Exhibit_G._Ancillary_and_Laboratory_Requirements.xlsx

XLSX spreadsheet 29 KB Posted Dec 27, 2016

Attached to: MEPCOM Medical Referral Services
Solicitation number: W81K04-17-R-RFRL
Issued by: Department of the Army Medical Command

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Exhibit G - Ancillary and Laboratory Requirements

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EXHIBIT G - ANCILLARY AND LABORATORY REQUIREMETNS
CPT – Name - Ancillary	CPT	Est Qty
11100 - Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion	11100	5
11101 - Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure)	11101	2
31505 - Laryngoscopy, Diagnostic	31505	1000
31231 - Nasal Endoscopy, Diagnostic, Unilateral Or Bilateral (Separate Procedure)	31231	10
31575 - Laryngoscopy, Flexible Fiberoptic; Diagnostic	31575	5
36415 - Venipuncture Fee	36415	1000
51741 - Complex Uroflowmetry (Eg, Calibrated Electronic Equipment)	51741	5
51798 - Measurement Of Post-Voiding Residual Urine And/Or Bladder Capacity By Ultrasound, Non-Imaging	51798	5
69200 - Removal Foreign Body From External Auditory Canal; Without General Anesthesia	69200	10
69210 - Wax Removal	69210	3100
70160 - Radiologic Examination, Nasal Bones, Complete, Minimum Of 3 Views	70160	5
70210 - Radiologic Examination, Sinuses, Paranasal, Less Than 3 Views	70210	5
70220 - Radiologic Examination, Sinuses, Paranasal, Complete, Minimum Of 3 Views	70220	5
70260 - Radiologic Examination, Skull; Complete, Minimum Of 4 Views	70260	5
70370 – Throat & Fluoroscopy	70370	33
70371 – Speech Evaluation, Complex	70371	33
70450 - CT Scan, Head/Brain, W/O Contrast, Global	70450	35
70460 - CT Scan, Head/Brain, With Contrast, Global	70460	27
70480 - CT Scan, Renal W/O Contrast	70480	30
70481 - CT Scan, Renal With Contrast	70481	27
70482 - Ct Scan, Middle/Inner Ear, Global	70482	27
70486 - Computed Tomography, Maxillofacial Area; Without Contrast Material	70486	5
70551 - MRI Head, W/O Contrast, Global	70551	30
70552 - MRI Head, With Contrast, Global	70552	26
70553 - Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem); Without Contrast Material, Followed By Contrast Material(S) And Further Sequences	70553	5
71010 – Chest X-Ray	71010	35
71020 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral;	71020	130
71022 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral; With Oblique Projections	71022	15
71023 – Chest X-Ray And Fluoroscopy	71023	33
71100 – X-Ray Exam Of Ribs	71100	33
71101 – X-Ray Exam Of Ribs/Chest	71101	33
71111 – X-Ray Exam Of Ribs	71111	33
71120 – X-Ray Exam Of Breastbone	71120	33
71130 – X-Ray Exam Of Breastbone	71130	33
71250 - CT Scan, Chest, W/O Contrast, Global	71250	40
72052 - Radiologic Examination, Spine, Cervical; 6 Or More Views	72052	5
72010 – X-Ray Exam Of Spine	72010	70
72020 - Radiologic Examination, Spine, Single View, Specify Level	72020	5
72040 – X-Ray Exam Of Neck Spine	72040	50
72069 – X-Ray Exam Of Thoracic Spine	72069	150
72070 - Radiologic Examination, Spine; Thoracic, 2 Views	72070	50
72072 - Radiologic Examination, Spine; Thoracic, 3 Views	72072	15
72074 -Radiologic Examination, Spine; Thoracic, Minimum Of 4 Views	72074	15
72080 – X-Ray Exam Of Trunk Spine	72080	75
72090 - Radiologic Examination, Spine; Scoliosis Study, Including Supine And Erect Studies	72090	400
72100 – X-Ray Exam Of Lower Spine	72100	200
71110 - Radiologic Examination, Ribs, Bilateral; 3 Views	72110	65
72114 - Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, Minimum Of 6 Views	72114	15
72120 - Radiologic Examination, Spine, Lumbosacral; Bending Views Only, 2 Or 3 Views	72120	10
72125 - CT Scan, LS Spine, W/O Contrast, Global	72125	27
72141 - MRI C/Spine, W/O Contrast, Global	72141	26
72142 - MRI C/Spine, With Contrast, Global	72142	26
72146 - MRI Extremity, W/O Contrast, Global	72146	26
72147 - MRI Extremity, With Contrast, Global	72147	26
72148 - MRI T-Spine, W/O Contrast, Global	72148	26
72149 - MRI T-Spine, With, Contrast, Global	72149	26
72170 – X-Ray Exam Of Pelvis	72170	55
72190 – X-Ray Exam Of Pelvis	72190	37
72192 - CT Scan, Pelvis, W/O Contrast, Global	72192	27
72195 - MRI Pelvis, W/O Contrast, Global	72195	26
72200 – X-Ray Exam Sacroiliac Joints	72200	33
72202 - X-Ray Exam Sacroiliac Joints	72202	33
72220 – X-Ray Exam Of Tailbone	72220	33
72240 – Contract X-Ray Of Neck Spine	72240	33
