FAMILY PLANNING CLINIC MAXIMUM ALLOWABLE FEE SCHEDULE THIS IS YOUR WISCONSIN MEDICAID MAXIMUM ALLOWABLE FEE SCHEDULE, WHICH IS IN EFFECT AS OF THE DATE OF THIS REPORT. WISCONSIN MEDICAID CERTIFIED PROVIDERS WILL BE REIMBURSED FOR SERVICES PROVIDED TO PROGRAM RECIPIENTS AT THE LOWER OF THEIR USUAL AND CUSTOMARY CHARGE, OR THE MAXIMUM ALLOWABLE FEE. SERVICES REIMBURSED BASED ON PROVIDER SPECIFIC (CONTRACTED RATES) AND REGIONAL OR SPECIALTY BASED RATES ARE NOT INCLUDED IN THIS FEE SCHEDULE. COVERAGE OF FAMILY PLANNING SERVICES UNDER THE BADGERCARE PLUS BENCHMARK PLAN WILL BE THE SAME AS THE BADGERCARE PLUS STANDARD PLAN. ALTHOUGH THE FEE SCHEDULE DOES NOT ADDRESS THE VARIOUS COVERAGE LIMITATIONS ROUTINELY APPLIED BY WISCONSIN MEDICAID BEFORE FINAL PAYMENT IS DETERMINED (E.G., RECIPIENT AND PROVIDER ELIGIBILITY, BILLING INSTRUCTIONS, FREQUENCY OF SERVICES, THIRD PARTY LIABILITY, COPAYMENT, AGE RESTRICTIONS, PRIOR AUTHORIZATION, ETC.), IT DOES CONTAIN THE FOLLOWING INFORMATION: PROC/M1/M2/TM PROC - THE PROCEDURE CODE RECOGNIZED BY WISCONSIN MEDICAID TO IDENTIFY THE SERVICE PROVIDED. M1/M2 - ONE OR TWO APPLICABLE MODIFIER(S) AFFECTING REIMBURSEMENT AMOUNT. TM - DESCRIPTIVE MODIFIER USED TO CONVEY INFORMATION FORMERLY CONVEYED BY TOS. NOTE: IN CERTAIN INSTANCES THE MODIFIER LISTED IS BEING USED BOTH TO CONVEY INFORMATION FORMERLY CONVEYED BY TOS AND TO AFFECT THE REIMBURSEMENT AMOUNT. IN THESE INSTANCES THE MODIFIER WILL BE DISPLAYED TWICE, ONCE IN THE M1 OR M2 COLUMN AND ONCE IN THE TM COLUMN, EVEN THOUGH IT WILL ONLY BE BILLED ONCE ON THE CLAIM DETAIL. DESCRIPTION - AN ABBREVIATED DESCRIPTION OF THE PROCEDURE CODE PROVIDER TYPE - ALL APPLICABLE PERFORMING PROVIDER TYPES FOR THE PROCEDURE CODE. SEE TABLE I FOR A LISTING OF PROVIDER TYPES APPLICABLE TO THIS SCHEDULE. PAC - THE PRICING ACTION CODE IDENTIFIES NON-COVERED SERVICES OR THE SOURCE AND METHOD OF PRICING THE PROCEDURE (REFER TO TABLE II). EFFECT DATE - THE EFFECTIVE DATE OF SERVICE ON OR AFTER WHICH THE MAXIMUM ALLOWABLE FEE APPLIES. RVSU - THE ANESTHESIA RELATIVE VALUE SCALE UNIT (BASE UNITS) FOR THE PROCEDURE PERFORMED. MAX FEE - MAXIMUM ALLOWABLE FEES FOR THE PROCEDURE CODES LISTED. IF A MAX FEE IS NOT INDICATED, USE THE PAC AND TABLE II TO DETERMINE THE REASON (E.G., PAC 220 INDICATES SERVICE NOT COVERED; PAC 21J INDICATES INDIVIDUAL CONSIDERATION, ETC.). THIS INFORMATION IS INTENDED TO HELP YOU UNDERSTAND THE WISCONSIN MEDICAID MAXIMUM ALLOWABLE FEE SCHEDULE. IF YOU HAVE QUESTIONS, PLEASE CONTACT WISCONSIN MEDICAID PROVIDER SERVICES AT: (608) 221-9883 OR (800) 947-9627* *WHEN REQUESTING INFORMATION, PLEASE BE SPECIFIC AS TO WHICH PROVIDER TYPE YOU ARE REFERRING (I.E., FAMILY PLANNING CLINIC). TABLE I PROVIDER TYPE 71 - FAMILY PLANNING CLINIC TABLE II PRICING ACTION CODES (PAC) 11J, 21J - INDIVIDUAL CONSIDERATION, MEDICAL CONSULTANT 120, 220 - NON-COVERED SERVICE, NOT A WISCONSIN MEDICAID BENEFIT 170, 270 - PAID AT THE LOWER OF THE BILLED AMOUNT OR MAXIMUM ALLOWABLE FEE ACCORDING TO PROVIDER TYPE 25G - ANESTHESIA ONLY, RVS UNITS PLUS QTY TIMES MAX FEE TABLE III MODIFIERS MODIFIER DESCRIPTION -------------- ----------------------------------------------------------------------------------------- QW CLIA WAIVED SERVICES TC TECHNICAL COMPONENT 26 PROFESSIONAL COMPONENT 80 ASSISTANT SURGEON PROC DESCRIPTION PROC M1 M2 TM PROVIDER TYPE PAC EFFECT RVSU MAX FEE DATE 11975 INSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 11975 71 270 01/01/08 82.75 11976 REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES 11976 71 270 01/01/08 94.57 11977 REMOVAL WITH REINSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 11977 71 270 01/01/08 151.64 11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 11981 71 270 07/01/02 82.75 11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 11982 71 270 07/01/02 90.83 11983 REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 11983 71 270 07/01/02 151.64 54050 DESTRUCTION OF LESION(S) PENIS (EG/ CONDYLOMA/ HERPETIC VESICLE) SIMPLE; CHEMICAL 54050 71 270 07/01/02 22.37 54065 DESTRUCTION OF LESION(S) PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETI 54065 71 270 07/01/02 103.63 55250 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), 55250 71 270 07/01/02 253.52 55250 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), 55250 80 71 220 07/01/74 55450 LIGATION (PERCUTANEOUS) OF VAS DEFERENS, UNILATERAL OR 55450 71 270 07/01/02 74.58 55450 LIGATION (PERCUTANEOUS) OF VAS DEFERENS, UNILATERAL OR 55450 80 71 220 07/01/74 56440 MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST 56440 71 270 07/01/02 223.76 56501 DESTRUCTION OF LESION(S) VULVA; SIMPLE (EGLASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CH 56501 71 270 07/01/02 298.33 56605 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); ONE LESION 56605 71 270 07/01/02 93.83 56606 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL LESION 56606 71 270 07/01/02 35.76 56820 COLPOSCOPY OF THE VULVA 56820 71 270 10/01/05 97.30 56821 COLPOSCOPY OF THE VULVA; WITH BIOPSY(S) 56821 71 270 10/01/05 131.54 57061 DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY 57061 71 270 07/01/02 42.65 57170 DIAPHRAGM OR CERVICAL CAP FITTING WITH INSTRUCTIONS 57170 71 270 07/01/02 30.75 57420 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT, WITH BIOPSY(S) 57420 71 270 10/01/05 101.97 57421 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX 57421 71 270 10/01/05 140.03 57452 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 57452 71 270 01/01/06 85.42 57454 COLP OF CERVIX INCLDNG UPPER/ADJACENT VAGINA;W/BIOPSY(S) OF CERVIX & ENDOCRVCL CURETTAGE 57454 71 270 07/01/07 128.63 57455 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX 57455 71 270 10/01/05 128.55 57456 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH ENDOCERVICAL CURETTAGE 57456 71 270 10/01/05 121.03 57461 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION 57461 71 270 10/01/05 320.28 57500 BIOPSY OF CERVIX,SINGLE OR MULT,OR LOCAL EXCISION OF LESION,WITH OR WITHOUT FULGURATION 57500 71 270 07/01/02 56.20 57511 CAUTERIZATION OF CERVIX; 57511 71 270 07/01/02 67.90 57520 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAG 57520 71 270 07/01/02 426.69 57520 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAG 57520 80 71 220 07/01/74 58100 ENDOMET SAMPLING (BIOP) W/OR W/O ENDOCERV SAMPLING (BIOP), W/O CERVICAL DILAT, ANY METHO 58100 71 270 07/01/02 54.69 58100 ENDOMET SAMPLING (BIOP) W/OR W/O ENDOCERV SAMPLING (BIOP), W/O CERVICAL DILAT, ANY METHO 58100 80 71 220 07/01/74 58120 DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC 58120 71 270 07/01/02 227.56 58120 DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC 58120 80 71 220 07/01/74 58300 INSERTION OF INTRAUTERINE DEVICE (IUD) 58300 71 270 07/01/02 33.28 58301 REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301 71 270 07/01/02 29.94 58600 LAGATION OR TRANSECTION* OF FALLOPIAN TUBE (S) ABD/VAG APPROACH UNILATERAL/BILATERAL 58600 80 71 270 07/01/02 97.11 58600 LIGATION OR TRANSECTION* OF FALLOPIAN TUBE(S) ABD/VAG APPROACH UNILATERAL/BILATERAL 58600 71 270 07/01/02 485.68 58605 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S)/ ABDOMINAL OR VAGINAL APPROACH/ POSTPARTUM 58605 71 270 07/01/02 438.98 58605 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S)/ ABDOMINAL OR VAGINAL APPROACH/ POSTPARTUM 58605 80 71 220 01/01/93 58611 LIGATION/TRANSECTION FALLOPIAN TUBE(S) WHEN DONE AT TIME OF CESAREAN DELIVERY/INTRA-ABDO 58611 71 270 07/01/02 133.44 58611 LIGATION/TRANSECTION FALLOPIAN TUBE(S) WHEN DONE AT TIME OF CESAREAN DELIVERY/INTRA-ABDO 58611 80 71 220 01/01/93 58615 OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG- BAND- CLIP- FALOPE RING- FULGURATION 58615 71 270 07/01/02 480.34 58615 OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG- BAND- CLIP- FALOPE RING- FULGURATION 58615 80 71 220 01/01/93 58670 LAPAROSCOPY, SURG;W FULGURATION OF OVIDUCTS (W/WO TRANSECTION) 58670 80 71 270 07/01/02 93.85 58670 LAPAROSCOPY, SURG;W/FULGURATION OF OVIDUCTS (W/WO TRANSECTION) 58670 71 270 07/01/02 469.22 58671 LAPAROSCOPY, SURGICAL; WITH OCCULUSION OF OVIDUCTS BY DEVICE (EG,BAND,CLIP,/FALOPE RING) 58671 80 71 270 07/01/02 94.32 58671 LAPAROSCPOY, SURG;W/OCCLUSION OF OVIDUCTS BY DEVICE (E.G. BAND, CLIP, OR FALOPE RING) 58671 71 270 07/01/02 471.63 59000 AMNIOCENTESIS; DIAGNOSTIC 59000 71 270 07/01/02 54.28 59840 LEGAL (THERAPEUTIC) ABORTION BY DILATION AND CURETTAGE AND/OR EXTRACTION 59840 71 270 07/01/02 344.92 59840 LEGAL (THERAPEUTIC) ABORTION BY DILATION AND CURETTAGE AND/OR EXTRACTION 59840 80 71 220 07/01/74 59841 LEGAL (THERAPEUTIC) ABORTION BY DILATION AND EVACUATION 59841 71 270 07/01/02 344.92 59841 LEGAL (THERAPEUTIC) ABORTION BY DILATION AND EVACUATION 59841 80 71 220 01/01/84 59850 LEGAL (THERAPEUTIC) ABORTION, BY ONE OR MORE INTRA-AMNIOTIC 59850 71 270 07/01/02 344.92 59850 LEGAL (THERAPEUTIC) ABORTION, BY ONE OR MORE INTRA-AMNIOTIC 59850 80 71 220 07/01/74 59851 LEGAL (THERAPEUTIC) ABORTION, BY ONE OR MORE INTRA-AMNIOTIC 59851 71 270 07/01/02 344.92 59851 LEGAL (THERAPEUTIC) ABORTION, BY ONE OR MORE INTRA-AMNIOTIC 59851 80 71 220 07/01/74 71010 RADIOLOGIC EXAMINATION/ CHEST; SINGLE VIEW/ FRONTAL 71010 71 270 07/01/02 27.71 71010 RADIOLOGIC EXAMINATION/ CHEST; SINGLE VIEW/ FRONTAL 71010 TC 71 270 07/01/02 17.66 71010 RADIOLOGICAL EXAMINATION/CHEST; SINGLE VIEW/FRONTAL 71010 26 71 270 07/01/02 10.04 71015 RADIOLOGIC EXAMINATION/ CHEST; STEREO/ FRONTAL 71015 71 270 07/01/02 31.36 71015 RADIOLOGIC EXAMINATION/ CHEST; STEREO/ FRONTAL 71015 26 71 270 07/01/02 11.89 71015 RADIOLOGIC EXAMINATION/ CHEST; STEREO/ FRONTAL 71015 TC 71 270 07/01/02 19.47 71020 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL 71020 71 270 07/01/02 35.42 71020 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL 71020 26 71 270 07/01/02 12.25 71020 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL 71020 TC 71 270 07/01/02 23.17 71021 DADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL; WITH APICAL LORDOTIC 71021 26 71 270 07/01/02 15.28 71021 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL; WITH APICAL LORDOTIC 71021 71 270 07/01/02 42.88 71021 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL; WITH APICAL LORDOTIC 71021 TC 71 270 07/01/02 27.61 71022 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS 71022 71 270 07/01/02 45.11 71022 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS 71022 26 71 270 07/01/02 17.49 71022 RADIOLOGIC EXAMINATION/ CHEST/ TWO VIEWS/ FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS 71022 TC 71 270 07/01/02 27.61 71030 RADIOLOGIC EXAMINATION/ CHEST/ COMPLETE/ MINIMUM OF FOUR VIEWS 71030 71 270 07/01/02 46.91 71030 RADIOLOGIC EXAMINATION/ CHEST/ COMPLETE/ MINIMUM OF FOUR VIEWS 71030 26 71 270 07/01/02 17.49 71030 RADIOLOGIC EXAMINATION/ CHEST/ COMPLETE/ MINMUM OF FOUR VIEWS 71030 TC 71 270 07/01/02 29.44 71034 RADIOLOGIC EXAMINATION/ CHEST/ COMPLETE/ MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY 71034 71 270 07/01/02 79.75 71034 RADIOLOGIC EXAMINATION/ CHEST/ COMPLETE/ MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY 71034 26 71 270 07/01/02 26.05 71034 RADIOLOGIC EXAMINATION/ CHEST/ COMPLETE/ MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY 71034 TC 71 270 07/01/02 53.69 71035 RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS, EG, LATERAL 71035 71 270 07/01/02 29.52 71035 RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS, EG, LATERAL 71035 26 71 270 07/01/02 10.04 71035 RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS, EG, LATERAL 71035 TC 71 270 07/01/02 19.47 72170 RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS 72170 71 270 07/01/02 28.78 72170 RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS 72170 26 71 270 07/01/02 9.31 72170 RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS 72170 TC 71 270 07/01/02 19.47 72190 RADIOLOGIC EXAMINATION, PELVIS; 72190 71 270 07/01/02 36.88 72190 RADIOLOGIC EXAMINATION, PELVIS; 72190 26 71 270 07/01/02 11.89 72190 RADIOLOGIC EXAMINATION, PELVIS; 72190 TC 71 270 07/01/02 25.00 72200 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 72200 71 270 07/01/02 29.13 72200 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 72200 26 71 270 07/01/02 9.65 72200 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 72200 TC 71 270 07/01/02 19.47 72202 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 72202 71 270 07/01/02 33.95 72202 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 72202 26 71 270 07/01/02 10.77 72202 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 72202 TC 71 270 07/01/02 23.17 74000 RADIOLOGIC EXAMINATION, ABDOMEN; 74000 71 270 07/01/02 29.52 74000 RADIOLOGIC EXAMINATION, ABDOMEN; 74000 26 71 270 07/01/02 10.04 74000 RADIOLOGIC EXAMINATION, ABDOMEN; 74000 TC 71 270 07/01/02 19.47 74010 RADIOLOGIC EXAMINATION, ABDOMEN; 74010 71 270 07/01/02 34.79 74010 RADIOLOGIC EXAMINATION, ABDOMEN; 74010 26 71 270 07/01/02 13.43 74010 RADIOLOGIC EXAMINATION, ABDOMEN; 74010 TC 71 270 07/01/02 21.37 74020 RADIOLOGIC EXAMINATION, ABDOMEN; 74020 71 270 07/01/02 38.81 74020 RADIOLOGIC EXAMINATION, ABDOMEN; 74020 26 71 270 07/01/02 15.64 74020 RADIOLOGIC EXAMINATION, ABDOMEN; 74020 TC 71 270 07/01/02 23.17 74710 PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION 74710 71 270 07/01/02 58.72 74710 PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION 74710 26 71 270 07/01/02 19.34 74710 PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION 74710 TC 71 270 07/01/02 39.38 74740 HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 74740 71 270 07/01/02 70.15 76390 MAGNETIC RESONANCE SPECTROSCOPY 76390 71 21J 01/01/98 76700 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE 76700 TC 71 270 07/01/02 73.54 76705 ECHOGRAPHY/ ABDOMINAL/ B-SCAN; LIMITED 76705 71 270 07/01/02 86.47 76705 ECHOGRAPHY/ ABDOMINAL/ B-SCAN; LIMITED 76705 26 71 270 07/01/02 33.49 76805 ULTRASOUND,PREGNANT UTERUS,REAL TIME W IMAGE DOCO, FETAL/MATERNAL EVAL; SNGL/FRST GESTAN 76805 71 270 07/01/02 134.56 76815 ULTRASOUND, PREGNANT UTERUS, REAL TIME W IMAGE DOCO/LIMITED; ONE OR MORE FETUSES 76815 71 270 07/01/02 89.79 76815 ULTRASOUND, PREGNANT UTERUS, REAL TIME W IMAGE DOCO/LIMITED; ONE OR MORE FETUSES 76815 26 71 270 07/01/02 36.83 76831 SALINE INFUSION SONOHYSTEROGRAPHY (SIS), INCLUDING COLOR FLOW DOPPLER, WHEN PERFORMED 76831 71 270 10/01/05 83.84 76856 ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE 76856 71 270 07/01/02 96.52 76856 ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE 76856 26 71 270 07/01/02 39.47 76885 ULTRASOUND,INFANT HIPS,REAL TIME W/IMAGING DOCUMENTATION;DYNAMIC (EG,REQ PHY MANIPULATIO 76885 71 270 10/01/05 84.21 76886 ULTRASOUND,INFANT HIPS,REAL TIME W/IMAGING DOCUMENTATION;LIMITED,STATIC (NOT REQ PHY MAN 76886 71 270 10/01/05 75.17 76946 ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, IMAGING SUPERVISION AND INTERPRETATION 76946 71 270 07/01/02 78.65 76970 ULTRASOUND STUDY FOLLOW-UP (SPECIFY) 76970 71 270 07/01/02 62.11 76970 ULTRASOUND STUDY FOLLOW-UP (SPECIFY) 76970 26 71 270 07/01/02 22.73 76999 UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL) 76999 71 21J 07/01/74 76999 UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL) 76999 26 71 21J 07/01/74 78103 BONE MARROW IMAGING; 78103 71 270 07/01/02 160.43 78103 BONE MARROW IMAGING; 78103 26 71 270 07/01/02 42.43 78103 BONE MARROW IMAGING; 78103 TC 71 270 07/01/02 118.00 78231 SITH SERIAL IMAGES 78231 71 270 07/01/02 147.80 78231 WITH SERIAL IMAGES 78231 26 71 270 07/01/02 29.81 78231 WITH SERIAL IMAGES 78231 TC 71 270 07/01/02 118.00 78232 SALIVARY GLAND FUNCTION STUDY 78232 71 270 07/01/02 158.38 78232 SALIVARY GLAND FUNCTION STUDY 78232 26 71 270 07/01/02 26.79 78232 SALIVARY GLAND FUNCTION STUDY 78232 TC 71 270 07/01/02 131.60 78299 UNLISTED GASTROINTESTINAL PROCEDURE, DIAGNOSTIC 78299 71 21J 07/01/74 78299 UNLISTED GASTROINTESTINAL PROCEDURE, DIAGNOSTIC 78299 26 71 21J 07/01/74 78299 UNLISTED GASTROINTESTINAL PROCEDURE, DIAGNOSTIC 78299 TC 71 21J 07/01/74 78599 UNLISTED RESPIRATORY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78599 71 21J 07/01/74 78599 UNLISTED RESPIRATORY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78599 26 71 21J 07/01/74 78599 UNLISTED RESPIRATORY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78599 TC 71 21J 07/01/74 78730 URINARY BLADDER RESIDUAL STUDY (LIST SEPARATELY IN ADDTN TO CODE FOR PRIMARY PROCEDURE) 78730 71 270 07/01/02 74.51 78730 URINARY BLADDER RESIDUAL STUDY (LIST SEPARATELY IN ADDTN TO CODE FOR PRIMARY PROCEDURE) 78730 26 71 270 07/01/02 20.07 78730 URINARY BLADDER RESIDUAL STUDY (LIST SEPARATELY IN ADDTN TO CODE FOR PRIMARY PROCEDURE) 78730 TC 71 270 07/01/02 54.42 78799 UNLISTED GENITOURINARY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78799 71 21J 07/01/74 78799 UNLISTED GENITOURINARY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78799 26 71 21J 07/01/74 78799 UNLISTED GENITOURINARY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78799 TC 71 21J 07/01/74 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) 80048 71 270 01/01/00 11.70 80050 GENERAL HEALTH PANEL: SEE CPT FOR TESTS THAT MUST BE INCLUDED IN THE PANEL 80050 71 270 07/01/02 50.93 80051 ELECTROLYTE PANEL 80051 71 270 01/01/98 9.69 80055 OBSTETRIC PANEL 80055 71 270 07/01/02 18.84 80061 LIPID PANEL: SEE CPT FOR