CCR Template



Final Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC36415$5.10Routine venipuncture36416$5.10Capillary blood collection78267$18.80Breath tst attain/anal c-1478268$160.50Breath test analysis c-1480047$23.34Metabolic panel ionized ca80047QW$23.34Metabolic panel ionized ca80048$17.75Metabolic panel total ca80048QW$17.75Metabolic panel total ca80050$49.30General Health Panel (80053+85004+85027)80051$14.72Electrolyte panel80051QW$14.72Electrolyte panel80053$22.17Comprehen metabolic panel80053QW$22.17Comprehen metabolic panel80055$100.33Obstetric panel80061$28.10Lipid panel80061QW$28.10Lipid panel80069$18.22Renal function panel80069QW$18.22Renal function panel80074$99.98Acute hepatitis panel80076$17.15Hepatic function panel80081$157.11Obstetric panel80150$31.64Assay of amikacin80155$65.57Drug assay caffeine80156$30.57Assay carbamazepine total80157$27.81Assay carbamazepine free80158$37.88Drug assay cyclosporine80159$38.81Drug assay clozapine80162$27.86Assay of digoxin total80163$27.86Assay of digoxin free80164$28.42Assay dipropylacetic acd tot80165$28.42Dipropylacetic acid free80168$34.29Assay of ethosuximide80169$28.83Drug assay everolimusFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC80170$34.37Assay of gentamicin80171$36.84Drug screen quant gabapentin80173$30.57Assay of haloperidol80175$27.81Drug screen quan lamotrigine80176$30.84Assay of lidocaine80177$27.81Drug scrn quan levetiracetam80178$13.87Assay of lithium80178QW$13.87Assay of lithium80180$37.88Drug scrn quan mycophenolate80183$27.81Drug scrn quant oxcarbazepin80184$26.01Assay of phenobarbital80185$27.81Assay of phenytoin total80186$28.88Assay of phenytoin free80188$34.82Assay of primidone80190$102.00Assay of procainamide80192$35.16Assay of procainamide80194$30.65Assay of quinidine80195$28.83Assay of sirolimus80197$28.83Assay of tacrolimus80198$29.68Assay of theophylline80199$46.09Drug screen quant tiagabine80200$33.85Assay of tobramycin80201$25.02Assay of topiramate80202$28.42Assay of vancomycin80203$27.81Drug screen quant zonisamide80299$31.69Quantitative assay drug80305$22.88Drug test prsmv dir opt obs80305QW$22.88Drug test prsmv dir opt obs80306$30.53Drug test prsmv instrmnt80307$122.11Drug test prsmv chem anlyzr80400$68.46Acth stimulation panel80402$182.50Acth stimulation panel80406$164.25Acth stimulation panelFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC80408$263.40Aldosterone suppression eval80410$56.24Calcitonin stimul panel80412$1,362.75Crh stimulation panel80414$108.38Testosterone response80415$117.28Estradiol response panel80416$355.84Renin stimulation panel80417$92.33Renin stimulation panel80418$1,216.23Pituitary evaluation panel80420$275.20Dexamethasone panel80422$96.70Glucagon tolerance panel80424$105.98Glucagon tolerance panel80426$311.47Gonadotropin hormone panel80428$140.00Growth hormone panel80430$219.86Growth hormone panel80432$283.54Insulin suppression panel80434$484.55Insulin tolerance panel80435$216.21Insulin tolerance panel80436$191.34Metyrapone panel80438$105.81Trh stimulation panel80439$141.07Trh stimulation panel81000$6.83Urinalysis nonauto w/scope81001$6.66Urinalysis auto w/scope81002$5.92Urinalysis nonauto w/o scope81003$4.71Urinalysis auto w/o scope81003QW$4.71Urinalysis auto w/o scope81005$4.54Urinalysis81007$50.97Urine screen for bacteria81007QW$50.97Urine screen for bacteria81015$6.39Microscopic exam of urine81020$7.99Urinalysis glass test81025$14.64Urine pregnancy test81050$6.31Urinalysis volume measure81105$256.51Hpa-1 genotypingFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC81106$256.51Hpa-2 genotyping81107$256.51Hpa-3 genotyping81108$256.51Hpa-4 genotyping81109$256.51Hpa-5 genotyping81110$256.51Hpa-6 genotyping81111$256.51Hpa-9 genotyping81112$256.51Hpa-15 genotyping81120$328.53Idh1 common variants81121$502.84Idh2 common variants81161$474.30Dmd dup/delet analysis81162$3,829.98Brca1&2 seq & full dup/del81170$510.00Abl1 gene81175$1,201.93Asxl1 full gene sequence81176$507.69Asxl1 gene target seq alys81200$80.33Aspa gene81201$1,326.00Apc gene full sequence81202$476.00Apc gene known fam variants81203$340.00Apc gene dup/delet variants81205$161.48Bckdhb gene81206$344.11Bcr/abl1 gene major bp81207$303.98Bcr/abl1 gene minor bp81208$364.85Bcr/abl1 gene other bp81209$66.83Blm gene81210$298.18Braf gene81211$4,072.93Brca1&2 seq & com dup/del81212$748.00Brca1&2 185&5385&6174 var81213$940.10Brca1&2 uncom dup/del var81214$2,212.41Brca1 full seq & com dup/del81215$637.93Brca1 gene known fam variant81216$314.70Brca2 gene full sequence81217$637.93Brca2 gene known fam variant81218$507.69Cebpa gene full sequence81219$255.27Calr gene com variantsFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC81220$946.22Cftr gene com variants81221$165.27Cftr gene known fam variants81222$739.62Cftr gene dup/delet variants81223$848.30Cftr gene full sequence81224$286.88Cftr gene intron poly t81225$495.31Cyp2c19 gene com variants81226$766.55Cyp2d6 gene com variants81227$297.18Cyp2c9 gene com variants81228$1,530.00Cytogen micrarray copy nmbr81229$1,972.00Cytogen m array copy no&snp81230$297.18Cyp3a4 gene common variants81231$297.18Cyp3a5 gene common variants81232$297.18Dpyd gene common variants81235$551.79Egfr gene com variants81238$1,020.00F9 full gene sequence81240$111.67F2 gene81241$128.25F5 gene81242$62.25Fancc gene81243$96.97Fmr1 gene detection81244$76.31Fmr1 gene characterization81245$281.37Flt3 gene81246$141.10Flt3 gene analysis81247$297.18G6pd gene alys cmn variant81248$637.93G6pd known familial variant81249$1,020.00G6pd full gene sequence81250$99.43G6pc gene81251$80.33Gba gene81252$171.90Gjb2 gene full sequence81253$104.58Gjb2 gene known fam variants81254$59.50Gjb6 gene com variants81255$87.47Hexa gene81256$137.17Hfe gene81257$173.84Hba1/hba2 geneFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC81258$637.93Hba1/hba2 gene fam vrnt81259$1,020.00Hba1/hba2 full gene sequence81260$66.83Ikbkap gene81261$415.53Igh gene rearrange amp meth81262$116.54Igh gene rearrang dir probe81263$618.12Igh vari regional mutation81264$313.40Igk rearrangeabn clonal pop81265$451.33Str markers specimen anal81266$518.18Str markers spec anal addl81267$435.40Chimerism anal no cell selec81268$547.33Chimerism anal w/cell select81269$344.08Hba1/hba2 gene dup/del vrnts81270$192.39Jak2 gene81272$560.17Kit gene targeted seq analys81273$212.28Kit gene analys d816 variant81275$328.53Kras gene variants exon 