72255 – Contrast X-Ray, Thorax Spine	72255	33
72265 – Contract X-Ray, Lower Spine	72265	33
72270 – Contrast X-Ray Of Spine	72270	33
72285 – X-Ray C/T Spine Disk	72285	33
72295 – X-Ray Of Lower Spine Disk	72295	33
73000 – X-Ray Exam Of Collar Bone	73000	75
73010 – X-Ray Exam Of Shoulder Blade	73010	55
73020 – X-Ray Exam Of Shoulder	73020	45
73030 – X-Ray Exam Of Shoulder	73030	500
73040 – X-Ray Exam Of Shoulder	73040	55
73050 - Radiologic Examination; Acromioclavicular Joints, Bilateral, With Or Without Weighted Distraction	73050	5
73060 – X-Ray Exam Of Humerus	73060	55
73070 – X-Ray Exam Of Elbow	73070	100
73080 – X-Ray Exam Of Elbow	73080	150
73085 – Contrast X-Ray Of Elbow	73085	33
73090 – X-Ray Exam Of Forearm	73090	100
73100 – X-Ray Of Wrist 2 Views	73100	100
73110 – X-Ray Exam Of Wrist	73110	100
73115 – Contrast X-Ray Of Wrist	73115	33
73120 – X-Ray Exam Of Hand	73120	75
73130 – X-Ray Exam Of Hand	73130	55
73140 – X-Ray Exam Of Finder (S)	73140	55
73221 - MRI Shoulder, W/O Contrast, Global	73221	27
73500 – X-Ray Exam Of Hip	73500	50
73510 – X-Ray Exam Of Hip	73510	85
73520 – X-Ray Exam Of Hips	73520	60
73525 – Contrast X-Ray Of Hip	73525	33
73530 – Contrast X-Ray Of Hip	73530	33
73540 – X-Ray Exam Of Pelvis & Hips	73540	33
73550 – X-Ray Exam Of Thigh	73550	100
73560 – X-Ray Exam Of Knee, 1 Or 2	73560	300
73562 – X-Ray Exam Of Knee, 3	73562	400
73564 – X-Ray Exam, Knee 4 Or More	73564	275
73565 – X-Ray Exam Of Knees	73565	65
73580 – Contrast X-Ray Of Knee Joint	73580	33
73590 – X-Ray Exam Of Lower Leg	73590	100
73600 – X-Ray Exam Of Ankle	73600	150
73610 – X-Ray Exam Of Ankle	73610	220
73615 – Contrast X-Ray Of Ankle	73615	33
73620 – X-Ray Exam Of Foot	73620	200
73630 – X-Ray Foot 2 Views	73630	400
73650 – X-Ray Exam Of Heel	73650	55
73660 – X-Ray Exam Of Toe (S)	73660	55
73700 - CT Scan, Lower Extremity, W/O Contrast, Global	73700	27
73721 - MRI Lower Extremity Joint, W/O Contrast, Global	73721	30
74000 – X-Ray Exam Of Abdomen	74000	50
74010 – X-Ray Exam Of Abdomen	74010	33
74020 – X-Ray Exam Of Abdomen	74020	33
74022 – X-Ray Exam Series, Abdomen	74022	33
74146 - Computed Tomography, Abdomen And Pelvis; Without Contrast Material	74176	5
74178 - Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(S) And Further Sections In One Or Both Body Regions	74178	8
74150 - CT Scan, Abdomen, With & W/O Contrast, Global	74150	27
74190 – X-Ray Exam Or Peritoneum	74190	33
74210 – Contrast X-Ray Exam Of Throat	74210	33
74220 – Contrast X-Ray, Esophagus	74220	33
74240 – X-Ray Exam, Upper Gi Tract	74240	33
74241 – X-Ray Exam, Upper Gi Tract	74241	33
74245 – X-Ray Exam, Upper Gi Tract	74245	33
74246 – Contrast X-Ray Upper Gi Tract	74246	33
74247 – Contrast X-Ray Upper Gi Tract	74247	33
74249 – Contrast X-Ray Upper Gi Tract	74249	33
74250 – X-Ray Exam Of Small Bowel	74250	33
74251 – X-Ray Exam Of Small Bowel	74251	33
74260 – X-Ray Exam Of Small Bowel	74260	33
74270 – Contrast X-Ray Exam Of Colon	74270	33
74280 – Contrast X-Ray Exam Of Colon	74280	33
74283 – Contrast X-Ray Exam Of Colon	74283	33
74290– Contrast X-Ray, Gallbladder	74290	33
74300 – X-Ray Bile Ducts/Pancreas	74300	33
74305 – X-Ray Bile Ducts/Pancreas	74305	33
74320 – Contrast X-Ray Of Bile Ducts	74320	33
74327 – X-Ray Bile Stone Removal	74327	33
74328 – X-Ray Bile Duct Endoscopy	74328	33
74329 – X-Ray For Pancreas Endoscopy	74329	33
74330 – X-Ray Bile/Pancreas Endoscopy	74330	33
74340 – X-Ray Guide For GI Tube	74340	33
74355 – X-Ray Guide, Intestinal Tube	74355	33
74360 – X-Ray Guide, Gi Dilation	74360	33
74363 – X-Ray, Bile Duct Dilation	74363	33
74400 – Contrast X-Ray, Urinary Tract	74400	33
74410 - Contrast X-Ray, Urinary Tract	74410	33
74415 - Contrast X-Ray, Urinary Tract	74415	33
74420 - Contrast X-Ray, Urinary Tract	74420	33
74425 - Contrast X-Ray, Urinary Tract	74425	33
74430 – Contrast X-Ray, Bladder	74430	33
74440 – X-Ray, Male Genital Tract	74440	33
74445 – X-Ray Exam Of Penis	74445	33
74450 – X-Ray, Urethra/Bladder	74450	33
74455 – X-Ray, Urethra/Bladder	74455	33
74470 – X-Ray Exam Of Kidney Lesion	74470	33
74475 – X-Ray Control, Cath Insert	74475	33
74480 – X-Ray Control, Cath Insert	74480	33
74485 – X-Ray Guide, Gu Dilation	74485	33
74740 – X-Ray, Female Genital Tract	74740	33
74742 – X-Ray, Fallopian Tube	74742	33
