Test List with Prices and CPT Codes - Maine

Test Name Adenovirus RT-PCR AFB Smear Anaplasma/Ehrlichia RT-PCR Babesia PCR Bacti Miscellaneous Blood Lead C difficile PCR Campylobacter ID Campylobacter ID with PCR Chikungunya virus (CHIKV) RT-PCR CRE PCR (Carbapenem Resistance) Cryptosporidium PCR CT/GC E. coli Identification EEE Microsphere Immunoassay (MIA) Enteric Pathogen Screen Enterovirus PCR Haemophilus influenzae Identification Haemophilus influenzae Typing Hepatitis C IgG Herpes Simplex Virus PCR HIV EIA 4th Gen Screen HIV EIA 4th Gen Screen+HIV Confirmation Influenza by rRT-PCR Measles IgM Measles RT-PCR MRSA (Methicillin Resistance) PCR Mumps IgG Mumps IgM Mumps RT-PCR N menin PCR Neisseria gonorrhoeae confirmation Neisseria meningitidis grouping Norovirus RT-PCR Pertussis PCR PFGE C. difficile PFGE E. coli PFGE Salmonella PFGE Shigella Powassan/Deer Tick Virus RT-PCR Primary Culture

Test List with Prices and CPT Codes

Price Applicable CPT Code(s) $98.00 87809 $15.00 87206 $110.00 87798 $110.00 87798 $25.00 87040 (blood) 87046 (stool) 87088 (urine) 87070 (all other sources) $20.00 83655 $127.00 87493 $20.00 87077 $76.00 87077+if PCR add 87798 $110.00 87798 $110.00 87798 X5 (Tests for 5 genes) $103.00 87798 $20.00 87491,87591 $25.00 87046, 87147 X5 (serotyping) No charge 86652 $20.00 87045, 87046, 87077 $150.00 87498 $25.00 87040 (blood) 87070 (other source) No charge 87147 X6 (Tests for 6 subtypes) $22.00 86803 $98.00 87529 $22.00 87389 $72.00 87389, 86689 No charge 87502, 87503 $40.00 86765 $90.00 87798 $110.00 87798 X2 (Tests for 2 genes) $40.00 86735 $40.00 86735 $90.00 87798 $104.00 87798 $20.00 87077, 87140 $25.00 87077, 87147 X9 $132.00 87798 $108.00 87801 $150.00 87152 $150.00 87152 $150.00 87152 $150.00 87152 $110.00 87798 $25.00 87116

C:\Users\Richard.Danforth\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\WRX5ZJW1\Price_Test_CPT codes_Updated April2017_Section.xls

Primary Culture 2 Primary Culture Sequence Quantiferon TB Gold EIA Rabies-animal Respiratory Syncytial Virus (RSV) RT-PCR Rhinovirus RT-PCR RPR Quantitative RPR Syphilis screen Rubeola IgG Rubeola IgM Salmonella Identification Salmonella Serotyping Shiga Toxin Test/O157 by PCR Shigella ID/serotyping Syphilis serum TPPA Syphilis spinal fluid VDRL Syphillis VDRL Quantitative TB PCR Trioplex RT-PCR (CHIKV, Dengue, Zika virus) Varicella IgG Varicella/Herpes zoster PCR Vibrio Identification Viral Culture Viral culture if positive for Enterovirus Viral culture if positive for HSV1/2 Viral culture if positive for Influenza A/B Viral culture if positive for VZV VRE (Vancomycin Resistance) PCR WNV SLE (MIA) Yersinia Identification Zika virus RT-PCR

Comments Version 7 04/15/2016

Test List with Prices and CPT Codes

$25.00 87118 (second organism identified) $163.00 87153 $40.00 86480 $150.00 N/A $90.00 87807 $90.00 87797 No charge 86593 $10.00 86592 $40.00 86765 $40.00 86765 $25.00 87045 (stool), 87040 (blood), 87088 (urine), 87070 (all other sources) No charge 87147 (serology), 87150 (PCR) $120.00 87798 (Used in conjunction with 87046, 87147 if PCR positive) $25.00 87045, 87147 X4 (serotyping) $20.00 86403 $15.00 86592 No charge 86593 $10.00 87556 $110.00 87798 X3 (Tests for 3 agents) $40.00 86787 $76.00 87801 $25.00 87046,87077 $36.00 87252, 87253; if confirmed by PCR see specific agent $186.00 87252, 87498 $134.00 87252, 87529 $36.00 87252, 87502, 87503 $112.00 87252, 87801 $110.00 87798 X3 (Tests for 3 genes) No charge 86788 (WNV ), 86653 (SLE) $25.00 87046, 87077 $110.00 87798

C:\Users\Richard.Danforth\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\WRX5ZJW1\Price_Test_CPT codes_Updated April2017_Section.xls

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