281276$328.53Kras gene addl variants81280$707.34Long qt synd gene full seq81281$484.50Long qt synd known fam var81282$2,125.00Long qt syn gene dup/dlt var81283$128.25Ifnl3 gene81287$211.89Mgmt gene methylation anal81288$326.94Mlh1 gene81290$66.83Mcoln1 gene81291$111.08Mthfr gene81292$1,148.18Mlh1 gene full seq81293$562.70Mlh1 gene known variants81294$344.08Mlh1 gene dup/delete variant81295$648.89Msh2 gene full seq81296$574.14Msh2 gene known variants81297$362.61Msh2 gene dup/delete variant81298$1,091.15Msh6 gene full seq81299$523.60Msh6 gene known variantsFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC81300$404.60Msh6 gene dup/delete variant81301$607.72Microsatellite instability81302$897.38Mecp2 gene full seq81303$204.00Mecp2 gene known variant81304$255.00Mecp2 gene dup/delet variant81310$419.08Npm1 gene81311$502.84Nras gene variants exon 2&381313$433.59Pca3/klk3 antigen81314$560.17Pdgfra gene81315$435.10Pml/raralpha com breakpoints81316$435.10Pml/raralpha 1 breakpoint81317$1,201.93Pms2 gene full seq analysis81318$562.70Pms2 known familial variants81319$345.95Pms2 gene dup/delet variants81321$1,020.00Pten gene full sequence81322$89.85Pten gene known fam variant81323$510.00Pten gene dup/delet variant81324$1,289.21Pmp22 gene dup/delet81325$1,308.29Pmp22 gene full sequence81326$89.85Pmp22 gene known fam variant81327$-Sept9 methylation analysis81328$297.18Slco1b1 gene com variants81330$79.90Smpd1 gene common variants81331$86.82Snrpn/ube3a gene81332$91.61Serpina1 gene81334$560.17Runx1 gene targeted seq alys81335$297.18Tpmt gene com variants81340$438.46Trb@ gene rearrange amplify81341$104.07Trb@ gene rearrange dirprobe81342$422.89Trg gene rearrangement anal81346$297.18Tyms gene com variants81350$397.80Ugt1a1 gene81355$149.94Vkorc1 geneFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC81361$297.18Hbb gene com variants81362$637.93Hbb gene known fam variant81363$344.08Hbb gene dup/del variants81364$551.79Hbb full gene sequence81370$843.97Hla i & ii typing lr81371$687.68Hla i & ii type verify lr81372$686.10Hla i typing complete lr81373$233.72Hla i typing 1 locus lr81374$152.68Hla i typing 1 antigen lr81375$463.28Hla ii typing ag equiv lr81376$256.51Hla ii typing 1 locus lr81377$192.70Hla ii type 1 ag equiv lr81378$725.27Hla i & ii typing hr81379$703.89Hla i typing complete hr81380$372.01Hla i typing 1 locus hr81381$288.83Hla i typing 1 allele hr81382$259.57Hla ii typing 1 loc hr81383$229.04Hla ii typing 1 allele hr81400$108.73Mopath procedure level 181401$232.90Mopath procedure level 281402$255.56Mopath procedure level 381403$314.84Mopath procedure level 481404$467.21Mopath procedure level 581405$512.30Mopath procedure level 681406$480.90Mopath procedure level 781407$1,438.66Mopath procedure level 881408$3,400.00Mopath procedure level 981410$856.80Aortic dysfunction/dilation81411$2,295.32Aortic dysfunction/dilation81412$4,162.55Ashkenazi jewish assoc dis81413$1,227.57Car ion chnnlpath inc 10 gns81414$1,227.57Car ion chnnlpath inc 2 gns81415$8,126.00Exome sequence analysisFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC81416$20,400.00Exome sequence analysis81417$544.00Exome re-evaluation81420$1,290.39Fetal chrmoml aneuploidy81422$1,290.39Fetal chrmoml microdeltj81425$-Genome sequence analysis81426$-Genome sequence analysis81427$-Genome re-evaluation81430$2,762.50Hearing loss sequence analys81431$1,155.27Hearing loss dup/del analys81432$1,425.16Hrdtry brst ca-rlatd dsordrs81433$921.21Hrdtry brst ca-rlatd dsordrs81434$1,016.45Hereditary retinal disorders81435$1,227.57Hereditary colon ca dsordrs81436$1,227.57Hereditary colon ca dsordrs81437$921.21Heredtry nurondcrn tum dsrdr81438$921.21Heredtry nurondcrn tum dsrdr81439$1,227.57Hrdtry cardmypy gene panel81440$5,650.80Mitochondrial gene81442$3,644.12Noonan spectrum disorders81445$1,016.45Targeted genomic seq analys81448$1,227.57Hrdtry perph neurphy panel81450$1,291.20Targeted genomic seq analys81455$4,963.32Targeted genomic seq analys81460$2,187.90Whole mitochondrial genome81465$1,591.20Whole mitochondrial genome81470$-X-linked intellectual dblt81471$-X-linked intellectual dblt81490$1,429.11Autoimmune rheumatoid arthr81493$1,785.00Cor artery disease mrna81500$442.85Onco (ovar) two proteins81503$1,524.90Onco (ovar) five proteins81504$884.00Oncology tissue of origin81506$137.75Endo assay seven analFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC81507$1,351.50Fetal aneuploidy trisom risk81508$92.31Ftl cgen abnor two proteins81509$2,528.53Ftl cgen abnor 3 proteins81510$94.42Ftl cgen abnor three anal81511$260.95Ftl cgen abnor four anal81512$118.18Ftl cgen abnor five anal81519$6,584.10Oncology breast mrna81520$5,268.33Onc breast mrna 58 genes81521$6,584.10Onc breast mrna 70 genes81525$5,297.20Oncology colon mrna81528$865.08Oncology colorectal scr81535$985.08Oncology gynecologic81536$301.85Oncology gynecologic81538$4,880.70Oncology lung81539$1,292.00Oncology prostate prob score81540$6,375.00Oncology tum unknown origin81541$6,584.10Onc prostate mrna 46 genes81545$6,120.00Oncology thyroid81551$-Onc prostate 3 genes81595$5,508.00Cardiology hrt trnspl mrna82009$9.49Test for acetone/ketones82010$17.15Acetone assay82010QW$17.15Acetone assay82013$23.44Acetylcholinesterase assay82016$29.12Acylcarnitines qual82017$35.41Acylcarnitines quant82024$81.06Assay of acth82030$54.15Assay of adp & amp82040$10.39Assay of serum albumin82040QW$10.39Assay of serum albumin82042$13.23Other source albumin quan ea82042QW$13.23Other source albumin quan ea82043$12.14Ur albumin quantitativeFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC82043QW$12.14Ur albumin quantitative82044$10.59Ur albumin semiquantitative82044QW$10.59Ur albumin semiquantitative82045$71.23Albumin ischemia modified82075$51.00Assay of breath ethanol82085$20.38Assay of aldolase82088$85.53Assay of aldosterone82103$28.20Alpha-1-antitrypsin total82104$30.36Alpha-1-antitrypsin pheno82105$35.21Alpha-fetoprotein serum82106$35.21Alpha-fetoprotein amniotic82107$135.18Alpha-fetoprotein l382108$53.48Assay of aluminum82120$10.18Amines vaginal fluid qual82120QW$10.18Amines vaginal fluid qual82127$29.12Amino acid single qual82128$29.12Amino acids mult qual82131$39.07Amino acids single quant82135$34.53Assay aminolevulinic acid82136$35.41Amino acids quant 2-582139$35.41Amino acids quan 6 or more82140$30.58Assay of ammonia82143$15.90Amniotic fluid scan82150$13.60Assay of amylase82150QW$13.60Assay of