76511 - Ophthalmic Ultrasound, Diagnostic; Quantitative A-Scan Only	76511	5
76514 - Ophthalmic Ultrasound, Diagnostic; Corneal Pachymetry, Unilateral Or Bilateral (Determination Of Corneal Thickness)	76514	20
76536 - Ultrasound, Head, Global	76536	24
76604 - Ultrasound, Chest, Global	76604	24
76700 - Ultrasound, Abdomen, Global	76700	30
76705 - Ultrasound, Abdominal, Real Time With Image Documentation; Limited (Eg, Single Organ, Quadrant, Follow-Up)	76705	10
76770 - Ultrasound, Kidney(Renal), Global	76770	24
76775 - Ultrasound, Retroperitoneal (Eg, Renal, Aorta, Nodes), Real Time With Image Documentation; Limited	76775	5
76800 - Ultrasound, Spinal Canal, Global	76800	24
76830 - Ultrasound, Ovaries, Global	76830	24
76856 - Ultrasound, Pelvic (Nonobstetric), Global	76856	24
76870 - Ultrasound, Scrotum, Global	76870	100
	76872	5
76881 - Ultrasound, Extremities, Global	76881	24
77051 - Mammogram, Digital, Bilateral, Global	77051	40
77052 - Computer-Aided Detection (Computer Algorithm Analysis Of Digital Image Data For Lesion Detection) With Further Review For Interpretation, With Or Without Digitization Of Film Radiographic Images; Screening Mammography (List Separately In Addition To Code For Primary Procedure)	77052	10
77056 - Mammogram, Conventional, Bilateral, (Global)	77056	40
77057 - Screening Mammography, Bilateral (2-View Film Study Of Each Breast)	77057	5
78708 - Kidney Imaging Morphology; With Vascular Flow And Function, Single Study, With Pharmacological Intervention (Eg, Angiotensin Converting Enzyme Inhibitor And/Or Diuretic)	78708	5
91065 - Hydrogen Breath Test	91065	75
92015 - Refraction Test	92015	7000
92025 - Corneal Topography Test	92025	7000
92060 - Sensorimotor Examination With Multiple Measurements Of Ocular Deviation (Eg, Restrictive Or Paretic Muscle With Diplopia) With Interpretation And Report (Separate Procedure)	92060	10
92081 - Visual Field Testing (Automated Perimeter)	92081	175
92082 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report; Intermediate Examination (Eg, At Least 2 Isopters On Goldmann Perimeter, Or Semiquantitative, Automated Suprathreshold Screening Program, Humphrey Suprathreshold Automatic Diagnostic Test, Octopus Program 33)	92082	125
92083 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report	92083	400
92100 - Contact Tonometry	92100	175
92132 - Scanning Computerized Ophthalmic Diagnostic Imaging, Anterior Segment, With Interpretation And Report, Unilateral Or Bilateral	92132	5
92133 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Optic Nerve	92133	20
92134 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Retina	92134	10
92225 - Ophthalmoscopy, Extended, With Retinal Drawing (Eg, For Retinal Detachment, Melanoma), With Interpretation And Report; Initial	92225	1400
92285 - Stereoscopic	92285	175
92504 - Binocular Ear Test	92504	1000
92250 - Fundus Photography With Interpretation And Report	92250	200
92275 - Electroretinography With Interpretation And Report	92275	5
92283 - Color Vision Examination, Extended, Eg, Anomaloscope Or Equivalent	92283	5
92285 - External Ocular Photography With Interpretation And Report For Documentation Of Medical Progress (Eg, Close-Up Photography, Slit Lamp Photography, Goniophotography, Stereo-Photography)	92285	5
92504 - Binocular Microscopy (Separate Diagnostic Procedure)	92504	15
92550 - Tympanometry And Reflex Threshold Measurements	92550	25
92552 - Pure Tone Audiometry (Threshold); Air Only	92552	50
92553 - Audiogram W/Air & Bone Conduction	92553	800
92555 - Speech Audiometry Threshold;	92555	10
92556 - Speech Audiometry Threshold; With Speech Recognition	92556	60
92557 - Audiogram W/Speech Reception Threshold	92557	800
92567 - Tympanometry (Impedance Testing)	92567	100
92571 - Filtered Speech Test	92571	25
92577 - Stenger Test, Speech	92577	5
92587 - Distortion Product Evoked Otoacoustic Emissions; Limited Evaluation (To Confirm The Presence Or Absence Of Hearing Disorder, 3-6 Frequencies) Or Transient Evoked Otoacoustic Emissions, With Interpretation And Report	92587	5
93000 - Ecg – Complete, 12-Lead	93000	1300
93005 - Electrocardiogram, Routine Ecg With At Least 12 Leads; Tracing Only, Without Interpretation And Report	93005	25
93010 - Electrocardiogram, Routine Ecg With At Least 12 Leads; Interpretation And Report Only	930010	25
