36C10G18R0208-1-0017006.xlsx
XLSX spreadsheet 70 KB Posted
- Attached to
- Customer Care Network Region 4
- Solicitation number
- 36C10G18R02081
About this file
This is a solicitation for a Customer Care Network contract in Region 4 to provide durable medical equipment, medical devices, orthotics, and prosthetic items to veterans. The contract will have a one year base period and six one-year option periods. The Department of Veterans Affairs Strategic Acquisition Center in Frederick is the contracting agency.
The solicitation seeks pricing for various CLINs for DME, medical devices, orthotics and prosthetics. Pricing is requested at the Healthcare Common Procedure Coding System code level for items such as prosthetics, orthotics, medical equipment and supplies. The contractor must submit all DME, medical device, orthotic and prosthetic prescriptions through the VA Community Care Provider Portal or by fax to the relevant VA medical center. The contractor will also be required to comply with provisions for rural and non-Medicare reimbursed care.
36C10G18R0208-1 0017 CCN Reg4 Pricing Template v10 05202019.xlsx
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Main Pricing Sheet
| Community Care Network - Region 4 | |||||||||||
| Prices Proposal for CLINs | |||||||||||
| Color legend: Green cells require offeror input. Dark gray is summary or N/A, light gray prices governed by existing rates or is on other sheets. | |||||||||||
| Offeror Name: | |||||||||||
| Prices per specific CLIN per year | |||||||||||
| CLIN | DESCRIPTION | UNIT/Directions | BASE | OPTION I | OPTION II | OPTION III | OPTION IV | OPTION V | OPTION VI | OPTION VII | OPTION TO EXTEND SERVICES |
| CLIN X001 | Healthcare Services | Equal to 100% of Medicare Rate | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare |
| CLIN X002 | Reimbursement for Highly Rural Care Areas with Scarce Medical Services | Please use "CCN Reg4 CLIN X002 Pricing Template v1 05202019" workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook | See CLIN X002 Pricing Template Workbook |
| CLIN X003 | Urgent/Emergent Durable Medical Equipment (DME), Medical Devices, Orthotics, and Prosthetic items | Equal to 100% of Medicare Rate | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare |
| CLIN X004 | Home Health Care | Summary CLIN, Not separately priced (NSP) | |||||||||
| CLIN X004AA | Skilled Home Health | Equal to 100% of Medicare Rate | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare | Equal to 100% Medicare |
| CLIN X004AB | Unskilled Home Health | VA fee schedule used | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched |
| CLIN X005 | Seasonal Influenza Vaccination | Each, $_____ | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X006 | Non-Medicare Healthcare Services, VA Fee Schedule | Non-Medicare Healthcare Services, VA Fee Schedule | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched | VA Fee Sched |
| CLIN X007 | Non-Medicare, Non-VA Fee Schedule | Non-Medicare, Non-VA Fee Schedule | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 | 38 CFR 17.55/ CFR 17.56 |
| CLIN X008 | Home Infusion Therapy | Insert maximum % billed charges in green cells for therapy (excluding drugs) not listed on Medicare or VA Fee schedules. | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X009 | Urgent and Emergent Medication | Summary CLIN, NSP | |||||||||
| CLIN X009AA | Brand Name Medication | Percent of AWP | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X009AB | Generic Medication | Percent of AWP | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X009AC | Dispensing Fee | Each in $/prescription | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X010 | Dental Services | Please use "(Pricing Sheet (CLIN X010)" | See CLIN X010 Sheet | See CLIN X010 Sheet | See CLIN X010 Sheet | See CLIN X010 Sheet | See CLIN X010 Sheet | See CLIN X010 Sheet | See CLIN X010 Sheet | See CLIN X010 Sheet | See CLIN X010 Sheet |
| CLIN X011 | Administrative Services | Summary CLIN, NSP | |||||||||
| CLIN X011Ax | Administrative Services for Healthcare Services | $ Price for Each Active Veteran per month, Summary CLIN NSP | |||||||||
| CLIN X011AA | Quantity Tier 1 | Each Active Veteran, 0 – 94,999 | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X011AB | Quantity Tier 2 | Each Active Veteran 95,000 – 144,999 | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X011AC | Quantity Tier 3 | Each Active Veteran 145,000+ | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X011Bx | Administrative Services for Dental | $ Price for Each Active Veteran per month, Summary CLIN, NSP | |||||||||
| CLIN X011BA | Quantity Tier 1 | Each Active Veteran, 0 –5,799 | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X011BB | Quantity Tier 2 | Each Active Veteran 5,800 – 6,599 | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X011BC | Quantity Tier 3 | Each Active Veteran 6,600+ | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X011CA | Administrative Services for Pharmacy Benefit Management (PBM) | $ Price for Each Active Veteran per month | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X011DA | Administrative Services for Assisted Reproductive Technology services (ART) | $ Price for Each Collateral Spouse per month | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X012 | Implementation and Transition Out | Summary CLIN, NSP | |||||||||
| CLIN X012AA | Implementation | Lump sum $ price based on # of milestones completed in a year. | N/A | N/A | N/A | N/A | N/A | N/A | See option to extend 52.217-8 & 9 | ||
