $88.6787506 iadna-dna/rna probe tq 6-11 $134.3387507 iadna-dna/rna probe tq 12-25 $248.4887510 infectious agent detection by nucleic acid (dna or rna); gardnerella v $24.9987511 infectious agent detection by nucleic acid (dna or rna); gardnerella v $30.5687512 infectious agent detection by nucleic acid (dna or rna); gardnerella v $40.5887515 infectious agent detection by nucleic acid (dna or rna); hepatitis b vi $24.9987516 infectious agent detection by nucleic acid (dna or rna); hepatitis b vi $30.5687517 infectious agent detection by nucleic acid (dna or rna); hepatitis b vi $40.5887520 infectious agent detection by nucleic acid (dna or rna); hepatitis c, d $24.9987521 infectious agent detection by nucleic acid (dna or rna); hepatitis c, a $30.5687522 infectious agent detection by nucleic acid (dna or rna); hepatitis c, $40.5887525 infectious agent detection by nucleic acid (dna or rna); hepatitis g, d $24.9987526 infectious agent detection by nucleic acid (dna or rna); hepatitis g, a $30.5687527 infectious agent detection by nucleic acid (dna or rna); hepatitis g, $40.5887528 infectious agent detection by nucleic acid (dna or rna); herpes simpl $24.9987529 infectious agent detection by nucleic acid (dna or rna); herpes simpl $30.5687530 infectious agent detection by nucleic acid (dna or rna); herpes simpl $40.5887531 infectious agent detection by nucleic acid (dna or rna); herpes virus‐ $24.9987532 infectious agent detection by nucleic acid (dna or rna); herpes virus‐ $30.56
87533 infectious agent detection by nucleic acid (dna or rna); herpes virus‐ $40.5887534 infectious agent detection by nucleic acid (dna or rna); hiv‐1, direct p $24.9987535 infectious agent detection by nucleic acid (dna or rna); hiv‐1, amplifi $30.5687536 infectious agent detection by nucleic acid (dna or rna); hiv‐1, quantif $66.2487537 infectious agent detection by nucleic acid (dna or rna); hiv‐2, direct p $24.9987538 infectious agent detection by nucleic acid (dna or rna); hiv‐2, amplifi $30.5687539 infectious agent detection by nucleic acid (dna or rna); hiv‐2, quantif $40.5887540 infectious agent detection by nucleic acid (dna or rna); legionella $24.9987541 infectious agent detection by nucleic acid (dna or rna); legionella $30.5687542 infectious agent detection by nucleic acid (dna or rna); legionella $40.5887550 infectious agent detection by nucleic acid (dna or rna); mycobacteria $24.9987551 infectious agent detection by nucleic acid (dna or rna); mycobacteria $30.5687552 infectious agent detection by nucleic acid (dna or rna); mycobacteria $40.5887555 infectious agent detection by nucleic acid (dna or rna); mycobacteria $24.9987556 infectious agent detection by nucleic acid (dna or rna); mycobacteria $30.5687557 infectious agent detection by nucleic acid (dna or rna); mycobacteria $40.5887560 infectious agent detection by nucleic acid (dna or rna); mycobacteria $24.9987561 infectious agent detection by nucleic acid (dna or rna); mycobacteria $30.5687562 infectious agent detection by nucleic acid (dna or rna); mycobacteria $40.5887580 infectious agent detection by nucleic acid (dna or rna); mycoplasma $24.9987581 infectious agent detection by nucleic acid (dna or rna); mycoplasma $30.5687582 infectious agent detection by nucleic acid (dna or rna); mycoplasma $40.5887590 infectious agent detection by nucleic acid (dna or rna); neisseria gon $24.9987591 infectious agent detection by nucleic acid (dna or rna); neisseria gon $30.5687592 infectious agent detection by nucleic acid (dna or rna); neisseria gon $40.5887623 hpv low-risk types $30.3887624 hpv high-risk types $30.3887625 hpv types 16 & 18 only $30.3887631 infectious agent detection by nucleic acid (dna or rna); respiratory v $87.7787632 infectious agent detection by nucleic acid (dna or rna); respiratory v $132.9787633 infectious agent detection by nucleic acid (dna or rna); respiratory v $245.9687640 