93015 - Stress Test	93015	300
93016 - Cardiovascular Stress Test Using Maximal Or Submaximal Treadmill Or Bicycle Exercise, Continuous Electrocardiographic Monitoring, And/Or Pharmacological Stress; Supervision Only, Without Interpretation And Report	93016	5
93018 - Cardiovascular Stress Test Using Maximal Or Submaximal Treadmill Or Bicycle Exercise, Continuous Electrocardiographic Monitoring, And/Or Pharmacological Stress; Interpretation And Report Only	93018	5
93224 - External Electrocardiographic Recording Up To 48 Hours By Continuous Rhythm Recording And Storage; Includes Recording, Scanning Analysis With Report, Review And Interpretation By A Physician Or Other Qualified Health Care Professional	93224	20
93306 - Echocardiogram (2D-M/Mode W/Color), Global	93306	1400
93307 - EEG, Echocardiogram (2D-M/Mode Doppler W/O Color)	93307	64
93320 - Doppler Echocardiography, Pulsed Wave And/Or Continuous Wave With Spectral Display (List Separately In Addition To Codes For Echocardiographic Imaging); Complete	93320	5
93325 - Doppler Echocardiography Color Flow Velocity Mapping (List Separately In Addition To Codes For Echocardiography)	93325	5
93350 - Stress Echocardiogram	93350	275
93351 - Echocardiography, Transthoracic, Real-Time With Image Documentation (2d),	93351	10
93888 - Transcranial Doppler Study Of The Intracranial Arteries; Limited Study	93880	10
93965 - Doppler Vascular Study, Upper Or Lower Extremities Multiple	93965	24
93970 - Duplex Doppler Scan, Upper Or Lower Extremities	93970	24
93975 - Duplex Scan Of Arterial Inflow And Venous Outflow Of Abdominal, Pelvic, Scrotal Contents And/Or Retroperitoneal Organs; Complete Study	93975	10
94010 - Pft – Pre/Post Bronchodilator, Global	94010	375
94060 - Bronchodilation Responsiveness, Spirometry As In 94010, Pre- And Post-Bronchodilator Administration	94060	600
94070 - Bronchospasm Provocation Evaluation, Multiple Spirometric Determinations As In 94010, With Administered Agents (Eg, Antigen[S], Cold Air, Methacholine)	94070	25
94620 - Pft – Pre/Post Exercise, Global	94620	75
94726: -Plethysmography For Determination Of Lung Volumes And, When Performed, Airway Resistance	94726	40
94727 - Gas Dilution Or Washout For Determination Of Lung Volumes And, When Performed, Distribution Of Ventilation And Closing Volumes	94727	5
94729 - Diffusing Capacity (Eg, Carbon Monoxide, Membrane) (List Separately In Addition To Code For Primary Procedure)	94729	50
95004 - Allergy Test	95004	500
95017 - Allergy Testing, Any Combination Of Percutaneous (Scratch, Puncture, Prick) And Intracutaneous (Intradermal), Sequential And Incremental, With Venoms, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests	95017	60
95018 - Allergy Testing, Any Combination Of Percutaneous (Scratch, Puncture, Prick) And Intracutaneous (Intradermal), Sequential And Incremental, With Drugs Or Biologicals, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests	95018	30
95024 - Intracutaneous (Intradermal) Tests With Allergenic Extracts, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests	95024	175
95044 - Patch Or Application Test(S) (Specify Number Of Tests)	95044	60
95070 - Pft – Methacholine Challenge, Global	95070	150
95076 - Ingestion Challenge Test (Sequential And Incremental Ingestion Of Test Items, Eg, Food, Drug Or Other Substance); Initial 120 Minutes Of Testing	95076	5
95134 - Venom Test Battery – All 5 Venom Tests	95134	100
95805 - Sleep Studies	95805	64
95812 - Eeg, Interpretation	95812	64
95816 - EEG, Resting, Complete	95816	70
95819 - Electroencephalogram (Eeg); Including Recording Awake And Asleep	95819	30
95886 - Needle Electromyography, Each Extremity, With Related Paraspinal Areas, When Performed	95886	5
95908 - Nerve Conduction Studies; 3-4 Studies	95908	5
95909 - Nerve Conduction Studies; 5-6 Studies	95909	5
96101 - Psychological Testing (Includes Psychodiagnostic Assessment Of Emotionality, Intellectual Abilities	96101	1400
97750 - Physical Performance Test Or Measurement (Eg, Musculoskeletal, Functional Capacity), With Written Report, Each 15 Minutes	97750	30
J7674 - Methacholine Chloride Administered As Inhalation Solution Through A Nebulizer, Per 1 Mg	J7674	800
Q0091 - Screening Papanicolaou Smear; Obtaining, Preparing And Conveyance Of Cervical Or Vaginal Smear To Laboratory	Q0091	10
		41927