amylase82154$60.52Androstanediol glucuronide82157$61.44Assay of androstenedione82160$52.48Assay of androsterone82163$43.08Assay of angiotensin ii82164$30.65Angiotensin i enzyme test82172$35.85Assay of apolipoprotein82175$39.81Assay of arsenic82180$20.74Assay of ascorbic acidFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC82190$31.30Atomic absorption82232$33.95Assay of beta-2 protein82239$35.94Bile acids total82240$55.78Bile acids cholylglycine82247$10.52Bilirubin total82247QW$10.52Bilirubin total82248$10.52Bilirubin direct82252$9.57Fecal bilirubin test82261$35.41Assay of biotinidase82270$7.45Occult blood feces82271$9.04Occult blood other sources82271QW$9.04Occult blood other sources82272$7.19Occult bld feces 1-3 tests82274$33.39Assay test for blood fecal82274QW$33.39Assay test for blood fecal82286$10.83Assay of bradykinin82300$48.59Assay of cadmium82306$62.14Vitamin d 25 hydroxy82308$56.24Assay of calcitonin82310$10.83Assay of calcium82310QW$10.83Assay of calcium82330$28.70Assay of calcium82330QW$28.70Assay of calcium82331$22.68Calcium infusion test82340$12.65Assay of calcium in urine82355$24.29Calculus analysis qual82360$27.01Calculus assay quant82365$27.06Calculus spectroscopy82370$26.28X-ray assay calculus82373$37.89Assay c-d transfer measure82374$10.25Assay blood carbon dioxide82374QW$10.25Assay blood carbon dioxide82375$25.86Assay carboxyhb quantFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC82376$23.92Assay carboxyhb qual82378$39.80Carcinoembryonic antigen82379$35.41Assay of carnitine82380$19.36Assay of carotene82382$46.41Assay urine catecholamines82383$52.58Assay blood catecholamines82384$53.01Assay three catecholamines82387$37.89Assay of cathepsin-d82390$22.54Assay of ceruloplasmin82397$29.63Chemiluminescent assay82415$26.59Assay of chloramphenicol82435$9.66Assay of blood chloride82435QW$9.66Assay of blood chloride82436$10.56Assay of urine chloride82438$10.25Assay other fluid chlorides82441$12.61Test for chlorohydrocarbons82465$9.13Assay bld/serum cholesterol82465QW$9.13Assay bld/serum cholesterol82480$16.52Assay serum cholinesterase82482$16.68Assay rbc cholinesterase82485$43.35Assay chondroitin sulfate82495$42.57Assay of chromium82507$58.36Assay of citrate82523$39.22Collagen crosslinks82523QW$39.22Collagen crosslinks82525$26.04Assay of copper82528$47.26Assay of corticosterone82530$35.07Cortisol free82533$34.20Total cortisol82540$9.72Assay of creatine82542$40.95Col chromotography qual/quan82550$13.67Assay of ck (cpk)82550QW$13.67Assay of ck (cpk)Final Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC82552$28.10Assay of cpk in blood82553$24.24Creatine mb fraction82554$24.91Creatine isoforms82565$10.76Assay of creatinine82565QW$10.76Assay of creatinine82570$10.86Assay of urine creatinine82570QW$10.86Assay of urine creatinine82575$19.84Creatinine clearance test82585$24.04Assay of cryofibrinogen82595$13.57Assay of cryoglobulin82600$40.72Assay of cyanide82607$31.64Vitamin b-1282608$30.06B-12 binding capacity82610$31.48Cystatin c82615$17.14Test for urine cystines82626$53.04Dehydroepiandrosterone82627$46.67Dehydroepiandrosterone82633$65.03Desoxycorticosterone82634$61.44Deoxycortisol82638$25.70Assay of dibucaine number82652$80.80Vit d 1 25-dihydroxy82656$24.21Pancreatic elastase fecal82657$37.89Enzyme cell activity82658$74.85Enzyme cell activity ra82664$104.55Electrophoretic test82668$39.44Assay of erythropoietin82670$58.63Assay of estradiol82671$67.80Assay of estrogens82672$45.53Assay of estrogen82677$50.75Assay of estriol82679$52.38Assay of estrone82679QW$52.38Assay of estrone82693$31.28Assay of ethylene glycolFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC82696$49.50Assay of etiocholanolone82705$10.69Fats/lipids feces qual82710$35.28Fats/lipids feces quant82715$39.05Assay of fecal fat82725$31.91Assay of blood fatty acids82726$37.89Long chain fatty acids82728$28.61Assay of ferritin82731$135.18Assay of fetal fibronectin82735$38.91Assay of fluoride82746$30.86Assay of folic acid serum82747$36.35Assay of folic acid rbc82757$36.38Assay of semen fructose82759$45.08Assay of rbc galactokinase82760$23.49Assay of galactose82775$44.22Assay galactose transferase82776$19.96Galactose transferase test82777$75.23Galectin-382784$19.52Assay iga/igd/igg/igm each82785$34.54Assay of ige82787$16.83Igg 1 2 3 or 4 each82800$18.70Blood ph82803$44.32Blood gases any combination82805$133.91Blood gases w/o2 saturation82810$18.31Blood gases o2 sat only82820$22.68Hemoglobin-oxygen affinity82930$11.42Gastric analy w/ph ea spec82938$37.13Gastrin test82941$37.01Assay of gastrin82943$29.99Assay of glucagon82945$8.25Glucose other fluid82946$31.64Glucagon tolerance test82947$8.25Assay glucose blood quant82947QW$8.25Assay glucose blood quantFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC82948$8.57Reagent strip/blood glucose82950$9.96Glucose test82950QW$9.96Glucose test82951$27.01Glucose tolerance test (gtt)82951QW$27.01Glucose tolerance test (gtt)82952$8.23Gtt-added samples82952QW$8.23Gtt-added samples82955$20.35Assay of g6pd enzyme82960$12.70Test for g6pd enzyme82962$5.58Glucose blood test82963$45.08Assay of glucosidase82965$22.36Assay of gdh enzyme82977$15.11Assay of ggt82977QW$15.11Assay of ggt82978$29.92Assay of glutathione82979$19.82Assay rbc glutathione82985$31.64Assay of glycated protein82985QW$31.64Assay of glycated protein83001$39.00Assay of gonadotropin (fsh)83001QW$39.00Assay of gonadotropin (fsh)83002$38.86Assay of gonadotropin (lh)83002QW$38.86Assay of gonadotropin (lh)83003$34.99Assay growth hormone (hgh)83006$128.52Growth stimulation gene 283009$141.37H pylori (c-13) blood83010$26.40Assay of haptoglobin quant83012$45.71Assay of haptoglobins83013$141.37H pylori (c-13) breath83014$16.49H pylori drug admin83015$39.53Heavy metal qual any anal83018$46.10Heavy metal quant each nes83020$27.01Hemoglobin electrophoresis83021$37.89Hemoglobin chromotographyFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC83026$6.82Hemoglobin copper sulfate83030$18.26Fetal hemoglobin chemical83033$13.60Fetal hemoglobin assay qual83036$20.38Glycosylated hemoglobin test83036QW$20.38Glycosylated hemoglobin test83037$20.38Glycosylated hb home device83037QW$20.38Glycosylated hb home device83045$11.03Blood methemoglobin test83050$15.39Blood methemoglobin assay83051$15.35Assay of plasma hemoglobin83060$17.36Blood sulfhemoglobin assay83065$15.30Assay of hemoglobin heat83068$17.77Hemoglobin stability