infectious agent detection by nucleic acid (dna or rna); staphylococc $30.5687641 infectious agent detection by nucleic acid (dna or rna); staphylococc $30.5687650 infectious agent detection by nucleic acid (dna or rna); streptococcu $24.9987651 infectious agent detection by nucleic acid (dna or rna); streptococcu $30.5687652 infectious agent detection by nucleic acid (dna or rna); streptococcu $40.5887653 infectious agent detection by nucleic acid (dna or rna); streptococcu $30.5687660 infectious agent detection by nucleic acid (dna or rna); trichomonas $24.9987797 infectious agent detection by nucleic acid (dna or rna), not otherwis $24.9987798 infectious agent detection by nucleic acid (dna or rna), not otherwis $30.5687799 infectious agent detection by nucleic acid (dna or rna), not otherwis $40.5887800 infectious agent detection by nucleic acid (dna or rna), multiple orga $49.9787801 infectious agent detection by nucleic acid (dna or rna), multiple orga $61.1087802 infectious agent antigen detection by immunoassay with direct optic $14.2887803 infectious agent antigen detection by immunoassay with direct optic $14.2887804 infectious agent antigen detection by immunoassay with direct optic $14.2887806 hiv antigen w/hiv antibodies $29.34
87807 infectious agent antigen detection by immunoassay with direct optic $14.2887808 infectious agent antigen detection by immunoassay with direct optic $14.2887809 infectious agent antigen detection by immunoassay with direct optic $14.2887810 infectious agent detection by immunoassay with direct optical obser $14.2887850 infectious agent detection by immunoassay with direct optical obser $14.2887880 infectious agent detection by immunoassay with direct optical obser $14.2887899 infectious agent detection by immunoassay with direct optical obser $14.2887900 infectious agent drug susceptibility phenotype prediction using regu $101.4987901 infectious agent genotype analysis by nucleic acid (dna or rna), hiv 1 $97.2687902 infectious agent genotype analysis by nucleic acid (dna or rna); hepa $97.2687903 infectious agent phenotype analysis by nucleic acid (dna or rna) with $339.1287904 infectious agent phenotype analysis by nucleic acid (dna or rna) with $20.3087905 infectious agent enzymatic activity other than virus (eg, sialidase act $16.5987906 infectious agent genotype analysis by nucleic acid (dna or rna); hiv‐1 $48.9887910 infectious agent genotype analysis by nucleic acid (dna or rna); cytom $95.6787912 infectious agent genotype analysis by nucleic acid (dna or rna); hepa $95.6788104 26 cytopathology,fld,wash or brush, excpt cerv or vag $22.5988104 TC cytopathology,fld,wash or brush, excpt cerv or vag $25.8288104 cytopathology,fld,wash or brush, excpt cerv or vag $48.4188106 26 cytopathology filter method only with interpretati $22.5988106 TC cytopthlgy,fld,wash or brush,expt cer or vag fltme $37.4188106 cytopathology filter method only with interpretati $60.0088108 26 cytopathology, concentration technique, smears and interpretation $22.5988108 TC cytopathology, concentration technique, smears and interpretation $34.3188108 cytopathology, concentration technique, smears and interpretation $56.8988112 26 cytopathology, selective cellular enhancement technique with interp $46.3388112 TC cytopathology, selective cellular enhancement technique with interp $34.8788112 cytopathology, selective cellular enhancement technique with interp $81.2088120 26 cytopathology, in situ hybridization (eg, fish), urinary tract specimen $43.3788120 TC cytopathology, in situ hybridization (eg, fish), urinary tract specimen $326.6088120 cytopathology, in situ hybridization (eg, fish), urinary tract specimen $370.0688121 26 cytopathology, in situ hybridization (eg, fish), urinary tract specimen $38.5588121 TC cytopathology, in situ hybridization (eg, fish), urinary tract specimen $273.9988121 cytopathology, in situ hybridization (eg, fish), urinary tract specimen $312.5488125 26 cytopathology forensic $10.6888125 TC cytopathology, forensic $6.4188125 cytopathology forensic $17.0988130 26 buccal smear $19.7188130 buccal smear $18.7588140 26 sex chromatin ident periph blood smear $10.0588140 sex chromatin ident periph blood smear $9.9688141 cytopathology, cervical or vaginal (any reporting system); requiring $21.9888142 cytopathology, cervical or vaginal (any reporting system), collected i $25.2488143 cytopathology, cervical or vaginal (any reporting system), collected i $25.2488147 cytopathology smears, cervical or vaginal; screening by automated s $13.1688148 cytopathology smears, cervical or vaginal; screening by automated s $13.1688150 cytopathology, slides, cervical or vaginal; manual screening under ph $13.16
88152 cytopathology, slides, cervical or vaginal; with manual screening and $13.1688153 cytopathology, slides, cervical or vaginal; with manual screening and $13.1688154 cytopathology, slides, cervical or vaginal; with manual screening and $13.1688155 cytopathology, slides, cervical or vaginal, definitive hormonal evalua $7.4788160 26 cytopathology, smears, any other source; screening and interpretati $20.1988160 TC cytopathology, smears, any other source; screening and interpretati $20.7488160 cytopathology, smears, any other source; screening and interpretati $40.9288161 26 cytopathology,any othr source; prep,screen & inter $19.9088161 TC cytopathology,any othr source; prep,screen & inter $22.7288161 cytopathology,any othr source; prep,screen & inter $42.6288162 26 cytopathology, extend stdy involv over5slid &/ormu $30.8788162 TC cytopathology, extend stdy involv over5slid &/ormu $30.9188162 cytopathology 5 slides &/or multiple stains $61.7888164 cytopathology, slides, cervical or vaginal (the bethesda system); man $13.1688165 cytopathology, slides, cervical or vaginal (the bethesda system); with $13.1688166 cytopathology, slides, cervical or vaginal (the bethesda system); with $13.1688167 cytopathology, slides, cervical or vaginal (the bethesda system); with $13.1688172 26 cytopathology, evaluation of fine needle aspirate; immediate cytohi $24.3788172 TC cytopathology, evaluation of fine needle aspirate; immediate cytohi $17.3588172 cytopathology, evaluation of fine needle aspirate; immediate cytohi $41.7288173 26 eval fn ndl sspir w/wo prep sm; interpret & report $56.1588173 TC eval fn ndl sspir w/wo prep sm; interpret & report $49.5788173 eval fn ndl sspir w/wo prep sm; interpret & report $105.7388174 cytopathology, cervical or vaginal (any reporting system), collected i $26.6288175 cytopathology, cervical or vaginal (any reporting system), collected i $32.3888177 26 cytopathology, evaluation of fine needle aspirate; immediate cytohi $17.7288177 TC cytopathology, evaluation of fine needle aspirate; immediate cytohi $5.1588177 cyopathology, evaluation of fine needle aspirate; immediate cytohis $22.8588182 26 flow cytometry (dna analysis) $29.1988182 TC cell cycle or dna analysis $51.0888182 cell cycle or dna analysis $80.2888184 flow cytometry, cell surface, cytoplasmic, or nuclear marker, technic $61.1688185 flow cytometry, cell surface, cytoplasmic, or nuclear marker, technic $36.2988187 flow cytometry, interpretation; 2 to 8 markers $53.3488188 flow cytometry, interpretation; 9 to 15 markers $65.6888189 flow cytometry, interpretation; 16 or more markers $83.8888230 26 tissue culture for non‐neoplastic disease $118.7588230 TC tissue culture for non‐neoplastic disease $38.9888230 tissue culture for non‐neoplastic disease $145.1688233 26 tissue culture, skin $143.6388233 TC tissue culture, skin $47.2988233 tissue culture, skin $175.3588235 26 tissue culture, placenta $150.3388235 TC tissue culture, placenta $49.5188235 tissue culture, placenta $183.4888237 26 tissue culture for neoplastic disorders; bone marrow, blood cells $128.8188237 TC tissue culture for neoplastic disorders; bone marrow, blood cells $42.35
