Laboratory Fee Schedule - Maine.gov

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Procedure Code Laboratory Fee Schedule Effective January 1, 2013 Modifier Code Description Rate 84600 assay of volatiles $22.10 84620 xylose absorption test blood &/urine $4.50 84630 assay of zinc $10.80 84681 assay of c-peptide $27.00 84702 gonadotropin chorionic quantitative $18.00 84703 gonadotropin chorionic qualitative $8.42 84704 gonadotropin chorionic hcg free beta chain $20.70 84830 ovulation test visual color comparison hlh $7.00 84999 unlisted chemistry procedure $20.00 85002 bleeding time test $3.33 85004 blood count automated differential wbc count $6.62 85007 blood count smear mcrscp w/mnl difrntl wbc count $2.34 85008 bld count smear mcrscp w/o mnl difrntl wbc count $3.50 85009 blood count manual difrntl wbc count buffy coat $5.11 85013 blood count spun microhematocrit $2.30 85014 blood count hematocrit $2.34 85018 blood count hemoglobin $2.34 85025 blood count complete auto&auto difrntl wbc $10.69 85027 blood count complete automated $8.10 85032 blood count manual cell count each $3.50 85041 blood count red blood cell automated $2.34 85044 blood count reticulocyte automated $4.05 85045 blood count reticulocyte automated $5.50 85046 blood count reticulocytes auto 1/> cell meas $5.79 85048 blood count leukocyte wbc automated $2.34 85049 blood count platelet automated $3.31 85055 reticulated platelet assay $15.11 85060 blood smear peripheral interp phys w/writ report $16.72 85097 bone marrow smear interpretation $53.84 Fac/Non- Facility 85097 bone marrow smear interpretation $45.74 Facility 85130 chromogenic substrate assay $10.51 85170 blood clot retraction $2.34 85175 clot lysis time whole blood dilution $3.74 85210 clotting factor ii prothrombin specific $11.52 85220 clotting factor v acg/proaccelerin labile factor $11.52 85230 clotting factor vii proconvertin stable factor $11.52 85240 clotting factor viii ahg 1 stage $12.15 85244 clotting factor viii related antigen $24.30 85245 clotting factor viii vw factor ristocetin cofact $30.00 85246 clotting factor viii vw factor antigen $27.00 85247 clotting factor viii multimetric analysis $30.00 85250 clotting factor ix ptc/christmas $11.52 85260 clotting factor x stuart-prower $11.52 85270 clotting factor xi pta $11.52 85280 clotting factor xii hageman $11.52 85290 clotting factor xiii fibrin stabilizing $11.52 85291 clotting factor xiii fibrn stabiliz screen solub $6.08
Procedure Code Laboratory Fee Schedule Effective January 1, 2013 Modifier Code Description Rate 85292 clotting prekallikrein assay fletcher fact assay $26.03 85293 clotting hi molec weight kininogen assay $26.03 85300 clotting inhibitors antithrombin iii activity $11.52 85301 clotting inhibitrs antithrombn iii antigen assay $14.86 85302 clotting inhibitors protein c antigen $16.52 85303 clotting inhibitors protein c activity $16.69 85305 clotting inhibitors protein s total $15.95 85306 clotting inhibitors protein s free $18.71 85307 activated protein c apc resistance assay $9.60 85335 factor inhibitor test $17.69 85337 thrombomodulin $14.33 85345 coagulation time lee and white $5.91 85347 coagulation time activated $5.76 85348 coagulation time other methods $5.12 85360 euglobulin lysis $11.39 85362 fibrin dgradj splt produxs aggluj slide semiquan $8.10 85366 fibrin dgradj splt produxs paracoagj $9.88 85370 fibrin dgradj splt products quantitative $9.00 85378 fibrin dgradj products d-dimer qual/semiquan $9.81 85379 fibrin dgradj products d-dimer quantitative $13.99 85380 fibrin dgradj products d-dimer ultrasensitive $7.20 85384 fibrinogen activity $11.68 85385 fibrinogen antigen $11.68 85390 fibrinolysins/coagulopathy screen interp&repor $7.10 85390 26 fibrinolysins/coagulopathy screen interp&repor $3.61 85396 coagj/fbrnlys assay whole blood additive per day $12.54 85397 coagj&fibrinolysis functional actv nos ea anal $17.76 85400 fibrinolytic factors & inhibitors plasmin $12.16 85410 fbrnlyc factors&inhibitors alpha-2 antiplasmin $10.60 85415 fbrnlyc factors&inhibitors plsmng activator $11.00 85420 fbrnlyc factors&inhibitrs plsmng xcpt agic ass $8.98 85421 fbrnlyc factors&inhibitors plsmng agic assay $14.00 85441 heinz bodies direct $5.78 85445 heinz bodies induced acetyl phenylhydrazine $9.37 85460 hgb/rbcs fetal fetomaternal hemrrg difrntl lysis $10.64 85461 hgb/rbcs fetal fetomaternal hemrrg rosette $9.12 85475 hemolysin acid $12.20 85520 heparin assay $17.28 85525 heparin neutralization $16.28 85530 heparin-protamine tolerance tst $17.28 85536 iron stain peripheral blood $8.89 85540 wbc alkaline phosphatase count $5.76 85547 mechanical fragility rbc $11.83 85549 muramidase $25.78 85555 osmotic fragility rbc unincubated $5.76 85557 osmotic fragility rbc incubated $17.28 85576 platelet aggregation in vitro each agent $29.53 Fac/Non- Facility
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Laboratory Fee Schedule - Maine.gov

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