TESTS THAT MUST BE INCLUDED IN THE PANEL 80061 71 270 01/01/98 18.51 80061 QW 71 270 01/01/98 18.51 80074 ACUTE HEPATITIS PANEL 80074 71 270 01/01/00 65.82 81000 URINALYSIS, BY DIP STICK OR TABLET REAGENTFOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES 81000 71 270 01/01/98 4.37 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT; WITHOUT MICROSCOPY, NON-AUTOMATED 81002 71 270 01/01/98 3.54 81005 URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS 81005 71 270 01/01/98 3.00 81015 URINALYSIS; 81015 71 270 01/01/98 4.20 81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS 81025 71 270 01/01/98 8.74 81099 UNLISTED URINALYSIS PROCEDURE 81099 71 21J 07/01/92 82009 ACETONE OR OTHER KETONE BODIES, SERUM; QUALITATIVE 82009 71 270 01/01/98 6.25 82010 ACETONE; 82010 71 270 01/01/98 11.29 82010 QW 71 270 01/01/03 11.29 82042 ALBUMIN; URINE OR OTHER SOURCE, QUANTITATIVE, EACH SPECIMEN 82042 71 270 01/01/98 7.15 82143 AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) 82143 71 270 01/01/98 9.50 82157 ANDROSTENEDIONE 82157 71 270 01/01/98 40.46 82160 ANDROSTERONE 82160 71 270 01/01/98 34.57 82270 BLOOD,OCCULT,BY PEROXIDASE ACTIVITY;QUALITATIVE;FECES,SPECIMENS W/SINGLE DETERMINATION, 82270 71 270 07/01/02 3.58 82274 BOOD OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 82274 71 270 01/01/04 18.09 82274 QW 71 270 01/01/04 18.09 82310 CALCIUM; TOTAL 82310 71 270 01/01/98 7.12 82330 CALCIUM; IONIZED 82330 71 270 01/01/98 18.88 82340 CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN 82340 71 270 01/01/98 8.34 82435 CHLORIDE; BLOOD 82435 71 270 01/01/98 6.35 82436 CHLORIDE; URINE 82436 71 270 01/01/98 6.95 82465 CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 82465 71 270 01/01/98 6.02 82465 QW 71 270 07/01/01 6.02 82520 COCAINE OR METABOLITE 82520 71 270 07/01/98 9.66 82565 CREATININE; BLOOD 82565 71 270 01/01/98 7.07 82570 CREATININE; OTHER SOURCE 82570 71 270 01/01/98 7.15 82570 QW 71 270 01/01/03 7.15 82575 CREATININE; 82575 71 270 01/01/98 13.06 82607 CYANOCOBALAMIN (VITAMIN B-12); 82607 71 270 01/01/98 20.83 82626 DEHYDROEPIANDROSTERONE (DHEA) 82626 71 270 01/01/98 34.93 82633 DESOXYCORTICOSTERONE, 11- 82633 71 270 01/01/98 42.81 82634 DEOXYCORTISOL, 11- 82634 71 270 01/01/98 40.46 82651 DIHYDROTESTOSTERONE (DHT) 82651 71 270 01/01/98 35.68 82666 EPIANDROSTERONE 82666 71 270 01/01/98 29.69 82670 ESTRADIOL 82670 71 270 01/01/98 38.62 82671 ESTROGENS; 82671 71 270 01/01/98 44.64 82672 ESTROGENS; 82672 71 270 01/01/98 29.97 82677 ESTRIOL 82677 71 270 01/01/98 33.43 82679 ESTRONE 82679 71 270 01/01/98 34.50 82679 QW 71 270 01/01/03 34.50 82696 ETIOCHOLANOLONE 82696 71 270 01/01/98 32.60 82728 FERRITIN 82728 71 270 01/01/98 18.83 82746 FOLIC ACID; SERUM 82746 71 270 01/01/98 20.32 82759 GALACTOKINASE, RBC 82759 71 270 01/01/98 29.69 82760 GALACTOSE 82760 71 270 01/01/98 15.47 82775 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 82775 71 270 01/01/98 29.11 82776 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 82776 71 270 01/01/98 11.59 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP) 82947 71 270 01/01/98 5.42 82947 QW 71 270 01/01/98 5.42 82948 GLUCOSE; BLOOD, REAGENT STRIP 82948 71 270 01/01/98 4.37 82950 GLUCOSE; 82950 71 270 01/01/98 6.56 82950 QW 71 270 07/01/01 6.56 82951 GLUCOSE; 82951 71 270 07/01/98 17.80 82951 QW 71 270 07/01/01 17.80 82952 GLUCOSE; 82952 71 270 01/01/98 5.42 82952 QW 71 270 07/01/01 5.42 82953 GLUCOSE; 82953 71 270 01/01/98 20.93 82955 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); 82955 71 270 01/01/98 13.40 82960 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); 82960 71 270 01/01/98 8.38 82975 GLUTAMINE (GLUTAMIC ACID AMIDE) 82975 71 270 01/01/98 21.88 82977 GLUTAMYLTRANSFERASE, GAMMA (GGT) 82977 71 270 01/01/98 9.95 83001 GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 83001 71 270 01/01/98 25.69 83001 QW 71 270 01/01/03 25.69 83002 GONADOTROPIN; LUTEINIZING HORMONE (LH) 83002 71 270 01/01/98 25.60 83002 QW 71 270 01/01/03 25.60 83020 HEMOGLOBIN FRACTIONATION AND QUANTITATION; ELECTROPHORESIS (EG, A2, S, C, AND/OR F) 83020 71 270 07/01/98 6.30 83020 HEMOGLOBIN FRACTIONATION AND QUANTITATION; ELECTROPHORESIS (EG, A2, S, C, AND/OR F) 83020 26 71 270 01/01/05 19.57 83030 HEMOGLOBIN; 83030 71 270 01/01/98 11.43 83033 HEMOGLOBIN; F (FETAL), QUALITATIVE 83033 71 270 01/01/98 8.24 83036 HEMOGLOBIN; GLYCOSYLATED (A1C) 83036 71 270 01/01/98 13.42 83036 QW 71 270 01/01/03 13.42 83045 HEMOGLOBIN; 83045 71 270 01/01/98 6.85 83050 HEMOGLOBIN; 83050 71 270 07/01/98 4.05 83051 HEMOGLOBIN; 83051 71 270 07/01/98 4.83 83055 HEMOGLOBIN; 83055 71 270 01/01/98 6.80 83060 HEMOGLOBIN; 83060 71 270 01/01/98 11.43 83065 HEMOGLOBIN; 83065 71 270 01/01/98 9.52 83068 HEMOGLOBIN; 83068 71 270 01/01/98 11.71 83069 HEMOGLOBIN; 83069 71 270 01/01/98 5.45 83491 HYDROXYCORTICOSTEROIDS, 17-(17-OHCS) 83491 71 270 01/01/98 24.21 83498 HYDROXYPROGESTERONE, 17-D 83498 71 270 01/01/98 37.54 83499 HYDROXYPROGESTERONE, 20- 83499 71 270 01/01/98 34.83 83518 IMMUNOASSAY, FOR ANALYTE OTHER THAN ANTIBODY OR INFECTIOUS AGENT ANTIGEN, QUALITATIVE OR 83518 71 270 01/01/98 11.72 83518 QW 71 270 01/01/03 11.72 83540 IRON 83540 71 270 01/01/98 8.95 83550 IRON BINDING CAPACITY 83550 71 270 01/01/98 12.08 83582 KETOGENIC STEROIDS; FRACTIONATION 83582 71 270 01/01/98 19.59 83586 KETOSTEROIDS, 17- (17-KS); TOTAL 83586 71 270 01/01/98 17.69 83593 KETOSTEROIDS, 17- (17-KS); FRACTIONATION 83593 71 270 01/01/98 36.35 83633 LACTOSE, URINE; 83633 71 270 01/01/98 7.61 83634 LACTOSE, URINE; 83634 71 270 01/01/98 15.92 83655 LEAD 83655 71 270 01/01/98 16.72 83718 LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) 83718 71 270 01/01/98 11.31 83718 QW 71 270 01/01/98 11.31 83719 LIPOPROTEIN, DIRECT MEASUREMENT; DIRECT MEASUREMENT, VLDL CHOLESTEROL 