88237 tissue culture for neoplastic disorders; bone marrow, blood cells $157.3888239 26 tissue culture for neoplastic disorders; solid tumor $150.6188239 TC tissue culture for neoplastic disorders; solid tumor $49.6188239 tissue culture for neoplastic disorders; solid tumor $183.8288245 26 chromosome analysis for breakage syndromes; baseline sister chrom $151.9888245 TC chromosome analysis for breakage syndromes; baseline sister chrom $50.0688245 chromosome analysis for breakage syndromes; baseline sister chrom $185.4788248 26 chromosome analysis for breakage syndromes; baseline breakage, s $176.9588248 TC chromosome analysis for breakage syndromes; baseline breakage, s $58.3988248 chromosome analysis for breakage syndromes; baseline breakage, s $215.7888261 26 chromosome analysis; count 5 cells, 1 karyotype, with banding $180.6088261 TC chromosome analysis; count 5 cells, 1 karyotype, with banding $59.6088261 chromosome analysis; count 5 cells, 1 karyotype, with banding $220.2288262 26 chromosome analysis, count 15‐20 cells, 2 karyotypes w/banding $127.1188262 TC chromosome analysis, count 15‐20 cells, 2 karyotypes w/banding $41.7788262 chromosome analysis, option iii $155.3088263 26 chromosome analysis $153.4488263 TC chromosome analysis $50.5588263 chromosome analysis $187.2588264 26 chromosome analysis; analyze 20‐25 cells $127.1188264 TC chromosome analysis; analyze 20‐25 cells $41.7788264 chromosome analysis; analyze 20‐25 cells $155.3088267 26 chromosome analysis, amniotic fluid or chorioic villus, 15 cells $183.7288267 TC chromosome analysis, amniotic fluid or chorioic villus, 15 cells $60.6488267 chromosome analysis, amniotic fluid or chorioic villus, 15 cells $223.9988269 26 chromosome analysis, amniotic fluid cells, count cells from 6‐12 $169.9188269 TC chromosome analysis, amniotic fluid cells, count cells from 6‐12 $56.0488269 chromosome analysis, amniotic fluid $207.2488271 26 molecular cytogenetics; dna probe, each (eg, fish) $13.9788271 TC molecular cytogenetics; dna probe, each (eg, fish) $4.0688271 molecular cytogenetics; dna probe, each (eg, fish) $18.0388272 26 molecular cytogenetics; in situ hybridization, analyze 3‐5 cells $26.6188272 TC molecular cytogenetics; in situ hybridization, analyze 3‐5 cells $8.2788272 molecular cytogenetics; in situ hybridization, analyze 3‐5 cells $33.3688273 26 molecular cytogenetics; in situ hybridization, analyze 10‐30 cells $32.1088273 TC molecular cytogenetics; in situ hybridization, analyze 10‐30 cells $10.1088273 molecular cytogenetics; in situ hybridization, analyze 10‐30 cells $40.0388274 26 molecular cytogenetics; interphase in situ hybridization, analyze 25‐ $34.8588274 TC molecular cytogenetics; interphase in situ hybridization, analyze 25‐ $11.0388274 molecular cytogenetics; interphase in situ hybridization, analyze 25‐ $43.3788275 26 molecular cytogenetics; interphase in situ hybridization, analyze 100 $40.3588275 TC molecular cytogenetics; interphase in situ hybridization, analyze 100 $12.8688275 molecular cytogenetics; interphase in situ hybridization, analyze 100 $50.0488280 26 chrom analysis additional karotyping $24.8888280 TC chrom analysis additional karotyping $7.7088280 chrom analysis additional karotyping $31.2788283 26 banding for chromosome analysis $18.88