screen83069$8.30Assay of urine hemoglobin83070$9.96Assay of hemosiderin qual83080$35.41Assay of b hexosaminidase83088$61.98Assay of histamine83090$35.41Assay of homocystine83150$40.61Assay of homovanillic acid83491$36.79Assay of corticosteroids 1783497$27.06Assay of 5-hiaa83498$57.02Assay of progesterone 17-d83500$47.53Assay free hydroxyproline83505$51.02Assay total hydroxyproline83516$24.21Immunoassay nonantibody83516QW$24.21Immunoassay nonantibody83518$17.80Immunoassay dipstick83518QW$17.80Immunoassay dipstick83519$31.28Ria nonantibody83520$29.36Immunoassay quant nos nonab83520QW$29.36Immunoassay quant nos nonab83525$23.99Assay of insulin83527$27.17Assay of insulinFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC83528$33.69Assay of intrinsic factor83540$13.58Assay of iron83550$18.34Iron binding test83570$18.58Assay of idh enzyme83582$29.75Assay of ketogenic steroids83586$26.86Assay 17- ketosteroids83593$55.20Fractionation ketosteroids83605$22.42Assay of lactic acid83605QW$22.42Assay of lactic acid83615$12.67Lactate (ld) (ldh) enzyme83625$26.86Assay of ldh enzymes83630$41.21Lactoferrin fecal (qual)83631$41.21Lactoferrin fecal (quant)83632$42.45Placental lactogen83633$19.13Test urine for lactose83655$25.42Assay of lead83655QW$25.42Assay of lead83661$46.14L/s ratio fetal lung83662$39.70Foam stability fetal lung83663$39.70Fluoro polarize fetal lung83664$39.70Lamellar bdy fetal lung83670$19.23Assay of lap enzyme83690$14.47Assay of lipase83695$27.17Assay of lipoprotein(a)83698$78.73Assay lipoprotein pla283700$23.63Lipopro bld electrophoretic83701$57.56Lipoprotein bld hr fraction83704$66.22Lipoprotein bld quan part83718$17.20Assay of lipoprotein83718QW$17.20Assay of lipoprotein83719$24.41Assay of blood lipoprotein83721$20.03Assay of blood lipoprotein83721QW$20.03Assay of blood lipoproteinFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC83727$36.07Assay of lrh hormone83735$14.06Assay of magnesium83775$15.47Assay malate dehydrogenase83785$51.63Assay of manganese83789$40.99Mass spectrometry qual/quan83825$34.12Assay of mercury83835$35.56Assay of metanephrines83857$22.54Assay of methemalbumin83861$38.22Microfluid analy tears83861QW$38.22Microfluid analy tears83864$48.45Mucopolysaccharides83872$12.31Assay synovial fluid mucin83873$36.11Assay of csf protein83874$27.12Assay of myoglobin83876$86.46Assay myeloperoxidase83880$71.23Assay of natriuretic peptide83880QW$71.23Assay of natriuretic peptide83883$28.54Assay nephelometry not spec83885$51.44Assay of nickel83915$23.41Assay of nucleotidase83916$46.56Oligoclonal bands83918$40.12Organic acids total quant83919$34.53Organic acids qual each83921$36.06Organic acid single quant83930$13.87Assay of blood osmolality83935$14.31Assay of urine osmolality83937$62.65Assay of osteocalcin83945$27.01Assay of oxalate83950$135.18Oncoprotein her-2/neu83951$135.18Oncoprotein dcp83970$86.63Assay of parathormone83986$7.51Assay ph body fluid nos83986QW$7.51Assay ph body fluid nosFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC83987$7.51Exhaled breath condensate83993$41.21Assay for calprotectin fecal84030$11.54Assay of blood pku84035$7.68Assay of phenylketones84060$15.50Assay acid phosphatase84066$20.28Assay prostate phosphatase84075$10.86Assay alkaline phosphatase84075QW$10.86Assay alkaline phosphatase84078$15.32Assay alkaline phosphatase84080$31.03Assay alkaline phosphatases84081$34.66Assay phosphatidylglycerol84085$19.82Assay of rbc pg6d enzyme84087$21.66Assay phosphohexose enzymes84100$9.95Assay of phosphorus84105$10.86Assay of urine phosphorus84106$9.89Test for porphobilinogen84110$17.71Assay of porphobilinogen84112$166.79Eval amniotic fluid protein84119$22.71Test urine for porphyrins84120$30.87Assay of urine porphyrins84126$66.49Assay of feces porphyrins84132$9.66Assay of serum potassium84132QW$9.66Assay of serum potassium84133$9.04Assay of urine potassium84134$30.62Assay of prealbumin84135$40.17Assay of pregnanediol84138$39.73Assay of pregnanetriol84140$43.38Assay of pregnenolone84143$47.87Assay of 17-hydroxypregneno84144$43.79Assay of progesterone84145$56.24Procalcitonin (pct)84146$40.66Assay of prolactin84150$71.01Assay of prostaglandinFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC84152$38.61Assay of psa complexed84153$38.61Assay of psa total84154$38.61Assay of psa free84155$7.70Assay of protein serum84155QW$7.70Assay of protein serum84156$7.70Assay of protein urine84157$7.70Assay of protein other84157QW$7.70Assay of protein other84160$10.86Assay of protein any source84163$31.60Pappa serum84165$22.54Protein e-phoresis serum84166$37.42Protein e-phoresis/urine/csf84181$35.73Western blot test84182$49.66Protein western blot test84202$30.11Assay rbc protoporphyrin84203$18.07Test rbc protoporphyrin84206$45.37Assay of proinsulin84207$58.97Assay of vitamin b-684210$24.62Assay of pyruvate84220$19.82Assay of pyruvate kinase84228$24.41Assay of quinine84233$149.40Assay of estrogen84234$136.17Assay of progesterone84235$121.09Assay of endocrine hormone84238$76.74Assay nonendocrine receptor84244$46.16Assay of renin84252$42.47Assay of vitamin b-284255$53.58Assay of selenium84260$65.03Assay of serotonin84270$45.61Assay of sex hormone globul84275$28.20Assay of sialic acid84285$49.40Assay of silica84295$10.10Assay of serum sodiumFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC84295QW$10.10Assay of serum sodium84300$10.20Assay of urine sodium84302$10.20Assay of sweat sodium84305$44.63Assay of somatomedin84307$38.35Assay of somatostatin84311$14.67Spectrophotometry84315$5.58Body fluid specific gravity84375$66.30Chromatogram assay sugars84376$11.54Sugars single qual84377$11.54Sugars multiple qual84378$24.19Sugars single quant84379$24.19Sugars multiple quant84392$9.96Assay of urine sulfate84402$53.47Assay of free testosterone84403$54.18Assay of total testosterone84410$107.64Testosterone bioavailable84425$44.56Assay of vitamin b-184430$24.41Assay of thiocyanate84431$59.69Thromboxane urine84432$33.71Assay of thyroglobulin84436$14.42Assay of total thyroxine84437$13.57Assay of neonatal thyroxine84439$18.92Assay of free thyroxine84442$31.03Assay of thyroid activity84443$35.28Assay thyroid stim hormone84443QW$35.28Assay thyroid stim hormone84445$106.73Assay of tsi globulin84446$29.77Assay of vitamin e84449$37.77Assay of transcortin84450$10.86Transferase (ast) (sgot)84450QW$10.86Transferase (ast) (sgot)84460$11.12Alanine amino (alt) (sgpt)84460QW$11.12Alanine amino (alt) (sgpt)Final Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC84466$26.79Assay of transferrin84478$12.05Assay of triglycerides84478QW$12.05Assay of triglycerides84479$13.57Assay of thyroid (t3 or t4)84480$29.77Assay triiodothyronine (t3)84481$35.56Free assay (ft-3)84482$33.08T3 reverse84484$21.20Assay of troponin quant84485$15.11Assay duodenal fluid trypsin84488$15.32Test feces for trypsin84490$16.88Assay of feces for trypsin84510$21.83Assay of tyrosine84512$17.15Assay of troponin qual84520$8.30Assay of urea nitrogen84520QW$8.30Assay of urea nitrogen84525$8.72Urea nitrogen semi-quant84540$9.96Assay of urine/urea-n84545$13.87Urea-n clearance test84550$9.49Assay of blood/uric acid84550QW$9.49Assay of blood/uric acid84560$9.96Assay of urine/uric acid84577$35.28Assay of feces/urobilinogen84578$7.60Test urine urobilinogen84580$17.14Assay of urine urobilinogen84583$10.56Assay of urine urobilinogen84585$32.52Assay of urine vma84586$74.15Assay of vip84588$71.23Assay of vasopressin84590$24.36Assay of vitamin a84591$29.00Assay of nos vitamin84597$28.80Assay of vitamin k84600$33.75Assay of volatiles84620$24.87Xylose tolerance testFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC84630$23.90Assay of zinc84681$43.69Assay of c-peptide84702$31.60Chorionic gonadotropin test84703$15.79Chorionic gonadotropin assay84703QW$15.79Chorionic gonadotropin assay84704$31.60Hcg free betachain test84830$21.59Ovulation tests85002$9.47Bleeding time test85004$13.57Automated diff wbc count85007$7.21Bl smear w/diff wbc count85008$7.21Bl smear w/o diff wbc count85009$8.62Manual diff wbc count b-coat85013$11.90Spun microhematocrit85014$4.98Hematocrit85014QW$4.98Hematocrit85018$4.98Hemoglobin85018QW$4.98Hemoglobin85025$16.30Complete cbc w/auto diff wbc85025QW$16.30Complete cbc w/auto diff wbc85027$13.57Complete cbc automated85032$9.04Manual cell count each85041$6.34Automated rbc count85044$9.04Manual reticulocyte count85045$8.38Automated reticulocyte count85046$11.70Reticyte/hgb concentrate85048$5.32Automated leukocyte count85049$9.40Automated platelet count85055$60.76Reticulated platelet assay85130$24.96Chromogenic substrate assay85170$27.71Blood clot retraction85175$34.63Blood clot lysis time85210$27.25Clot factor ii prothrom spec85220$37.04Blooc clot factor v testFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC85230$37.57Clot factor vii proconvertin85240$37.57Clot factor viii ahg 1 stage85244$42.86Clot factor viii reltd antgn85245$48.14Clot factor viii vw ristoctn85246$48.14Clot factor viii vw antigen85247$48.14Clot factor viii multimetric85250$39.97Clot factor ix ptc/chrstmas85260$37.57Clot factor x stuart-power85270$37.57Clot factor xi pta85280$40.61Clot factor xii hageman85290$34.29Clot factor xiii fibrin stab85291$18.67Clot factor xiii fibrin scrn85292$39.73Clot factor fletcher fact85293$39.73Clot factor wght kininogen85300$24.87Antithrombin iii activity85301$22.70Antithrombin iii antigen85302$25.21Clot inhibit prot c antigen85303$29.04Clot inhibit prot c activity85305$24.36Clot inhibit prot s total85306$32.16Clot inhibit prot s free85307$32.16Assay activated protein c85335$27.01Factor inhibitor test85337$29.36Thrombomodulin85345$9.04Coagulation time lee & white85347$8.94Coagulation time activated85348$7.82Coagulation time otr method85360$17.65Euglobulin lysis85362$14.47Fibrin degradation products85366$136.78Fibrinogen test85370$23.83Fibrinogen test85378$16.52Fibrin degrade semiquant85379$21.35Fibrin degradation quant85380$21.35Fibrin degradj d-dimerFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC85384$17.83Fibrinogen activity85385$24.58Fibrinogen antigen85390$26.32Fibrinolysins screen i&r85397$52.46Clotting funct activity85400$16.17Fibrinolytic plasmin85410$16.17Fibrinolytic antiplasmin85415$36.07Fibrinolytic plasminogen85420$13.70Fibrinolytic plasminogen85421$21.37Fibrinolytic plasminogen85441$8.81Heinz bodies direct85445$14.31Heinz bodies induced85460$16.24Hemoglobin fetal85461$15.91Hemoglobin fetal85475$18.62Hemolysin acid85520$27.47Heparin assay85525$24.85Heparin neutralization85530$27.47Heparin-protamine tolerance85536$13.57Iron stain peripheral blood85540$18.05Wbc alkaline phosphatase85547$18.05Rbc mechanical fragility85549$39.36Muramidase85555$14.03Rbc osmotic fragility85557$28.03Rbc osmotic fragility85576$45.08Blood platelet aggregation85576QW$45.08Blood platelet aggregation85597$37.72Phospholipid pltlt neutraliz85598$37.72Hexagnal phosph pltlt neutrl85610$8.25Prothrombin time85610QW$8.25Prothrombin time85611$8.28Prothrombin test85612$29.73Viper venom prothrombin time85613$20.11Russell viper venom diluted85635$20.67Reptilase testFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC85651$7.45Rbc sed rate nonautomated85652$5.66Rbc sed rate automated85660$11.56Rbc sickle cell test85670$12.10Thrombin time plasma85675$14.37Thrombin time titer85705$20.21Thromboplastin inhibition85730$12.61Thromboplastin time partial85732$13.57Thromboplastin time partial85810$24.50Blood viscosity examination86000$14.65Agglutinins febrile antigen86001$13.29Allergen specific igg86003$10.95Allg spec ige crude xtrc ea86005$16.73Allg spec ige multiallg scr86008$37.64Allg spec ige recomb ea86021$31.60Wbc antibody identification86022$38.56Platelet antibodies86023$26.15Immunoglobulin assay86038$25.36Antinuclear antibodies86039$23.43Antinuclear antibodies (ana)86060$15.32Antistreptolysin o titer86063$12.10Antistreptolysin o screen86140$10.86C-reactive protein86141$27.17C-reactive protein hs86146$53.41Beta-2 glycoprotein antibody86147$53.41Cardiolipin antibody ea ig86148$33.73Anti-phospholipid antibody86152$515.68Cell enumeration & id86155$33.56Chemotaxis assay86156$14.06Cold agglutinin screen86157$16.92Cold agglutinin titer86160$25.18Complement antigen86161$25.18Complement/function activity86162$42.65Complement total (ch50)Final Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC86171$21.01Complement fixation each86200$27.17Ccp antibody86215$27.80Deoxyribonuclease antibody86225$28.85Dna antibody native86226$25.42Dna antibody single strand86235$37.64Nuclear antigen antibody86255$25.30Fluorescent antibody screen86256$25.30Fluorescent antibody titer86277$33.03Growth hormone antibody86280$17.20Hemagglutination inhibition86294$43.47Immunoassay tumor qual86294QW$43.47Immunoassay tumor qual86300$43.69Immunoassay tumor ca 15-386301$43.69Immunoassay tumor ca 19-986304$43.69Immunoassay tumor ca 12586305$43.69Human epididymis