83719 71 270 01/01/98 16.08 83727 LUTEINIZING RELEASING FACTOR (LRH) 83727 71 270 01/01/98 23.76 83840 METHADONE 83840 71 270 01/01/98 22.56 83887 NICOTINE 83887 71 270 01/01/98 32.73 83890 MOLECULAR DIAGNOSTICS; MOLECULAR ISOLATION OR EXTRACTION 83890 71 270 01/01/98 5.54 83892 NUCLEAR MOLECULAR DIAGNOSTICS; ENZYMATIC DIGESTION 83892 71 270 01/01/98 5.54 83894 MOLECULAR DIAGNOSTICS; SEPARATION BY GEL ELECTROPHORESIS (EG, AGAROSE, POLYACRYLAMIDE) 83894 71 270 01/01/98 5.54 83896 NUCLEAR MOLECULAR DIAGNOSTICS; NUCLEIC ACID PROBE, EACH 83896 71 270 01/01/98 5.54 83898 MOLECULAR DIAGNOSTICS; AMPLIFICATION, TARGET, EACH NUCLEIC ACID SEQUENCE 83898 71 270 07/01/02 3.69 83902 MOLECULAR DIAGNOSTICS; REVERSE TRANSCRIPTION 83902 71 270 01/01/98 14.27 84132 POTASSIUM; SERUM 84132 71 270 01/01/98 6.35 84135 PREGNANEDIOL 84135 71 270 01/01/98 26.44 84138 PREGNANETRIOL; RIA 84138 71 270 01/01/98 26.16 84144 PROGESTERONE 84144 71 270 07/01/98 25.72 84146 PROLACTIN 84146 71 270 01/01/98 26.78 84295 SODIUM; SERUM 84295 71 270 01/01/98 6.65 84300 SODIUM; 84300 71 270 01/01/98 6.72 84315 SPECIFIC GRAVITY (EXCEPT URINE) 84315 71 270 01/01/98 3.46 84403 TESTOSTERONE; TOTAL 84403 71 270 07/01/98 34.84 84425 THIAMINE (VITAMIN B-1) 84425 71 270 01/01/98 29.35 84436 THYROXINE; TOTAL 84436 71 270 01/01/98 9.50 84437 THYROXINE; REQUIRING ELUTION (EG, NEONATAL) 84437 71 270 01/01/98 8.95 84439 THYROXINE; FREE 84439 71 270 01/01/98 12.46 84442 THYROXINE BINDING GLOBULIN (TBG) 84442 71 270 01/01/98 20.44 84443 THYROID STIMULATING HORMONE (TSH) 84443 71 270 01/01/98 23.21 84445 THYROID STIMULATING IMMUNE GLOBULINS (TSI) 84445 71 270 07/01/98 32.15 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 84450 71 270 01/01/98 7.14 84450 QW 71 270 01/01/05 7.14 84478 TRIGLYCERIDES 84478 71 270 01/01/98 7.95 84478 QW 71 270 01/01/98 7.95 84479 THYROID HORMONE (T3 OR T4)UPTAKE OR THYROID HORMONE BINGING RATIO (THER) 84479 71 270 01/01/98 8.95 84480 TRIODOTHYRONINE T-3; TOTAL (TT-3) 84480 71 270 01/01/98 19.60 84481 THRIDOTHYRONINE (T-3); FREE 84481 71 270 07/01/98 16.33 84702 GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE 84702 71 270 01/01/98 20.80 84703 GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE 84703 71 270 07/01/98 10.38 84703 QW 71 270 01/01/03 10.38 84999 UNLISTED CHEMISTRY PROCEDURE 84999 71 21J 07/01/92 85002 BLEEDING TIME 85002 71 270 07/01/98 4.68 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT 85007 71 270 01/01/98 4.76 85009 BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT 85009 71 270 01/01/98 5.14 85013 BLOOD COUNT; SPUN MICR0HEMATOCRIT 85013 71 270 01/01/98 3.27 85014 BLOOD COUNT; HEMATOCRIT (HCT) 85014 71 270 01/01/98 3.27 85014 QW 71 270 01/01/98 3.27 85018 BLOOD COUNT; HEMOGLOBIN (HGB) 85018 71 270 01/01/98 3.27 85018 QW 71 270 07/01/01 3.27 85027 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) 85027 71 270 01/01/98 8.95 85032 BLOOD COUNT, MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, OR PLATELET) EACH 85032 71 270 01/01/03 6.01 85041 BLOOD COUNT; RED BLOOD CELL(RBC), AUTOMATED 85041 71 270 01/01/98 4.16 85044 BLOOD COUNT; RETICULOCYTE, MANUAL 85044 71 270 01/01/98 5.94 85048 BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 85048 71 270 01/01/98 3.52 85060 BLOOD SMEAR/ PERIPHERAL/ INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT 85060 71 270 01/01/04 23.42 85651 SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED 85651 71 270 07/01/02 4.00 85660 SICKLING OF RBC, REDUCTION, SLIDE METHOD 85660 71 270 01/01/98 7.63 85999 UNLISTED HEMATOLOGY PROCEDURE 85999 71 21J 07/01/92 86078 INVESTIGATION OF TRANSFUSION REACTION INCLUDING SUSPICION OF TRANSMISSIBLE DISEASE/ INTR 86078 71 270 07/01/02 44.77 86079 AUTHORIZATION FOR DEVIATION FROM STANDARD BLOOD BANKING PROCEDURES/ WITH WRITTEN REPORT 86079 71 270 07/01/02 26.64 86090 BLOOD TYPING; 86090 71 270 07/01/02 10.04 86280 HEMAGGLUTINATION INHIBITION TEST (HAI) 86280 71 270 07/01/98 10.79 86310 HETEROPHILE ANTIBODIES; TITERS AFTER ABSORPTION WITH BEEF CELLS AND GUINEA PIG KIDNEY 86310 71 270 01/01/98 10.19 86580 SKIN TEST; TUBERCULOSIS/ INTRADERMAL 86580 71 270 10/01/03 9.21 86592 SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART) 86592 71 270 01/01/98 5.90 86593 SYPHILIS TEST; QUANTITATIVE 86593 71 270 01/01/98 6.09 86631 ANTIBODY; CHLAMYDIA 86631 71 270 07/01/98 8.03 86689 ANTIBODY; HTLV OR HIV ANTIBODY, CONFIRMATIORY TEST (EG, WESTERN BLOT) 86689 71 270 01/01/98 26.75 86694 ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST 86694 71 270 01/01/98 19.89 86695 ANTIBODY; HERPES SIMPLEX, TYPE I 86695 71 270 01/01/98 18.23 86701 ANTIBODY; HIV-1 86701 71 270 01/01/98 12.28 86701 QW 71 270 01/01/04 12.28 86703 ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY 86703 71 270 01/01/98 18.96 86706 HEPATITIS B SURFACE ANTIBODY (HBSAB) 86706 71 270 01/01/98 14.84 86762 ANTIBODY; RUBELLA 86762 71 270 01/01/98 19.89 86765 ANTIBODY; RUBEOLA 86765 71 270 01/01/98 17.81 86781 ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA-ABS) 86781 71 270 07/01/02 10.94 86787 ANTIBODY; VARICELLA-ZOSTER 86787 71 270 07/01/01 8.00 86800 THYROGLOBULIN ANTIBODY 86800 71 270 01/01/98 21.98 86850 ANTIBODY SCREEN RBC, EACH SERUM TECHNIQUE 86850 71 270 07/01/02 27.37 86900 BLOOD TYPING; ABO 86900 71 270 07/01/98 3.79 86901 BLOOD TYPING; RH (D) 86901 71 270 07/01/02 8.81 86999 UNLISTED TRANSFUSION MEDICINE PROCEDURE 86999 71 21J 07/01/92 87001 ANIMAL INOCULATION, SMALL ANIMAL; 87001 71 270 01/01/98 18.27 87003 ANIMAL INOCULATION, SMALL ANIMAL; 87003 71 270 01/01/98 23.26 87015 CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS 87015 71 270 07/01/98 5.16 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIF. OF ISOLATES 87040 71 270 01/01/98 14.27 87045 CULTURE,BACTERIAL;STOOL,AEROBIC W/ISOLATION