88283 TC banding for chromosome analysis $5.7088283 banding for chromosome analysis $24.0088285 26 chromosome analysis, additional cells counted $18.6288285 TC chromosome analysis, additional cells counted $5.6188285 chromosome analysis, additional cells counted, each study $23.6788289 26 chromosome analysis, additional high resolution study $33.9488289 TC chromosome analysis, additional high resolution study $10.7288289 high resolution for chromosome analysis $42.2688291 cytogenetics and molecular cytogenetics, interpretation and report $23.3388300 26 level i‐surgical pathology, gross exam only $3.4988300 TC level i‐surgical pathology, gross exam only $14.6188300 level i‐surgical pathology, gross exam only $18.0988302 26 level ii‐surgical pathology, grossµ exam $5.3088302 TC level ii‐surgical pathology, grossµ exam $32.6188302 level ii‐surgical pathology, grossµ exam $37.9188304 26 level iii ‐ surgical pathology, gross and microscopic examination $8.9088304 TC level iii ‐ surgical pathology, gross and microscopic examination $39.3988304 level iii ‐ surgical pathology, gross and microscopic examination $48.2988305 26 level iv ‐ surgical pathology, gross and microscopic examination $30.5788305 TC level iv ‐ surgical pathology, gross and microscopic examination $51.9388305 level iv ‐ surgical pathology, gross and microscopic examination $82.5088307 26 level v ‐ surgical pathology, gross and microscopic examination $65.0188307 TC level v ‐ surgical pathology, gross and microscopic examination $100.3788307 level v ‐ surgical pathology, gross and microscopic examination $165.3888309 26 level vi‐surgicla pathology, gross & micro exam $112.2688309 TC level vi‐surgicla pathology, gross & micro exam $137.6888309 surgical pathology seven or more blocks $249.9588311 26 decalcification procedure $9.7988311 TC decalcification procedure $4.7188311 decalcification procedure $14.5088312 26 special stains; group i for microorganisms, each $21.6988312 TC special stains; group i for microorganisms, each $55.8788312 special stains; group i for microorganisms, each $77.5788313 26 group ii, all other,excpt immunocytochem &immunope $9.5188313 TC group ii, all other,excpt immunocytochem &immunope $46.8288313 group ii, all other,excpt immunocytochem &immunope $56.3388314 26 histochemical staining with frozen section $18.3888314 TC group ii, histochemical staining w/frozen section $50.7088314 histochemical staining with frozen section $69.0888319 26 histochemistry emzyme costituents (each) $21.3888319 TC determinative histochemistry or cytochemistry/enzyme /each $86.3188319 determinative histochemistry or cytochemistry/enzyme /each $107.6988321 consultation on tissue exam $64.9188323 26 cons report referred material reg preparation slid $70.4588323 TC consult & report on referred mat' req.prep of sld $43.9188323 consult & report on referred mat' req.prep of sld $114.3788325 comprehensive review records slides w/report $100.92
88329 operating room consultation $27.3688331 26 pathology consultation during surgery; first tissue block, with frozen $49.0088331 TC pathology consultation during surgery; first tissue block, with frozen $22.5488331 pathology consultation during surgery; first tissue block, with frozen $71.5588332 26 pathlgy consult dur. surg; ea add tis blk w/frz sc $24.0788332 TC pathlgy consult dur. surg; ea add tis blk w/frz sc $8.0288332 pathlgy consult dur. surg; ea add tis blk w/frz sc $32.0988333 26 pathology consultation during surgery; cytologic examination (eg, to $49.0388333 TC pathology consultation during surgery; cytologic examination (eg, to $24.2388333 pathology consultation during surgery; cytologic examination (eg, to $73.2688334 26 pathology consultation during surgery; cytologic examination (eg, to $29.4888334 TC pathology consultation during surgery; cytologic examination (eg, to $14.8188334 pathology consultation during surgery; cytologic examination (eg, to $44.2888342 26 immunocytochemistry each antibody $33.9188342 TC immunocytochemistry each antibody $44.4888342 immunocytochemistry each antibody $78.3888346 26 immunofluorescent stdy, ea. antibdy; direct method $34.5088346 TC immunofluorescent stdy, ea. antibdy; direct method $44.2088346 immunofluorescent stdy, ea. antibdy; direct method $78.6888347 26 immunofluorescent study indirect method $33.0888347 TC immunofluorescent study indirect method $29.5088347 immunofluorescent study indirect method $62.5788348 26 