protein 486308$10.86Heterophile antibody screen86308QW$10.86Heterophile antibody screen86309$13.57Heterophile antibody titer86310$15.47Heterophile antibody absrbj86316$43.69Immunoassay tumor other86317$31.45Immunoassay infectious agent86318$30.75Immunoassay infectious agent86318QW$30.75Immunoassay infectious agent86320$50.86Serum immunoelectrophoresis86325$46.94Other immunoelectrophoresis86327$50.86Immunoelectrophoresis assay86329$29.48Immunodiffusion nes86331$25.14Immunodiffusion ouchterlony86332$51.15Immune complex assay86334$46.90Immunofix e-phoresis serum86335$61.59Immunfix e-phorsis/urine/csf86336$32.71Inhibin aFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC86337$44.93Insulin antibodies86340$31.64Intrinsic factor antibody86341$41.53Islet cell antibody86343$26.15Leukocyte histamine release86344$17.66Leukocyte phagocytosis86352$285.14Cell function assay w/stim86353$102.90Lymphocyte transformation86355$79.19B cells total count86356$56.20Mononuclear cell antigen86357$79.19Nk cells total count86359$79.19T cells total count86360$98.62T cell absolute count/ratio86361$56.20T cell absolute count86367$132.23Stem cells total count86376$30.53Microsomal antibody each86382$35.50Neutralization test viral86384$23.90Nitroblue tetrazolium dye86386$37.03Nuclear matrix protein 2286386QW$37.03Nuclear matrix protein 2286403$21.39Particle agglut antbdy scrn86406$22.32Particle agglut antbdy titr86430$11.90Rheumatoid factor test qual86431$11.90Rheumatoid factor quant86480$130.08Tb test cell immun measure86481$170.00Tb ag response t-cell susp86590$23.19Streptokinase antibody86592$8.96Syphilis test non-trep qual86593$9.25Syphilis test non-trep quant86602$21.35Antinomyces antibody86603$27.01Adenovirus antibody86606$31.60Aspergillus antibody86609$27.03Bacterium antibody86611$21.35Bartonella antibodyFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC86612$27.08Blastomyces antibody86615$27.68Bordetella antibody86617$32.52Lyme disease antibody86618$35.73Lyme disease antibody86618QW$35.73Lyme disease antibody86619$28.08Borrelia antibody86622$18.75Brucella antibody86625$27.54Campylobacter antibody86628$25.19Candida antibody86631$24.82Chlamydia antibody86632$26.62Chlamydia igm antibody86635$24.09Coccidioides antibody86638$25.45Q fever antibody86641$30.24Cryptococcus antibody86644$30.21Cmv antibody86645$35.36Cmv antibody igm86648$31.91Diphtheria antibody86651$27.68Encephalitis californ antbdy86652$27.68Encephaltis east eqne anbdy86653$27.68Encephaltis st louis antbody86654$27.68Encephaltis west eqne antbdy86658$27.34Enterovirus antibody86663$27.54Epstein-barr antibody86664$32.10Epstein-barr nuclear antigen86665$38.08Epstein-barr capsid vca86666$21.35Ehrlichia antibody86668$24.07Francisella tularensis86671$25.72Fungus nes antibody86674$30.89Giardia lamblia antibody86677$30.45Helicobacter pylori antibody86682$27.30Helminth antibody86684$33.25Hemophilus influenza antibdy86687$17.61Htlv-i antibodyFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC86688$29.39Htlv-ii antibody86689$40.63Htlv/hiv confirmj antibody86692$36.02Hepatitis delta agent antbdy86694$30.21Herpes simplex nes antbdy86695$27.68Herpes simplex type 1 test86696$40.63Herpes simplex type 2 test86698$26.23Histoplasma antibody86701$18.65Hiv-1antibody86701QW$18.65Hiv-1antibody86702$28.37Hiv-2 antibody86703$28.76Hiv-1/hiv-2 1 result antbdy86704$25.30Hep b core antibody total86705$24.72Hep b core antibody igm86706$22.54Hep b surface antibody86707$24.28Hepatitis be antibody86708$25.99Hepatitis a antibody86709$23.63Hepatitis a igm antibody86710$28.44Influenza virus antibody86711$30.21John cunningham antibody86713$32.11Legionella antibody86717$25.70Leishmania antibody86720$27.68Leptospira antibody86723$27.68Listeria monocytogenes86727$27.01Lymph choriomeningitis ab86732$27.68Mucormycosis antibody86735$27.39Mumps antibody86738$27.78Mycoplasma antibody86741$27.68Neisseria meningitidis86744$27.68Nocardia antibody86747$31.55Parvovirus antibody86750$27.68Malaria antibody86753$25.99Protozoa antibody nos86756$27.05Respiratory virus antibodyFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC86757$40.63Rickettsia antibody86759$30.99Rotavirus antibody86762$30.21Rubella antibody86765$27.03Rubeola antibody86768$27.68Salmonella antibody86771$41.62Shigella antibody86774$31.06Tetanus antibody86777$30.21Toxoplasma antibody86778$30.23Toxoplasma antibody igm86780$27.78Treponema pallidum86780QW$27.78Treponema pallidum86784$26.37Trichinella antibody86787$27.03Varicella-zoster antibody86788$35.36West nile virus ab igm86789$30.21West nile virus antibody86790$27.03Virus antibody nos86793$27.68Yersinia antibody86794$35.36Zika virus igm antibody86800$33.39Thyroglobulin antibody86803$29.94Hepatitis c ab test86803QW$29.94Hepatitis c ab test86804$32.52Hep c ab test confirm86805$322.17Lymphocytotoxicity assay86806$99.88Lymphocytotoxicity assay86807$133.71Cytotoxic antibody screening86808$62.29Cytotoxic antibody screening86812$54.16Hla typing a b or c86813$121.72Hla typing a b or c86816$58.46Hla typing dr/dq86817$180.44Hla typing dr/dq86821$76.74Lymphocyte culture mixed86825$186.13Hla x-math non-cytotoxic86826$62.10Hla x-match noncytotoxc addlFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC86828$109.12Hla class i&ii antibody qual86829$109.12Hla class i/ii antibody qual86830$169.46Hla class i phenotype qual86831$145.25Hla class ii phenotype qual86832$550.38Hla class i high defin qual86833$553.86Hla class ii high defin qual86834$750.43Hla class i semiquant panel86835$677.82Hla class ii semiquant panel86850$16.61Rbc antibody screen86880$11.31Coombs test direct86885$12.02Coombs test indirect qual86886$10.86Coombs test indirect titer86900$6.27Blood typing serologic abo86901$6.27Blood typing serologic rh(d)86902$10.80Blood type antigen donor ea86904$27.78Blood typing patient serum86905$8.04Blood typing rbc antigens86906$16.27Bld typing serologic rh phnt86940$17.22Hemolysins/agglutinins auto86941$25.42Hemolysins/agglutinins87003$35.34Small animal inoculation87015$14.01Specimen infect agnt concntj87040$21.66Blood culture for bacteria87045$19.82Feces culture aerobic bact87046$19.82Stool cultr aerobic bact ea87070$18.09Culture othr specimn aerobic87071$19.82Culture aerobic quant other87073$19.82Culture bacteria anaerobic87075$19.87Cultr bacteria except blood87076$16.95Culture anaerobe ident each87077$16.95Culture aerobic identify87077QW$16.95Culture aerobic identify87081$13.91Culture