PRELIMINARY EXAM(EG,KIA,LIA)SALMONELLA/SHIGL 87045 71 270 01/01/98 13.04 87070 CULTURE,BACTERIAL;ANY OTHER SOURCE EXCPT URINE,BLOOD OR STOOL,AEROBIC, W/ISOLATION/PRESU 87070 71 270 01/01/98 11.90 87075 CULTURE,BACTERIAL;ANY SOURCE EXCPT BLOOD,ANAEROBIC W/ISOLATION PRESUMPTIVE ID OF ISOLATE 87075 71 270 01/01/98 13.08 87076 CULTURE, BACTERIAL; ANAEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTI 87076 71 270 07/01/01 11.16 87081 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; 87081 71 270 01/01/98 9.16 87081 QW 71 270 01/01/00 9.16 87084 CULT, PRESUMP, PATHOGENIC ORGANIS, SCREEN ONLY, COMMER KIT; COLONY ESTIMAT DENSITY CHART 87084 71 270 07/01/98 10.42 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE 87086 71 270 01/01/98 11.16 87088 CULTURE, BACTERIAL; WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF EACH ISOLATE, URINE 87088 71 270 01/01/98 11.18 87101 CULTURE, FUNGI ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, NAIL 87101 71 270 01/01/98 10.66 87102 CULTURE, FUNGI, ISOLATION; OTHER SOURCE (EXCEPT BLOOD) 87102 71 270 01/01/98 11.61 87106 CULTURE, FUNGI, DEFINITIVE IDENTIFICATION OF EACH ORGANISM; YEAST 87106 71 270 01/01/98 14.27 87109 CULTURE, MYCOPLASMA, ANY SOURCE 87109 71 270 07/01/98 13.77 87116 CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI W/ ISOLATION & PRESUMPTIVE IDENT OF ISOLATE 87116 71 270 01/01/98 14.93 87118 CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH ISOLATE 87118 71 270 01/01/98 15.13 87140 CULTURE, TYPING; IMMUNOFLUORESCENT METHOD, EACH ANTISERUM 87140 71 270 07/01/98 6.30 87143 CULTURE, TYPING; GAS LIQUID CHROMATOGRAPHY OR HIGH PRESSURE LIQUID CHROMATOGRAPHY METHOD 87143 71 270 01/01/98 17.32 87147 CULTURE, TYPING; IMMUNOLOGIC METHOD, OTHER THAN IMMUNOFLUORESENCE, PER ANTISERUM 87147 71 270 01/01/98 7.15 87158 CULTURE, TYPING; 87158 71 270 01/01/98 7.23 87164 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, 87164 71 270 07/01/98 12.33 87164 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, 87164 26 71 270 01/01/05 18.52 87166 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, 87166 71 270 01/01/98 15.61 87177 OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION 87177 71 270 01/01/98 12.30 87181 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR DILUTION METHOD, PER AGENT 87181 71 270 01/01/98 6.56 87184 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS) 87184 71 270 01/01/98 9.53 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION, EACH MULTI- 87186 71 270 01/01/98 11.94 87188 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT, MACROBROTH DILUTION METHOD, EACH AGENT 87188 71 270 01/01/98 9.17 87190 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MYCOBACTERIA, PROPORTION METHOD, EACH AGENT 87190 71 270 07/01/98 3.98 87205 SMEAR, PRIMARY SOURCE W/ INTERPRETATION;GRAM/GIEMSA STAIN FOR BACTERIA,FUNGI,OR CELL TYP 87205 71 270 01/01/98 5.90 87206 SMEAR, PRIMARY SOURCE W/ INTERP; FLUORESCENT &/O ACID FAST STAIN FOR BACTERIA,FUNGI,PARA 87206 71 270 01/01/98 7.42 87207 SMEAR, PRIMARY SOURCE W/ INTERP; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES 87207 71 270 01/01/98 8.28 87207 SMEAR, PRIMARY SOURCE W/ INTERP; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES 87207 26 71 270 01/01/05 19.92 87210 SMEAR, PRIMARY SOURCE WITH INTERPRETATION;WET MOUNT FOR INFECTIOUS AGENTS (SALINE,INDIA 87210 71 270 01/01/98 5.90 87210 QW 71 270 01/01/03 5.90 87220 TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPA 87220 71 270 01/01/98 5.90 87250 VIRUS ISLOATION; INOCULATION OF EMBRYONATED EGGS/SMALL ANIMAL, INCL OBSERVATION & DISSEC 87250 71 270 01/01/98 27.02 87254 VIRUS ISOLATION; CENTRIFUGE ENHANCED TECHNIQUE, INCLD IDENTF. W/IMMUNOFLUORESCENCE STAIN 87254 71 270 01/01/01 6.76 87270 INFECTIOUS AGENT ANTIGEN DETECT BY FLUORES ANTIBODY TECHN; CHLAMYDIA TRACHOMATIS 87270 71 270 01/01/98 16.58 87274 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE;HERPES SIMPLEX VIRUS I 87274 71 270 01/01/98 16.58 87320 INFECTIOUS AGENT ANTIGEN DETECT BY ENZYME IMMUNOASSAY TECHN;TYPES 40/41 CHLAMYDIA TRACHO 87320 71 270 01/01/98 16.58 87340 INFECTIOUS AGENT ANTIGEN DETECT BY ENZYME IMMUNOASSAY TECHN;TYPES 40/41 HEPATITIS B SURF 87340 71 270 01/01/98 14.27 87350 INFECTIOUS AGENT ANTIGEN DETECT BY ENZYME IMMUNOASSAY TECHN; TYPES 40/41 HEPATITIS BE AN 87350 71 270 01/01/98 15.92 87380 INFECTIOUS AGENT ANTIGEN DETECT BY ENZYME IMMUNOASSAY TECHN; TYPES 40/41 HEPATITIS,DELTA 87380 71 270 01/01/98 22.69 87390 INFECTIOUS AGENT ANTIGEN DETECT BY ENZYME IMMUNOASSAY TECHN; TYPES 40/41 HIV-1 87390 71 270 01/01/98 24.38 87391 INFECTIOUS AGENT ANTIGEN DETECT BY ENZYME IMMUNOASSAY TECHN; TYPES 40/41 HIV-2 87391 71 270 01/01/98 24.38 87449 INFECTIOUS AGENT ANTIGEN DETECT BY ENZYME IMMUNOASSAY TECHN;MULTI STEP,NOT OTHERWISE SPE 87449 71 270 01/01/98 16.58 87449 QW 71 270 01/01/03 16.58 87485 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; CHLAMYDIA PNEUMONIAE, DIRECT PROBE TECHNIQUE 87485 71 270 01/01/98 27.71 87486 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE 87486 71 270 01/01/98 48.50 87487 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; CHLAMYDIA PNEUMONIAE, QUANTIFICATION 87487 71 270 01/01/03 59.85 87490 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; CHLAMYDIA TRACHOMATIS, DIRECT PROBE TECHNIQUE 87490 71 270 01/01/98 27.71 87491 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQ 87491 71 270 01/01/98 48.50 87492 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; CHLAMYDIA TRACHOMATIS, QUANTIFICATION 87492 71 270 01/01/03 48.84 87510 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; GARDNERELLA VAGINALIS, DIRECT PROBE TECHNIQUE 87510 71 270 01/01/98 27.71 87511 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; GARDENERELLA VAGINALIS, AMPLIFIED