| CLIN X012BA | Transition Out | Lump sum $ price for total incremental cost to transition-out above and beyond the status quo, applicable if Transition Out services exercised by VA in applicable Option Year | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X013 | Data | Contractual CLIN, no defined price. | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| CLIN X014 | Agreed Upon Procedures Audit | Total price for audit | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X015 | Healthcare Services Approved Under the Veterans Millennium Health Care Act (MILLBILL) | MILL BILL rates | MILL BILL rates | MILL BILL rates | MILL BILL rates | MILL BILL rates | MILL BILL rates | MILL BILL rates | MILL BILL rates | MILL BILL rates | MILL BILL rates |
| CLIN X016 | Optional: Appointment Scheduling & Comprehensive Care Coordination | Summary CLIN, NSP | |||||||||
| CLIN X016AA | Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination | Implementation price per VA Facility at Government site | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X016BA | Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination at the Contractor’s site | Implementation price at contractor's site (only one implementation payment during the entire contract) | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X016Cx | Optional: Appointment Scheduling and Comprehensive Care Coordination (CCC) | $ Price per Unique Approved Referral for each of the tiers of a PoP. Summary CLIN, NSP | |||||||||
| CLIN X016CA | Sched. & CCC Tier 1 | 0 – 331,400 | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X016CB | Sched. & CCC Tier 2 | 331,401– 773,300 | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X016CC | Sched. & CCC Tier 3 | 773,301– 1,215,200 | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X016CD | Sched. & CCC Tier 4 | 1,215,201– 1,657,000 | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X016CE | Sched. & CCC Tier 5 | 1,657,001– 2,540,600 | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X017 | Optional: Care Coordination Follow-Up | Summary CLIN, NSP | |||||||||
| CLIN X017AA | Optional: Implementation for Care Coordination Follow-Up | One-time lump sum $ in the year the option is exercised. | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | |
| CLIN X017BA | Optional: Care Coordination (CC) Follow-Up Administration | Monthly $ firm fixed price per Veteran that receives Care Coordination Follow Up Services | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X018 | Optional: Comprehensive Case Management Program Administration | Summary CLIN, NSP | |||||||||
| CLIN X018AA | Optional: Implementation for Comprehensive Case Management Program | One-time lump sum $ in the year the option is exercised. | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | |
| CLIN X018Bx | Optional: Comprehensive Case Management (CCM) Program Administration | $ Price per Unique Approved Applicable Referral for each of the tiers of a PoP. Summary CLIN, NSP | |||||||||
| CLIN X018BA | CCM Tier 1 | 0 – 41,000 per year | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X018BB | CCM Tier 2 | 41,001 – 82,000 per year | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X018BC | CCM Tier 3 | 82,001+ per year | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X019 | Optional: Comprehensive Disease Management Administration | Summary CLIN, NSP | |||||||||
| CLIN X019AA | Optional: Implementation for Comprehensive Disease Management | One-time lump sum $ in the year the option is exercised. | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | |
| CLIN X019Bx | Optional: Comprehensive Disease Management (CDM) Program Administration | $ Price per Unique Approved Applicable Referral for each of the tiers of a PoP, Summary CLIN, NSP. | |||||||||
| CLIN X019BA | CDM Tier 1 | 0 – 41,000 per year | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X019BB | CDM Tier 2 | 41,001 – 82,000 per year | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X019BC | CDM Tier 3 | 82,001+ per year | N/A | See option to extend 52.217-8 & 9 | |||||||
| CLIN X020 | Assisted Reproductive Technology (ART) Services | Please use "(Pricing Sheet (CLIN X020)" | See CLIN X020 Sheet | See CLIN X020 Sheet | See CLIN X020 Sheet | See CLIN X020 Sheet | See CLIN X020 Sheet | See CLIN X020 Sheet | See CLIN X020 Sheet | See CLIN X020 Sheet | See CLIN X020 Sheet |
| CLIN X021 | Disaster Medication | Summary CLIN, NSP | |||||||||
| CLIN X021AA | Brand Name Medication | Percent of AWP | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X021AB | Generic Medication | Percent of AWP | See option to extend 52.217-8 & 9 | ||||||||
| CLIN X021AC | Dispensing Fee | Each in $/prescription | See option to extend 52.217-8 & 9 |
Source Selection Sensitive
Pricing Sheet (CLIN X010)
| Community Care Network - Region 4 |
| Price Proposal for CLIN X010 -Dental CDT Codes |
| Offeror Name: | ||||||||||
| Prices per specific code per year | ||||||||||
| CDT Code | Description | BASE | OPTION I | OPTION II | OPTION III | OPTION IV | OPTION V | OPTION VI | OPTION VII | OPTION TO EXTEND SERVICES |
| D0140 | D0140-LIMIT ORAL EVAL PROBLM FOCUS | See option to extend 52.217-8 & 9 | ||||||||
| D0150 | D0150-COMPREHENSVE ORAL EVALUATION | See option to extend 52.217-8 & 9 | ||||||||
| D0210 | D0210-INTRAORAL FULL IMAGE SERIES | See option to extend 52.217-8 & 9 | ||||||||
| D0330 | D0330-DENTAL PANORAMIC IMAGE | See option to extend 52.217-8 & 9 | ||||||||
| D1110 | D1110-DENTAL PROPHYLAXIS ADULT | See option to extend 52.217-8 & 9 | ||||||||
| D2391 | D2391-POST 1 SRFC RESINBASED CMPST | See option to extend 52.217-8 & 9 | ||||||||
| D2392 | D2392-POST 2 SRFC RESINBASED CMPST | See option to extend 52.217-8 & 9 | ||||||||
| D2393 | D2393-POST 3 SRFC RESINBASED CMPST | See option to extend 52.217-8 & 9 | ||||||||
| D2740 | D2740-CROWN PORCELAIN/CERAMIC SUBS | See option to extend 52.217-8 & 9 | ||||||||
| D2750 | D2750-CROWN PORCELAIN W/ H NOBLE M | See option to extend 52.217-8 & 9 | ||||||||
| D2752 | D2752-CROWN PORCELAIN W/ NOBLE MET | See option to extend 52.217-8 & 9 | ||||||||