electron microscopy diagnostic $60.8788348 TC electron microscopy diagnostic $425.3288348 electron microscopy diagnostic $486.1988355 26 morphometric analysis skeletal muscle $71.4588355 TC morphometric analysis skeletal muscle $116.7788355 morphometric analysis skeletal muscle $188.2288356 26 morphometric analysis nerve $114.1088356 TC morphometric analysis nerve $115.5488356 morphometric analysis nerve $229.6488358 26 morphometric analysis of tumor $37.1988358 TC morphometric analysis of tumor $24.2588358 morphometric analysis of tumor $61.4488360 26 morphometric analysis, tumor immunohistochemistry (eg, her‐2/ne $44.1088360 TC morphometric analysis, tumor immunohistochemistry (eg, her‐2/ne $50.7088360 morphometric analysis, tumor immunohistochemistry (eg, her‐2/ne $94.8088361 26 morphometric analysis; tumor immunohistochemistry (eg, her‐2/ne $47.3188361 TC morphometric analysis; tumor immunohistochemistry (eg, her‐2/ne $71.7488361 morphometric analysis; tumor immunohistochemistry (eg, her‐2/ne $119.0688362 26 nerve teasing preparation $87.2788362 TC nerve teasing preparation $119.5988362 nerve teasing preparation $206.8688365 26 tissue in situ hybridization, interpretation and report $47.4288365 TC tissue in situ hybridization, interpretation and report $75.8588365 tissue in situ hybridization, interpretation and report $123.2788367 26 morphometric analysis, in situ hybridization, (quantitative or $50.78
88367 TC morphometric analysis, in situ hybridization, (quantitative or $137.1188367 morphometric analysis, in situ hybridization, (quantitative or $187.9088368 26 morphometric analysis, in situ hybridization, (quantitative or $53.5688368 TC morphometric analysis, in situ hybridization, (quantitative or $112.2488368 morphometric analysis, in situ hybridization, (quantitative or $165.8088371 26 protein analysis of tissue by western blot w/interpretation & rep $14.9088372 26 protein analysis of tissue by western blot, immunological probe $14.9088372 TC protein analysis of tissue by western blot, immunological probe $15.2188387 26 macroscopic examination, dissection, and preparation of tissue for $19.8888387 TC macroscopic examination, dissection, and preparation of tissue for $4.8088387 macroscopic examination, dissection, and preparation of tissue for $24.6988388 26 macroscopic examination, dissection, and preparation of tissue for $12.3988388 TC macroscopic examination, dissection, and preparation of tissue for $2.3688388 macroscopic examination, dissection, and preparation of tissue for $14.7588720 bilirubin, total, transcutaneous $6.2988738 hemoglobin (hgb), quantitative, transcutaneous $6.4188740 hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglo $6.5488741 hemoglobin, quantitative, transcutaneous, per day; methemoglobin $6.5489050 cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fl $5.9089051 synovial fluid diff $6.4989055 leukocyte assessment, fecal, qualitative or semiquantitative $5.3189060 crystal id, synovial fluid $8.9189125 fat stain, feces, urine, or respiratory secretions $5.3889160 meat fibers feces $4.6089190 nasal smear for eosinophils $5.8089300 semen analysis; presence and/or motility of sperm including huhner $11.1089310 semen analysis; motility and count (not including huhner test) $10.4589320 semen analysis complete $15.0189325 sperm agglutination with antibody titer $13.3094010 spirometry, including graphic record, total and timed vital capacity, $25.8499195 therapeutic phlebotomy $54.94G0328 colorectal cancer screening; fecal occult blood test, immunoassay, 1 $19.96G0416 surgical pathology, gross and microscopic examination for prostate n $499.46G0431 drug screen, qualitative; multiple drug classes by high complexity te $91.26G0434 drug screen, other than chromatographic; any number of drug classe $18.26
Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions, changes, and deletion to this schedule.