PROBE TEHNIQU 87511 71 270 01/01/98 48.50 87512 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; GARDNERELLA VAGINALIS, QUANTIFICATION 87512 71 270 01/01/03 58.33 87515 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HEPATITIS B VIRUS, DIRECT PROBE TECHNIQUE 87515 71 270 01/01/98 27.71 87516 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HEPATITIS B VIRUS, AMPLIFIED PROBE TECHNIQUE 87516 71 270 01/01/98 48.50 87517 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HEPATITIS B VIRUS, QUANTIFICATION 87517 71 270 01/01/03 59.85 87528 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HERPES SIMPLEX VIRUS, DIRECT PROBE TECHNIQUE 87528 71 270 01/01/98 27.71 87530 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HERPES SIMPLEX VIRUS, QUANTIFICATION 87530 71 270 01/01/03 59.85 87531 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HERPES VIRUS-6, DIRECT PROBE TECHNIQUE 87531 71 270 01/01/98 27.71 87532 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HERPES VIRUS-6, AMPLIFIED PROBE TECHNIQUE 87532 71 270 01/01/98 48.50 87533 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HERPES VIRUS-6, QUANTIFICATION 87533 71 270 01/01/03 58.33 87534 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HIV-1, DIRECT PROBE TECHNIQUE 87534 71 270 01/01/98 27.71 87535 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HIV-1, AMPLIFIED PROBE TECHNIQUE 87535 71 270 01/01/98 48.50 87536 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HIV-1, QUANTIFICATION 87536 71 270 01/01/03 118.89 87537 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HIV-2, DIRECT PROBE TECHNIQUE 87537 71 270 01/01/98 27.71 87538 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID; HIV-2, AMPLIFIED PROBE TECHNIQUE 87538 71 270 01/01/98 48.50 87539 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; HIV-2, QUANTIFICATION 87539 71 270 01/01/03 59.85 87590 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; NEISSERIA GONORRHOEAE, DIRECT PROBE TECHNIQUE 87590 71 270 01/01/98 27.71 87591 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQU 87591 71 270 01/01/98 48.50 87620 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; PAPILLOMAVIRUS, HUMAN, DIRECT PROBE TECHNIQUE 87620 71 270 01/01/98 27.71 87621 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; PAPILLOMAVIRUS, HUMAN, AMPLIFIED PROBE TECHNIQU 87621 71 270 01/01/98 48.50 87622 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; PAPILLOMAVIRUS, HUMAN, QUANTIFICATION 87622 71 270 01/01/03 58.33 87650 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; STREPTOCOCCUS, GROUP A, DIRECT PROBE TECHNIQUE 87650 71 270 01/01/98 27.71 87651 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQ 87651 71 270 01/01/98 48.50 87652 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; STREPTOCOCCUS, GROUP A, QUANTIFICATION 87652 71 270 01/01/03 58.33 87797 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; NOT OTHERWISE SPECIFIED, DIRECT PROBE TECHNIQUE 87797 71 270 01/01/98 27.71 87798 INFECTIOUS AGENT DETECT BY NUCLEIC ACID; NOT OTHERWISE SPECIFIED, AMPLIFIED PROBE TECHNI 87798 71 270 01/01/98 48.50 87799 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID, NOT OTHERWISE SPECIFIED, QUANTIFICATION,EACH 87799 71 270 01/01/03 59.85 87808 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION 87808 71 270 01/01/07 16.76 87999 UNLISTED MICROBIOLOGY PROCEDURE 87999 71 21J 07/01/92 87999 UNLISTED MICROBIOLOGY PROCEDURE 87999 26 71 21J 02/01/00 88000 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; 88000 71 220 07/01/77 88005 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; 88005 71 220 07/01/77 88007 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; 88007 71 220 07/01/77 88012 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; 88012 71 220 07/01/77 88014 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; 88014 71 220 07/01/77 88016 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; 88016 71 220 07/01/77 88020 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; 88020 71 220 07/01/77 88025 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; 88025 71 220 07/01/77 88027 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; 88027 71 220 07/01/77 88028 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; 88028 71 220 07/01/77 88029 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; 88029 71 220 07/01/77 88036 NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; 88036 71 220 07/01/77 88037 NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; 88037 71 220 07/01/77 88040 NECROPSY (AUTOPSY); 88040 71 220 07/01/77 88045 NECROPSY (AUTOPSY); 88045 71 220 07/01/77 88099 UNLISTED NECROPSY (AUTOPSY) PROCEDURE 88099 71 220 07/01/77 88125 CYTOPATHOLOGY, FORENSIC (EG, SPERM) 88125 71 270 07/01/02 12.73 88125 CYTOPATHOLOGY, FORENSIC (EG, SPERM) 88125 26 71 270 07/01/02 11.33 88130 SEX CHROMATIN IDENTIFICATION; 88130 71 270 01/01/98 20.79 88140 SEX CHROMATIN IDENTIFICATION; 88140 71 270 01/01/98 11.05 88141 CYTOPATHOLOGY, CERVICAL OR VAGINAL; REQ INTERPRETATION BY PHYSICIAN (LIST SEPARATELY IN 88141 71 270 01/01/05 21.77 88142 CYTOPATHOLOGY,CERVICAL/VAGINAL,IN PRESERVATIVE;MANUAL SCREENING UNDER MD SUPERVISION 88142 71 270 01/01/00 28.00 88143 CYTOPATHOLOGY,CERVICAL/VAGINAL;W/MANUAL SCREENING/RESCREENING UNDER MD SUPERVISION 88143 71 270 01/01/00 28.00 88147 CYTOPATHOLOGY SMEARS,CERVICAL/VAGINAL;SCREENING BY AUTOMATED SYSTEM UNDER MD SUPERVISION 88147 71 270 01/01/00 14.60 88148 CYTOPATHOLOGY SMEARS,CERVICAL/VAGINAL;SCREEN BY AUTOMATED SYSTEM W/MANUAL RESCREENING 88148 71 270 01/01/00 14.60 88150 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION 88150 71 270 01/01/00 14.60 88152 CYTOPATHOLOGY,SLIDES,CERVICAL/VAGINAL;MANUAL SCREEN/COMPUTER RESCREEN,UNDER MD SUPERV 88152 71 270 01/01/00 