CPT – Name - Laboratory	CPT	Est Qty
80048 - Basic Metabolic Panel (Calicum, Total)	80048	1100
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)	80053	10
80061 - Lipid, Pnl W/Rfl Dldl	80061	1100
80076 - Hepatic Func Pnl	80076	150
81000 - Urinalysis, By Dip Stick Or Tablet Reagent For Bilirubin,	81000	125
81001 - Urinalysis, By Dip Stick Or Tablet Reagent For Bilirubin,	81001	400
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	81002	50
81003 - Glucose, Urine, Qaulitative	81003	200
81015 - Urinalysis; Microscopic Only	81015	175
82105 – Alpha-Fetoprotein (Afp); Serum	82105	75
82270 - Occult Blood Feces 3	82270	150
82465 - Cholesterol	82465	2300
82530 – Cortisol; Free	82530	75
82533 – Cortisol Total	82533	75
82565 - Creatinine	82565	175
82570 - Creatinine, Random Urine	82570	400
82575 – Creatinine Clearance	82575	170
82947 - Glucose	82947	400
82951 - Glucose, Tolerance Test, 2 Specimen	82951	400
82955 - Glucose-6-Phosphate Dehydrogenase (G-6-Pd), Blood	82955	150
82977 - GTT, Each Additional Beyond 3 Specimens	82977	375
82985 - A-1-1 Glycoprotein	82985	150
83002 - Lh (Luteinizing Hormone)	83002	150
83036 - Glycoslated (A1c)	83036	150
83050 - Hemoglobin A1c	83050	150
83690 - Lipase	83690	150
83718 - Hdl Cholesterol	83718	2300
83721 Cholesterol, Direct Ldl	83721	2300
84156 - Protein, Total Random Urine	84156	150
84403 - Testosterone, Total	84403	150
84450 - Aspartate Aminotransferase (Ast)	84450	150
84460 - Alanine Aminotransferase (Alt)	84460	150
84478 - Triglycerides, Serum	84478	2300
84520 -Urea Nitrogen (Bun)	84520	150
84702 - Hcg, Serum, Quant	84702	150
85014 - Hematocrit	85014	150
85018 - Hemoglobin	85018	150
85025 - Cbc (Diff/Plt)	85025	550
85041- Blood Count; Red Blood Cell (Rbc), Automated	85041	5
85049 - Platelet Count	85049	150
85370 - Fibrin Degradation Products, D-Dimer; Quantitative	85370	75
85610 - Prothrombin Time	85610	75
85730 - Thromboplastin Time, Partial (Ptt); Plasma Or Whole Blood 100	85730	75
86003 - Allergen Specific Ige; Quantitative Or Semiquantitative, Each Allergen	86003	10
86480 - Quantifeon(R)Tb Gold	86480	150
86617 - Lyme Disease, Igg/Igm Western	86617	150
87220 - Tissue Examination By Koh Slide Of Samples From Skin, Hair, Or Nails For Fungi Or Ectoparasite Ova Or Mites (Eg, Scabies)	87220	30
88104 - Cytopathology, Fluids, Washings Or Brushings, Except Cervical Or Vaginal; Smears With Interpretation	88104	1000
88142 - Cytopathology, Cervical Or Vaginal (Any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation; Manual Screening Under Physician Supervision	88142	30
88154 - Cytopathology, Slides, Cervical Or Vaginal; With Manual Screening And Computer-Assisted Rescreening Using Cell Selection And Review Under Physician Supervision	88154	5
88164 - Cytopathology, Slides, Cervical Or Vaginal (The Bethesda System); Manual Screening Under Physician Supervision	88164	5
88305 - Level Iv - Surgical Pathology, Gross And Microscopic Examination Abortion	88305	5
		19220