| D2790 | D2790-CROWN FULL CAST HIGH NOBLE M | See option to extend 52.217-8 & 9 | ||||||||
| D2950 | D2950-CORE BUILD-UP INCL ANY PINS | See option to extend 52.217-8 & 9 | ||||||||
| D3310 | D3310-END THXPY ANTERIOR TOOTH | See option to extend 52.217-8 & 9 | ||||||||
| D3320 | D3320-END THXPY BICUSPID TOOTH | See option to extend 52.217-8 & 9 | ||||||||
| D3330 | D3330-END THXPY MOLAR TOOTH | See option to extend 52.217-8 & 9 | ||||||||
| D4341 | D4341-PERIODONTAL SCALING & ROOT | See option to extend 52.217-8 & 9 | ||||||||
| D5110 | D5110-DENTURES COMPLETE MAXILLARY | See option to extend 52.217-8 & 9 | ||||||||
| D5120 | D5120-DENTURES COMPLETE MANDIBLE | See option to extend 52.217-8 & 9 | ||||||||
| D5213 | D5213-DENTURES MAXILL PART METAL | See option to extend 52.217-8 & 9 | ||||||||
| D5214 | D5214-DENTURES MANDIBL PART METAL | See option to extend 52.217-8 & 9 | ||||||||
| D6010 | D6010-ENDOSTEAL IMPLANT BODY PLACE | See option to extend 52.217-8 & 9 | ||||||||
| D6240 | D6240-PONTIC PORCELAIN HIGH NOBLE | See option to extend 52.217-8 & 9 | ||||||||
| D6245 | D6245-PONTIC PORCELAIN/CERAMIC | See option to extend 52.217-8 & 9 | ||||||||
| D6740 | D6740-RET CROWN PORCELAIN/CERAMIC | See option to extend 52.217-8 & 9 | ||||||||
| D6750 | D6750-RET CROWN PORCLN HIGH NOBLE | See option to extend 52.217-8 & 9 | ||||||||
| D7140 | D7140-EXTRACTION ERUPTED TOOTH/EXR | See option to extend 52.217-8 & 9 | ||||||||
| D7210 | D7210-SURG REM ERUPTED TOOTH | See option to extend 52.217-8 & 9 |
Source Selection Sensitive
Pricing Sheet (CLIN X020)
| Community Care Network - Region 4 |
| Price Proposal for CLIN X020 -ART IVF Codes |
| Offeror Name: | ||||||||||||
| Prices per specific code per year | ||||||||||||
| CPT Code | Description | UNIT/Directions | BASE | OPTION I | OPTION II | OPTION III | OPTION IV | OPTION V | OPTION VI | OPTION VII | OPTION TO EXTEND SERVICES | |
| 00840 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 00842 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; amniocentesis | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 01965 | Anesthesia for incomplete or missed abortion procedures | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 10021 | Fine needle aspiration; without imaging guidance | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 10022 | Fine needle aspiration; with imaging guidance | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 36415 | Collection of venous blood by venipuncture | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 36416 | Collection of capillary blood specimen (e.g., finger, heel, ear stick) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 52402 | Cystourethroscopy with transurethral resection or incision of ejaculatory ducts | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54110 | Excision of penile plaque (Peyronie disease) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54111 | Excision of penile plaque (Peyronie disease); with graft to 5 cm in length | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54112 | Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54500 | Biopsy of testis, needle (separate procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54505 | Biopsy of testis, incisional (separate procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54800 | Biopsy of epididymis, needle | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54900 | Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 54901 | Epididymovasostomy, anastomosis of epididymis to vas deferens; bilatera | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55200 | Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55300 | Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55400 | Vasovasostomy, vasovasorrhaphy | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55530 | Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55535 | Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55540 | The provider excises a varicocele, a dilation of the veins in the spermatic cord, often reaching into the scrotum, or ligates one or more spermatic veins and repairs a hernia. | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55550 | Laparoscopy, surgical, with ligation of spermatic veins for varicocele | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 55870 | Electroejaculation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58140 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58146 | Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58321 | Artificial insemination; intra-cervical | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58322 | Artificial insemination; intra-uterine | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58323 | Sperm washing for artificial insemination | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58340 | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58345 | Transcervical introduction of fallopian tube catheter for diagnosis and/or re- establishing patency (any method), with or without hysterosalpingography | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58350 | Chromotubation of oviduct, including materials | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58353 | Endometrial ablation, thermal, without hysteroscopic guidance | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58356 | Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58540 | Hysteroplasty, repair of uterine anomaly (Strassman type) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58545 | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58546 | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58555 | Hysteroscopy, diagnostic (separate procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58558 | Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58559 | Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58560 | Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58561 | Hysteroscopy, surgical; with removal of leiomyomata | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58660 | Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58662 | Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58670 | Laparoscopy, surgical; with fulguration of oviducts (with or without transection) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58672 | Laparoscopy, surgical; with fimbrioplasty | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58673 | Laparoscopy, surgical; with salpingostomy (salpingoneostomy) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58679 | Unlisted laparoscopy procedure, oviduct, ovary | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58700 | Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58740 | Lysis of adhesions (salpingolysis, ovariolysis) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58752 | Tubouterine implantation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58760 | Fimbrioplasty | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58770 | Salpingostomy (salpingoneostomy) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58800 | Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); vaginal approach | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58805 | Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); abdominal approach | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58920 | Wedge resection or bisection of ovary, unilateral or bilateral | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58970 | Follicle puncture for oocyte retrieval, any method | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58974 | Embryo transfer, intrauterine | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 58976 | Gamete, zygote, or embryo intrafallopian transfer, any method | |||||||||||
| Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||||
| 59160 | Curettage, postpartum | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 59812 | Treatment of incomplete abortion, any trimester, completed surgically | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 59820 | Treatment of missed abortion, completed surgically; first trimester | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 59821 | Treatment of missed abortion, completed surgically; second trimester | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 59830 | Treatment of septic abortion, completed surgically | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 71045 | Radiologic examination, chest; single view | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 71046 | Radiologic examination, chest; 2 views | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 71047 | Radiologic examination, chest; 3 views | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 71048 | Radiologic examination, chest; 4 or more views | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 74740 | Hysterosalpingography, radiological supervision and interpretation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 74742 | Transcervical catheterization of fallopian tube, radiological supervision and interpretation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76700 | Ultrasound, abdominal, real time with image documentation; complete | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76812 | Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76815 | Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76816 | Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a prev | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76830 | Ultrasound, transvaginal | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76831 | Saline infusion sonohysterography (SIS), including color flow Doppler, when performed | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76811 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76856 | Ultrasound, pelvic (nonobstetric), real time with image documentation; complete | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76857 | Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76870 | Ultrasound, scrotum and contents | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76872 | Ultrasound, transrectal | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76941 | Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76942 | Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 76948 | Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80047 | Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80048 | Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80050 | General health panel This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80053 | Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80076 | Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80414 | Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on 3 pooled blood samples) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80415 | Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on 3 pooled blood samples) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 80426 | Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81000 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81001 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81002 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81003 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81005 | Urinalysis; qualitative or semiquantitative, except immunoassays | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81007 | Urinalysis; bacteriuria screen, except by culture or dipstick | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81015 | Urinalysis; microscopic only | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81020 | Urinalysis; 2 or 3 glass test | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81025 | Urine pregnancy test, by visual