screen onlyFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC87084$46.02Culture of specimen by kit87086$16.93Urine culture/colony count87088$16.98Urine bacteria culture87101$16.17Skin fungi culture87102$17.65Fungus isolation culture87103$34.78Blood fungus culture87106$21.66Fungi identification yeast87107$21.66Fungi identification mold87109$32.30Mycoplasma87110$41.12Chlamydia culture87116$22.68Mycobacteria culture87118$24.84Mycobacteric identification87140$11.70Culture type immunofluoresc87143$26.28Culture typing glc/hplc87147$10.86Culture type immunologic87149$42.09Dna/rna direct probe87150$73.66Dna/rna amplified probe87152$13.16Culture type pulse field gel87153$242.11Dna/rna sequencing87158$13.16Culture typing added method87164$22.54Dark field examination87166$23.72Dark field examination87168$8.96Macroscopic exam arthropod87169$8.96Macroscopic exam parasite87172$8.96Pinworm exam87176$12.34Tissue homogenization cultr87177$18.68Ova and parasites smears87181$9.96Microbe susceptible diffuse87184$14.47Microbe susceptible disk87185$9.96Microbe susceptible enzyme87186$18.14Microbe susceptible mic87187$68.29Microbe susceptible mlc87188$13.94Microbe suscept macrobrothFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC87190$12.43Microbe suscept mycobacteri87197$31.54Bactericidal level serum87205$8.96Smear gram stain87206$11.31Smear fluorescent/acid stai87207$12.58Smear special stain87209$37.72Smear complex stain87210$9.89Smear wet mount saline/ink87210QW$9.89Smear wet mount saline/ink87220$8.96Tissue exam for fungi87230$41.43Assay toxin or antitoxin87250$41.06Virus inoculate eggs/animal87252$54.71Virus inoculation tissue87253$42.40Virus inoculate tissue addl87254$41.06Virus inoculation shell via87255$71.08Genet virus isolate hsv87260$25.16Adenovirus ag if87265$25.16Pertussis ag if87267$25.16Enterovirus antibody dfa87269$25.16Giardia ag if87270$25.16Chlamydia trachomatis ag if87271$25.16Cytomegalovirus dfa87272$25.16Cryptosporidium ag if87273$25.16Herpes simplex 2 ag if87274$25.16Herpes simplex 1 ag if87275$25.16Influenza b ag if87276$27.32Influenza a ag if87278$26.52Legion pneumophilia ag if87279$27.93Parainfluenza ag if87280$25.16Respiratory syncytial ag if87281$25.16Pneumocystis carinii ag if87283$103.36Rubeola ag if87285$25.16Treponema pallidum ag if87290$25.16Varicella zoster ag ifFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC87299$27.37Antibody detection nos if87300$25.16Ag detection polyval if87301$25.16Adenovirus ag ia87305$25.16Aspergillus ag ia87320$25.50Chylmd trach ag ia87324$25.16Clostridium ag ia87327$25.16Cryptococcus neoform ag ia87328$25.16Cryptosporidium ag ia87329$25.16Giardia ag ia87332$25.16Cytomegalovirus ag ia87335$25.16E coli 0157 ag ia87336$27.20Entamoeb hist dispr ag ia87337$25.16Entamoeb hist group ag ia87338$30.19Hpylori stool ia87338QW$30.19Hpylori stool ia87339$27.20H pylori ag ia87340$21.68Hepatitis b surface ag ia87341$21.68Hepatitis b surface ag ia87350$24.19Hepatitis be ag ia87380$34.44Hepatitis delta ag ia87385$25.16Histoplasma capsul ag ia87389$50.54Hiv-1 ag w/hiv-1 & hiv-2 ab87389QW$50.54Hiv-1 ag w/hiv-1 & hiv-2 ab87390$40.90Hiv-1 ag ia87391$37.23Hiv-2 ag ia87400$25.16Influenza a/b ag ia87420$25.16Resp syncytial ag ia87425$25.16Rotavirus ag ia87427$25.16Shiga-like toxin ag ia87430$28.58Strep a ag ia87449$25.16Ag detect nos ia mult87449QW$25.16Ag detect nos ia mult87450$20.13Ag detect nos ia singleFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC87451$20.13Ag detect polyval ia mult87471$73.66Bartonella dna amp probe87472$89.90Bartonella dna quant87475$42.09Lyme dis dna dir probe87476$73.66Lyme dis dna amp probe87480$42.09Candida dna dir probe87481$73.66Candida dna amp probe87482$94.76Candida dna quant87483$874.74Cns dna amp probe type 12-2587485$42.09Chylmd pneum dna dir probe87486$73.66Chylmd pneum dna amp probe87487$89.90Chylmd pneum dna quant87490$42.09Chylmd trach dna dir probe87491$73.66Chylmd trach dna amp probe87492$90.90Chylmd trach dna quant87493$73.66C diff amplified probe87495$51.05Cytomeg dna dir probe87496$73.66Cytomeg dna amp probe87497$89.90Cytomeg dna quant87498$73.66Enterovirus probe&revrs trns87500$73.66Vanomycin dna amp probe87501$107.70Influenza dna amp prob 1+87502$178.60Influenza dna amp probe87502QW$178.60Influenza dna amp probe87503$49.67Influenza dna amp prob addl87505$269.25Nfct agent detection gi87506$447.93Iadna-dna/rna probe tq 6-1187507$874.74Iadna-dna/rna probe tq 12-2587510$42.09Gardner vag dna dir probe87511$73.66Gardner vag dna amp probe87512$87.64Gardner vag dna quant87516$73.66Hepatitis b dna amp probe87517$89.90Hepatitis b dna quantFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC87520$53.07Hepatitis c rna dir probe87521$73.66Hepatitis c probe&rvrs trnsc87522$89.90Hepatitis c revrs trnscrpj87525$50.66Hepatitis g dna dir probe87526$73.66Hepatitis g dna amp probe87527$87.64Hepatitis g dna quant87528$42.09Hsv dna dir probe87529$73.66Hsv dna amp probe87530$89.90Hsv dna quant87531$98.60Hhv-6 dna dir probe87532$73.66Hhv-6 dna amp probe87533$87.64Hhv-6 dna quant87534$42.09Hiv-1 dna dir probe87535$73.66Hiv-1 probe&reverse trnscrpj87536$178.60Hiv-1 quant&revrse trnscrpj87537$42.09Hiv-2 dna dir probe87538$73.66Hiv-2 probe&revrse trnscripj87539$99.65Hiv-2 quant&revrse trnscripj87540$42.09Legion pneumo dna dir prob87541$73.66Legion pneumo dna amp prob87542$87.64Legion pneumo dna quant87550$42.09Mycobacteria dna dir probe87551$82.01Mycobacteria dna amp probe87552$89.90Mycobacteria dna quant87555$45.70M.tuberculo dna dir probe87556$73.66M.tuberculo dna amp probe87557$89.90M.tuberculo dna quant87560$46.39M.avium-intra dna dir prob87561$73.66M.avium-intra dna amp prob87562$89.90M.avium-intra dna quant87580$42.09M.pneumon dna dir probe87581$73.66M.pneumon dna amp probe87582$514.45M.pneumon dna quantFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC87590$45.70N.gonorrhoeae dna dir prob87591$73.66N.gonorrhoeae dna amp prob87592$89.90N.gonorrhoeae dna quant87623$73.66Hpv low-risk types87624$73.66Hpv high-risk types87625$73.66Hpv types 16 & 18 only87631$269.25Resp virus 3-5 targets87631QW$269.25Resp virus 3-5 targets87632$447.93Resp virus 6-11 targets87633$874.74Resp virus 12-25 targets87633QW$874.74Resp virus 12-25 targets87634$147.32Rsv dna/rna amp probe87640$73.66Staph a dna amp probe87641$73.66Mr-staph dna amp probe87650$42.09Strep a dna dir probe87650QW$42.09Strep a dna dir probe87651$73.66Strep a