Laboratory Fee Schedule - Maine.gov

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Procedure Code Laboratory Fee Schedule Effective January 1, 2013 Modifier Code Description Rate 87904 nfct phexyp resist tiss cul hiv ea addl drug $35.83 87905 infectious agent enzymatic actv oth/thn virus $9.46 87906 nfct gexyp dna/rna hiv 1 other region $56.55 87910 nfct agt genotype nucleic acid cytomegalovirus $59.94 87912 nfct agent genotype hepatitis b virus $59.94 87999 unlisted microbiology $7.19 88104 cytp flu washgs/brushings xcpt c/v smrs interpj $35.46 88104 TC cytp flu washgs/brushings xcpt c/v smrs interpj $17.73 88104 26 cytp flu washgs/brushings xcpt c/v smrs interpj $17.73 88106 cytp flu br/wa xcpt c/v filter meth only interpj $36.11 88106 TC cytp flu br/wa xcpt c/v filter meth only interpj $18.05 88106 26 cytp flu br/wa xcpt c/v filter meth only interpj $18.05 88108 cytp flu br/wa xcpt c/v smrs&filter interpj $33.59 88108 TC cytp flu br/wa xcpt c/v smrs&filter interpj $16.79 88108 26 cytp flu br/wa xcpt c/v smrs&filter interpj $16.79 88112 cytp slctv cell enhancement interpj xcpt c/v $59.75 88112 TC cytp slctv cell enhancement interpj xcpt c/v $29.87 88112 26 cytp slctv cell enhancement interpj xcpt c/v $29.87 88120 cytp insitu hybrid urine spec 3-5 probes ea mnl $433.54 88120 TC cytp insitu hybrid urine spec 3-5 probes ea mnl $382.20 88120 26 cytp insitu hybrid urine spec 3-5 probes ea mnl $51.34 88121 cytp insitu hybrid urne spec 3-5 probes cptr ea $366.18 88121 TC cytp insitu hybrid urne spec 3-5 probes cptr ea $320.67 88121 26 cytp insitu hybrid urne spec 3-5 probes cptr ea $45.51 88125 cytopathology forensic $20.77 88125 TC cytopathology forensic $7.86 88125 26 cytopathology forensic $12.46 88130 sex chromatin identification barr bodies $4.59 88140 sex chromatin identj peripheral blood smear $10.99 88141 cytp cervical/vaginal req interp physician $11.40 88142 cytp cerv/vag auto thin layer prep mnl screen $15.00 88143 cytp c/v flu auto thin mnl scr&rescr phys $27.85 88147 cytp smrs c/v scr automated system phys supv $7.30 88148 cytp smrs c/v scr auto sys mnl rescr phys $10.50 88150 cytp slides c/v mnl scr under phys $7.82 88152 cytp slides c/v mnl scr&cptr rescr phys $8.00 88153 cytp slides c/v mnl scr&rescr phys $4.17 88154 cytp slides c/v mnl scr&cptr-rescr cell s&i $4.17 88155 cytp slides c/v definitive hormonal eval $4.59 88160 cytp smrs any oth src scr&interpj $25.52 88160 TC cytp smrs any oth src scr&interpj $12.76 88160 26 cytp smrs any oth src scr&interpj $12.76 88161 cytp smrs any oth src prepj scr&interpj $27.51 88161 TC cytp smrs any oth src prepj scr&interpj $13.75 88161 26 cytp smrs any oth src prepj scr&interpj $13.75 88162 cytp smrs any oth src extnd std > 5 slides $72.57 88162 TC cytp smrs any oth src extnd std > 5 slides $35.80 Fac/Non- Facility
Procedure Code Laboratory Fee Schedule Effective January 1, 2013 Modifier Code Description Rate 88162 26 cytp smrs any oth src extnd std > 5 slides $36.77 88164 cytp slides cerv/vag mnl scrn physician supv $7.82 88165 cytp slides c/v mnl scr&rescr phys supv $4.17 88166 cytp slides c/v mnl scr&cptr rescr phys supv $4.17 88167 cytp slides c/v mnl scr&cptr rescr cell s&i $4.17 88172 cytp fine ndl aspirate immt cytohist std dx 1st $39.20 88172 TC cytp fine ndl aspirate immt cytohist std dx 1st $17.45 88172 26 cytp fine ndl aspirate immt cytohist std dx 1st $19.60 88173 cytp eval fine needle aspirate interp & report $67.42 88173 TC cytp eval fine needle aspirate interp & report $33.71 88173 26 cytp eval fine needle aspirate interp & report $33.71 88174 cytp c/v auto thin lyr prepj scr sys phys $7.30 88175 cytp c/v auto thin lyr prepj scr mnl rescr phys $19.61 88177 cytp fine ndl aspirate immt cytohist std ea eval $26.89 88177 TC cytp fine ndl aspirate immt cytohist std ea eval $5.99 88177 26 cytp fine ndl aspirate immt cytohist std ea eval $20.90 88182 flow cytometry cell cycle/dna analysis $96.51 88182 TC flow cytometry cell cycle/dna analysis $61.47 88182 26 flow cytometry cell cycle/dna analysis $33.96 88184 flow cytometry cell surf marker techl only 1st $24.06 88185 flow cytometry cell surf marker techl only ea $11.80 88187 flow cytometry interpj 2-8 markers $35.56 88188 flow cytometry interpj 9-15 markers $44.36 88189 flow cytometry interpj 16/> markers $58.45 88230 tiss cul non-neo disorders lymphocyte $47.60 88233 tiss cul non-neo disorders skn/oth solid tiss bx $120.83 88235 tiss cul non-neo disorders amniotic/chornc cells $120.83 88237 tiss cul neo disorders bone marrow blood cells $54.93 88239 tiss cul neo disorders solid tumor $202.78 88245 chrmsm breakage baseline sister 20-25 cll $204.62 88248 chrmsm breakage baseline breakage 50-100 cll $238.04 88249 chrmsm breakage synds score 100 cll $143.59 88261 chrmsm count 5 cell 1karyotype banding $141.75 88262 chrmsm count 15-20 cll 2karyotyp banding $171.33 88263 chrmsm count 45 cell mosaicism 2karyotype $206.58 88264 chrmsm analyze 20-25 cells $103.35 88267 chrmsm alys amniotic/villus 15 cell 1karyotype $225.99 88269 chrmsm situ amniotic cll 6-12 colonies 1karyotyp $228.63 88271 molecular cytogenetics dna probe each $29.44 88272 molecular cytogenetics chrmoml ish 3-5 cells $36.80 88273 molecular cytogenetics chrmoml ish 10-30 cll $44.17 88274 molecular cytogenetics interphase ish 25-99 cll $47.85 88275 molec cytg interphase ish analyze 100-300 cll $55.20 88280 chrmsm analysis addl karyotyp each study $28.35 88283 chrmsm analysis addl specialized banding $94.30 88285 chrmsm analysis addl cells counted each study $5.67 88289 chrmsm analysis addl high resolution study $47.34 Fac/Non- Facility
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Laboratory Fee Schedule - Maine.gov

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