99242 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: An Expanded Problem Focused History; An Expanded Problem Focused Examination; And Straightforward Medical Decision Making. Counseling And/Or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are Provided Consistent With The Nature Of The Problem(S) And The Patient's And/Or Family's Needs. Usually, The Presenting Problem(S) Are Of Low Severity. Typically, 30 Minutes Are Spent Face-To-Face With The Patient And/Or Family.	99242	21000
99243 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: A Detailed History; A Detailed Examination; And Medical Decision Making Of Low Complexity. Counseling And/Or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are Provided Consistent With The Nature Of The Problem(S) And The Patient's And/Or Family's Needs. Usually, The Presenting Problem(S) Are Of Moderate Severity. Typically, 40 Minutes Are Spent Face-To-Face With The Patient And/Or Family.	99243	1400
99244 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: A Comprehensive History; A Comprehensive Examination; And Medical Decision Making Of Moderate Complexity. Counseling And/Or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are Provided Consistent With The Nature Of The Problem(S) And The Patient's And/Or Family's Needs. Usually, The Presenting Problem(S) Are Of Moderate To High Severity. Typically, 60 Minutes Are Spent Face-To-Face With The Patient And/Or Family.	99244	2700
		25100

D0150 – Comprehensive Oral Evaluation – New or Established Patient	D0150	100
D0220 - Intraoral-periapical first film;	D0220	100
D0230 - Intraoral-periapical each additional film.	D0230	100
D0272 – Bitewings – Two Radiographic Images	D0272	100
D0273 – Bitewings – Three Radiographic Images	D0273	100
D0274 – Bitewings – Four Radiographic Images	D0274	100
		600
73620 – X-Ray Exam of Foot	73620