14.60 88153 CYTOPATHOLOGY SLIDES,CERVICAL/VAGINAL;MANUAL SCREENING/RESCREENING UNDER MD SUPERVISION 88153 71 270 01/01/00 14.60 88154 CYTOPATHOLOGY SLIDES,CERVICAL/VAGINAL;MANUAL SCREEN/COMP.RESCREEN,CELL SELECT/REVIEW,MD 88154 71 270 01/01/00 14.60 88155 CYTOPATHOLOGY,SLIDES,CERVICAL/VAGINAL,DEFINITIVE HORMONAL EVALUATION(IN ADD TO OTHER SER 88155 71 270 01/01/98 8.28 88160 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND INTERPRETATION 88160 71 270 07/01/02 29.80 88160 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND INTERPRETATION 88160 26 71 270 07/01/02 23.41 88161 PREPARATION/ SCREENING AND INTERPRETATION 88161 26 71 270 07/01/02 24.48 88161 SREPARATION/ SCREENING AND INTERPRETATION 88161 71 270 07/01/02 31.92 88162 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; EXTENDED STUDY INVOLVING > 5 SLIDES/MULT STAINS 88162 TC 71 270 01/01/04 12.44 88162 EXTENDED STUDY INVOLVING OVER 5 SLIDES AND/OR MULTIPLE STAINS 88162 71 270 03/01/03 53.42 88162 EXTENDED STUDY INVOLVING OVER 5 SLIDES AND/OR MULTIPLE STAINS 88162 26 71 270 03/01/03 40.08 88164 CYTOPATHOLOGY SLIDES,CERVICAL/VAGINAL(BETHESDA SYSTEM);MANUAL SCREEN W/MD SUPERVISION 88164 71 270 01/01/00 14.60 88165 CYTOPATHOLOGY SLIDES,CERVICAL/VAGINAL(BETHESDA SYSTEM);MANUAL SCREEN/RESCREEN,MD SUPR. 88165 71 270 01/01/00 14.60 88166 CYTOPATHOLOGY SLIDES,CERVICAL/VAGINAL(BETHESDA);MANUAL SCREEN/COMP.RESCREEN,MD SUPR. 88166 71 270 01/01/00 14.60 88167 CYTOPATH.SLIDES,CERVICAL/VAG.(BETHESDA);MANUAL SCREEN/COMP.RESCREEN,CELL SELECT/REVIEW 88167 71 270 01/01/00 14.60 88175 CYTOPATHOLOGY, CERVICAL/VAGINAL, COLLEC IN PRESERVATIVE FLUID, AUTO THIN LAYER PREP, PHY 88175 71 270 01/01/03 36.82 88199 UNLISTED CYTOPATHOLOGY PROCEDURE 88199 71 21J 07/01/92 88199 UNLISTED CYTOPATHOLOGY PROCEDURE 88199 26 71 21J 07/01/92 88261 CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING 88261 71 270 01/01/98 244.24 88262 CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 KARYOTYPES, WITH BANDING 88262 71 270 01/01/98 172.25 88263 CHROMOSOME ANALYSIS 88263 71 270 01/01/98 207.67 88267 CHROMOSOME ANALYSIS, AMNIOTIC FLUID/ CHORIONIC VILLUS, COUNT 15 CELLS, 1 KARYOTYPE, BAND 88267 71 270 01/01/98 248.44 88280 CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPING/ EACH STUDY 88280 71 270 01/01/98 34.68 88285 CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED/ EACH STUDY 88285 71 270 01/01/98 26.26 88299 UNLISTED CYTOGENETIC STUDY 88299 71 21J 07/01/92 88300 LEVEL I - SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY 88300 71 270 07/01/02 10.15 88300 LEVEL I - SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY 88300 26 71 270 01/01/05 4.38 88302 LEVEL II - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION 88302 71 270 07/01/02 20.03 88302 LEVEL II - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION 88302 26 71 270 03/01/03 7.09 88305 LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION 88305 71 270 07/01/02 64.87 88305 LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION 88305 26 71 270 03/01/03 39.37 88318 DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL COMPONENTS (EG/ COPPER/ ZINC) 88318 71 270 07/01/02 23.14 88318 DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL COMPONENTS (EG/ COPPER/ ZINC) 88318 26 71 270 07/01/02 18.92 88346 IMMUNOFLUORESCENT STUDY/ EACH ANTIBODY 88346 71 270 07/01/02 51.26 88346 IMMUNOFLUORESCENT STUDY/ EACH ANTIBODY 88346 26 71 270 07/01/02 40.99 88380 MICRODISSECTION (IE, SAMPLE PREP OF MICRO SCOPICALLY IDENTIFIED TARGET); LASER CAPTURE 88380 71 21J 01/01/02 88399 UNLISTED SURGICAL PATHOLOGY PROCEDURE 88399 71 21J 07/01/92 88399 UNLISTED SURGICAL PATHOLOGY PROCEDURE 88399 26 71 21J 07/01/92 89300 SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM INCLUDING HUHNER TEST (POST COITAL) 89300 71 270 01/01/98 12.32 89300 QW 71 270 01/01/98 12.32 89310 SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) 89310 71 270 01/01/98 11.89 89320 SEMEN ANALYSIS; VOLUME,COUNT, MOTILITY, AND DIFFERENTIAL 89320 71 270 01/01/98 16.66 89325 SPERM ANTIBODIES 89325 71 220 03/01/97 89330 SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST/ W/WO SPINNBARKEIT TEST 89330 71 220 03/01/97 90384 RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, FULL-DOSE, FOR INTRAMUSCULAR USE 90384 71 21J 01/01/99 90385 RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, MINI-DOSE, FOR INTRAMUSCULAR USE 90385 71 21J 01/01/99 90386 RHO(D) IMMUNE GLOBULIN (RHIGIV), HUMAN, FOR INTRAVENOUS USE 90386 71 21J 01/01/99 90649 HUMAN PAPILLOMA VIRUS VAC, TYPES 6, 11, 16, 18, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE 90649 71 270 03/01/07 3.28 90772 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION; SUBCUTANEOUS OR INTRAMUSCULAR 90772 71 270 01/01/06 3.28 93000 ELECTROCARDIOGRAM, WITH INTERPRETATION AND REPORT; 93000 71 270 01/01/05 25.01 93010 ELECTROCARDIOGRAM, WITH INTERPRETATION AND REPORT; 93010 71 270 01/01/05 8.75 99000 COLLECTION/ HANDLING AND/OR CONVEYANCE OF SPECIMEN 99000 71 270 07/01/02 3.74 99070 SUPPLIES AND MATERIALS (EXCEPT SPECTACLES) PROVIDED BY THE PHYSICIAN 99070 71 270 10/01/03 5.15 99201 OFFICE/OP VISIT-NEW PATIENT: PROB-FOCUSED HIST/EXAM & STRAIGHT MED DECISION (10 MIN) 99201 71 270 02/01/03 19.60 99202 OFFICE/OP VISIT-NEW PATIENT:EXPAND PROB-FOCUSED HIST/EXAM & STRAIGHT MED DECISION(20MIN) 99202 71 270 02/01/03 32.98 99203 OFFICE/OP VISIT-NEW PATIENT: DETAILED HIST/EXAM & MED DECISION-LOW COMPLEXITY (30 MIN) 99203 71 270 02/01/03 49.30 99204 OFFICE OR OTHER OUTPATIENT VISIT; NEW PATIENT; COMPREHENSIVE HISTORY/EXAM 99204 71 270 02/01/03 70.54 99205 OFFICE/OP VISIT-NEW PATIENT:COMPREHENSIVE HIST/EXAM, MED DECISION-HIGH-COMPLEXITY(60MIN) 99205 71 270 02/01/03 89.74 99211 OFFICE/ OP VISIT-ESTABLISHED PATIENT: MINIMAL PRESENTING PROBLEM (5 MIN) 99211