color comparison methods | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 82397 | Chemiluminescent assay | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 82670 | Estradiol | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 83001 | Gonadotropin; follicle stimulating hormone (FSH) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 83002 | Gonadotropin; luteinizing hormone (LH) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 83498 | Hydroxyprogesterone, 17-d | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 84144 | Progesterone | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 84402 | Testosterone; free | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 84403 | Testosterone; total | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 84702 | Gonadotropin, chorionic (hCG); quantitative | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 84703 | Gonadotropin, chorionic (hCG); qualitative | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 84704 | Gonadotropin, chorionic (hCG); free beta chain | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 84830 | Ovulation tests, by visual color comparison methods for human luteinizing hormone Flow cytometry, cell cycle or DNA analysis | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 85025 | Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 85610 | Prothrombin time; | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 85730 | Thromboplastin time, partial (PTT); plasma or whole blood | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 86689 | Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 86701 | Antibody; HIV-1 | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 86702 | Antibody; HIV-2 | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 86703 | Antibody; HIV-1 and HIV-2, single result | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88141 | Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88142 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88143 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88147 | Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88148 | Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88150 | Cytopathology, slides, cervical or vaginal; manual screening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88152 | Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88153 | Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88155 | Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code[s] for other technical and interpretation services) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88164 | Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88165 | Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88166 | Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88167 | Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88174 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88175 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88182 | Flow cytometry, cell cycle or DNA analysis | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88248 | Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88261 | Chromosome analysis; count 5 cells, 1 karyotype, with banding | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88262 | Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88263 | Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding | Unit $ Price | See option to extend 52.217-8 & 9 | 2 | ||||||||
| 88264 | Chromosome analysis; analyze 20-25 cells | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88267 | Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88269 | Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88271 | Molecular cytogenetics; DNA probe, each (eg, FISH) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88273 | Molecular cytogenetics; chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88280 | Chromosome analysis; additional karyotypes, each study | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88283 | Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88285 | Chromosome analysis; additional cells counted, each study Culture of oocyte(s)/embryo(s), less than 4 days; | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88363 | 88363 Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88380 | 88380 Microdissection (ie, sample preparation of microscopically identified target); laser capture | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88387 | 88387 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); each tissue preparation (eg, a single lymph node) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 88388 | 88388 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89250 | Culture of oocyte(s)/embryo(s), less than 4 days; | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89251 | Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89253 | Assisted embryo hatching, microtechniques (any method) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89254 | Oocyte identification from follicular fluid | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89255 | Preparation of embryo for transfer (any method) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89257 | Sperm identification from aspiration (other than seminal fluid) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89258 | Cryopreservation; embryo(s) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89259 | Cryopreservation; sperm | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89260 | Sperm isolation; simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89261 | Sperm isolation; complex prep (e.g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89264 | Sperm identification from testis tissue, fresh or cryopreserved | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89268 | Insemination of oocytes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89291 