73630 – X-Ray Foot 2 Views 73630

73650 – X-Ray Exam of Heel 73650

73660 – X-Ray Exam of Toe (S) 73660

74000 – X-Ray Exam of Abdomen 74000

74010 – X-Ray Exam of Abdomen 74010

74020 – X-Ray Exam of Abdomen 74020

74022 – X-Ray Exam Series, Abdomen 74022

74190 – X-Ray Exam or Peritoneum 74190

74210 – Contrast X-Ray Exam of Throat 74210

74220 – Contrast X-Ray, Esophagus 74220

74240 – X-Ray Exam, Upper GI Tract 74240

74241 – X-Ray Exam, Upper GI Tract 74241

74245 – X-Ray Exam, Upper GI Tract 74245

74246 – Contrast X-Ray Upper GI Tract 74246

74247 – Contrast X-Ray Upper GI Tract 74247

74249 – Contrast X-Ray Upper GI Tract 74249

74250 – X-Ray Exam of Small Bowel 74250

74251 – X-Ray Exam of Small Bowel 74251

74260 – X-Ray Exam of Small Bowel 74260

74270 – Contrast X-Ray Exam of Colon 74270

74280 – Contrast X-Ray Exam of Colon 74280

74283 – Contrast X-Ray Exam of Colon 74283

74290– Contrast X-Ray, Gallbladder 74290

74291– Contrast X-Ray, Gallbladder 74291

74300 – X-Ray Bile Ducts/Pancreas 74300

74305 – X-Ray Bile Ducts/Pancreas 74305

74320 – Contrast X-Ray of Bile Ducts 74320

74327 – X-Ray Bile Stone Removal 74327

74328 – X-Ray Bile Duct Endoscopy 74328

74329 – X-Ray for Pancreas Endoscopy 74329

74330 – X-Ray Bile/Pancreas Endoscopy 74330

74340 – X-Ray Guide for GI Tube 74340

74355 – X-Ray Guide, Intestinal Tube 74355

74360 – X-Ray Guide, GI Dilation 74360

74363 – X-Ray, Bile Duct Dilation 74363

74400 – Contrast X-Ray, Urinary Tract 74400

74410 - Contrast X-Ray, Urinary Tract 74410

74415 - Contrast X-Ray, Urinary Tract 74415

74420 - Contrast X-Ray, Urinary Tract 74420

74425 - Contrast X-Ray, Urinary Tract 74425

74430 – Contrast X-Ray, Bladder 74430

74440 – X-Ray, Male Genital Tract 74440

74445 – X-Ray Exam of Penis 74445

74450 – X-Ray, Urethra/Bladder 74450

74455 – X-Ray, Urethra/Bladder 74455

74470 – X-Ray Exam of Kidney Lesion 74470

74475 – X-Ray Control, Cath Insert 74475

74480 – X-Ray Control, Cath Insert 74480

74485 – X-Ray Guide, GU Dilation 74485

74740 – X-Ray, Female Genital Tract 74740

74742 – X-Ray, Fallopian Tube 74742

Dental Services

D0150 – Comprehensive Oral Evaluation – New or Established Patient	D0150
D0272 – Bitewings – Two Radiographic Images	D0272
D0273 – Bitewings – Three Radiographic Images	D0273
D0274 – Bitewings – Four Radiographic Images	D0274
D0220 - Intraoral-periapical first film;	D0220
D0230 - Intraoral-periapical each additional film.	D0230

File details come from the government source that posted it. Updated Nov 14, 2017.