dna amp probe87651QW$73.66Strep a dna amp probe87652$87.64Strep a dna quant87653$73.66Strep b dna amp probe87660$42.09Trichomonas vagin dir probe87661$73.66Trichomonas vaginalis amplif87662$107.70Zika virus dna/rna amp probe87797$51.05Detect agent nos dna dir87798$73.66Detect agent nos dna amp87799$89.90Detect agent nos dna quant87800$84.20Detect agnt mult dna direc87801$147.32Detect agnt mult dna ampli87801QW$147.32Detect agnt mult dna ampli87802$25.16Strep b assay w/optic87803$27.20Clostridium toxin a w/optic87804$28.14Influenza assay w/optic87804QW$28.14Influenza assay w/opticFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC87806$55.71Hiv antigen w/hiv antibodies87806QW$55.71Hiv antigen w/hiv antibodies87807$25.16Rsv assay w/optic87807QW$25.16Rsv assay w/optic87808$25.99Trichomonas assay w/optic87808QW$25.99Trichomonas assay w/optic87809$36.99Adenovirus assay w/optic87809QW$36.99Adenovirus assay w/optic87810$59.99Chylmd trach assay w/optic87850$41.75N. gonorrhoeae assay w/optic87880$28.10Strep a assay w/optic87880QW$28.10Strep a assay w/optic87899$27.32Agent nos assay w/optic87899QW$27.32Agent nos assay w/optic87900$273.56Phenotype infect agent drug87901$540.33Genotype dna hiv reverse t87902$540.33Genotype dna/rna hep c87903$1,025.58Phenotype dna hiv w/culture87904$54.71Phenotype dna hiv w/clt add87905$25.64Sialidase enzyme assay87905QW$25.64Sialidase enzyme assay87906$270.16Genotype dna/rna hiv87910$540.33Genotype cytomegalovirus87912$540.33Genotype dna hepatitis b88130$37.72Sex chromatin identification88140$16.76Sex chromatin identification88142$42.52Cytopath c/v thin layer88143$42.52Cytopath c/v thin layer redo88147$85.95Cytopath c/v automated88148$31.89Cytopath c/v auto rescreen88150$24.91Cytopath c/v manual88152$46.99Cytopath c/v auto redo88153$40.85Cytopath c/v redoFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC88155$24.91Cytopath c/v index add-on88164$24.91Cytopath tbs c/v manual88165$71.77Cytopath tbs c/v redo88166$24.91Cytopath tbs c/v auto redo88167$24.91Cytopath tbs c/v select88174$44.85Cytopath c/v auto in fluid88175$55.61Cytopath c/v auto fluid redo88230$244.49Tissue culture lymphocyte88233$295.36Tissue culture skin/biopsy88235$309.08Tissue culture placenta88237$265.08Tissue culture bone marrow88239$309.60Tissue culture tumor88240$22.22Cell cryopreserve/storage88241$21.20Frozen cell preparation88245$363.46Chromosome analysis 20-2588248$363.46Chromosome analysis 50-10088249$363.46Chromosome analysis 10088261$449.38Chromosome analysis 588262$261.60Chromosome analysis 15-2088263$315.42Chromosome analysis 4588264$261.60Chromosome analysis 20-2588267$377.32Chromosome analys placenta88269$349.08Chromosome analys amniotic88271$44.95Cytogenetics dna probe88272$69.19Cytogenetics 3-588273$67.42Cytogenetics 10-3088274$73.07Cytogenetics 25-9988275$87.02Cytogenetics 100-30088280$56.90Chromosome karyotype study88283$143.97Chromosome banding study88285$45.75Chromosome count additional88289$72.27Chromosome study additional88371$46.65Protein western blot tissueFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC88372$47.74Protein analysis w/probe88720$10.52Bilirubin total transcut88738$10.52Hgb quant transcutaneous88740$15.93Transcutaneous carboxyhb88741$15.93Transcutaneous methb89050$9.91Body fluid cell count89051$11.56Body fluid cell count89055$8.96Leukocyte assessment fecal89060$15.01Exam synovial fluid crystals89125$10.00Specimen fat stain89160$8.25Exam feces for meat fibers89190$9.96Nasal smear for eosinophils89300$18.75Semen analysis w/huhner89300QW$18.75Semen analysis w/huhner89310$18.07Semen analysis w/count89320$25.30Semen anal vol/count/mot89321$25.30Semen anal sperm detection89321QW$25.30Semen anal sperm detection89322$32.52Semen anal strict criteria89325$22.41Sperm antibody test89329$41.11Sperm evaluation test89330$20.76Evaluation cervical mucus89331$41.11Retrograde ejaculation anal0001M$122.72Infectious dis hcv 6 assays0001U$-Rbc dna hea 35 ag 11 bld grp0002M$855.78Liver dis 10 assays w/ash0002U$-Onc clrct 3 ur metab alg plp0003M$855.78Liver dis 10 assays w/nash0003U$1,615.00Onc ovar 5 prtn ser alg scor0004M$-Scoliosis dna alys0005U$1,292.00Onco prst8 3 gene ur alg0006M$-Onc hep gene risk classifier0006U$419.76Rx mntr 120+ drugs & sbstsFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESC0007M$-Onc gastro 51 gene nomogram0007U$194.53Rx test prsmv ur w/def conf0008U$1,016.45Hpylori detcj abx rstnc dna0009M$-Fetal aneuploidy trisom risk0009U$-Onc brst ca erbb2 amp/nonamp0010U$-Nfct ds strn typ whl gen seq0011U$194.53Rx mntr lc-ms/ms oral fluid0012U$-Germln do gene reargmt detcj0013U$-Onc sld org neo gene reargmt0014U$-Hem hmtlmf neo gene reargmt0016U$344.11Onc hmtlmf neo rna bcr/abl10017U$192.39Onc hmtlmf neo jak2 mut dnaG0027$13.65Semen analysisG0103$38.61Psa screeningG0123$42.52Screen cerv/vag thin layerG0143$45.99Scr c/v cyto,thinlayer,rescrG0144$74.75Scr c/v cyto,thinlayer,rescrG0145$55.61Scr c/v cyto,thinlayer,rescrG0147$24.91Scr c/v cyto, automated sysG0148$54.30Scr c/v cyto, autosys, rescrG0306$16.30Cbc/diffwbc w/o plateletG0307$13.57Cbc without plateletG0328$33.39Fecal blood scrn immunoassayG0328QW$33.39Fecal blood scrn immunoassayG0432$33.27Eia hiv-1/hiv-2 screenG0433$31.09Elisa hiv-1/hiv-2 screenG0433QW$31.09Elisa hiv-1/hiv-2 screenG0435$25.16Oral hiv-1/hiv-2 screenG0471$8.50Ven blood coll snf/hhaG0472$78.80Hep c screen high risk/otherG0472QW$78.80Hep c screen high risk/otherG0475$50.54Hiv combination assayG0475QW$50.54Hiv combination assayFinal Exhibit #8Clinical Laboratory Fee ScheduleEffective for Dates of Service on and after 1/1/2019HCPCSMODMAXIMUM FEESSHORTDESCG0476$73.66Hpv combo assay ca screenG0480$194.53Drug test def 1-7 classesG0481$266.20Drug test def 8-14 classesG0482$337.86Drug test def 15-21 classesG0483$419.76Drug test def 22+ classesG0499$59.33Hepb screen high risk indivG0659$122.11Drug test def simple all clG9143$253.35Warfarin respon genetic testP2028$10.39Cephalin floculation testP2029$10.39Congo red blood testP2031$10.39Hair analysisP2033$10.39Blood thymol turbidityP2038$10.39Blood mucoproteinP3000$24.91Screen pap by tech w md supvP9612$5.10Catheterize for urine specP9615$5.10Urine specimen collect multQ0111$24.91Wet mounts/ w preparationsQ0112$9.91Potassium hydroxide prepsQ0113$8.96Pinworm examinationsQ0114$16.56Fern testQ0115$42.50Post-coital mucous exam ................
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