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89300 | Semen analysis; presence and/or motility of sperm including Huhner test (post coital) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89310 | Semen analysis; motility and count (not including Huhner test) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89320 | Semen analysis; volume, count, motility, and differential | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89321 | Semen analysis; sperm presence and motility of sperm, if performed | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89322 | Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89325 | Sperm antibodies | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89330 | Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89331 | Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89352 | Thawing of cryopreserved; embryo(s) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89353 | Thawing of cryopreserved; sperm/semen, each aliquot | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 93000 | Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 93005 | Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 93010 | Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 96372 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99000 | Handling and/or conveyance of specimen for transfer from the office to a laboratory | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99024 | Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99070 | Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99078 | Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99201 | New patient, which requires these 3 key components, problem focused history, problem focused exam, and medical decision making of straightforward presenting problems are usually self-limited or minor problem, typically 10 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99202 | New patient, which requires these 3 key components, expanded problem focused history, expanded problem focused exam, and medical decision making of straightforward. Presenting problems are usually low to moderate severity problem, typically 20 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99203 | New patient, which requires these 3 key components, detailed history, detailed exam, and medical decision making of low complexity. Presenting problems are usually moderate severity problem, typically 30 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99204 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of moderate. Presenting problems are usually moderate to high severity problem, typically 45 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99205 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of high. Presenting problems are usually high severity problem, typically 60 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99211 | Established patient, may not require the presence of a physician or other qualifies health care professional. Minimal presenting problems, typically 5 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99212 | Established patient, which requires at least 2 of these 3 key components: problem focused history, problem focused exam, and straight forward medical decision making. Presenting problems are usually self-limited or minor problem, typically 10 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99213 | Established patient, which requires at least 2 of these 3 key components: expanded problem focused history, expanded problem focused exam, and low medical decision making. Presenting problems are usually low to moderate severity problem, typically 15 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99214 | Established patient, which requires at least 2 of these 3 key components: detailed history, detailed exam, and moderate medical decision making. Presenting problems are usually moderate severity problem, typically 25 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99215 | Established patient, which requires at least 2 of these 3 key components: comprehensive history, comprehensive exam, and high medical decision making. Presenting problems are usually Moderate to high severity problem, typically 40 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99217 | Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99218 | Initial observation care, per day, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99219 | Initial observation care, per day, requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99220 | Initial observation care, per day, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 99358 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, first hour | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89329 | Sperm evaluation; hamster penetration test | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89335 | Cryopreservation; reproductive tissue, testicular | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| 89353 | Thawing cryopreserved; sperm/semen each aliquot | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| add-on 99354 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, first hour | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| add-on 99355 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, each additional 30 minutes. | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| add-on 99356 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, each additional 30 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| add-on 99357 | Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service, each additional 30 minutes | Unit $ Price | See option to extend 52.217-8 & 9 | |||||||||
| G0027 | Semen analysis; presence and/or motility of sperm excluding Huhner | Unit $ Price | See option to extend 52.217-8 & 9 |
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