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					                                Ambulatory Surgery Center


             Procedure                                       Pricer   07/01/08
               Code                Short Description         Group      Rate
            10121        Remove foreign body                02         $446.00
            10180        Complex drainage, wound            02         $446.00
            11010        Debride skin, fx                   37         $251.52
            11011        Debride skin/muscle, fx            37         $251.52
            11012        Debride skin/muscle/bone, fx       37         $251.52
            11042        Debride skin/tissue                28         $164.42
            11043        Debride tissue/muscle              28         $164.42
            11044        Debride tissue/muscle/bone         52         $423.10
            11404        Exc tr-ext b9+marg 3.1-4 cm        01         $333.00
            11406        Exc tr-ext b9+marg > 4.0 cm        02         $446.00
            11424        Exc h-f-nk-sp b9+marg 3.1-4        02         $446.00
            11426        Exc h-f-nk-sp b9+marg > 4 cm       02         $446.00
            11444        Exc face-mm b9+marg 3.1-4 cm       01         $333.00
            11446        Exc face-mm b9+marg > 4 cm         02         $446.00
            11450        Removal, sweat gland lesion        02         $446.00
            11451        Removal, sweat gland lesion        02         $446.00
            11462        Removal, sweat gland lesion        02         $446.00
            11463        Removal, sweat gland lesion        02         $446.00
            11470        Removal, sweat gland lesion        02         $446.00
            11471        Removal, sweat gland lesion        02         $446.00
            11604        Exc tr-ext mlg+marg 3.1-4 cm       51         $418.49
            11606        Exc tr-ext mlg+marg > 4 cm         02         $446.00
            11624        Exc h-f-nk-sp mlg+marg 3.1-4       02         $446.00
            11626        Exc h-f-nk-sp mlg+mar > 4 cm       02         $446.00
            11644        Exc face-mm malig+marg 3.1-4       02         $446.00
            11646        Exc face-mm mlg+marg > 4 cm        02         $446.00
            11770        Removal of pilonidal lesion        03         $510.00
            11771        Removal of pilonidal lesion        03         $510.00
            11772        Removal of pilonidal lesion        03         $510.00
            11960        Insert tissue expander(s)          02         $446.00
            11970        Replace tissue expander            03         $510.00
            11971        Remove tissue expander(s)          01         $333.00
            12005        Repair superficial wound(s)        17          $91.24
            12006        Repair superficial wound(s)        17          $91.24
            12007        Repair superficial wound(s)        17          $91.24
            12016        Repair superficial wound(s)        17          $91.24
            12017        Repair superficial wound(s)        17          $91.24
            12018        Repair superficial wound(s)        17          $91.24
            12020        Closure of split wound             17          $91.24
            12021        Closure of split wound             17          $91.24
            12034        Layer closure of wound(s)          17          $91.24
            12035        Layer closure of wound(s)          17          $91.24
            12036        Layer closure of wound(s)          17          $91.24
            12037        Layer closure of wound(s)          42         $323.28
            12044        Layer closure of wound(s)          17          $91.24
            12045        Layer closure of wound(s)          17          $91.24
            12046        Layer closure of wound(s)          17          $91.24
            12047        Layer closure of wound(s)          42         $323.28
            12054        Layer closure of wound(s)          17          $91.24
            12055        Layer closure of wound(s)          17          $91.24


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                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            12056        Layer closure of wound(s)           17          $91.24
            12057        Layer closure of wound(s)           42         $323.28
            13100        Repair of wound or lesion           42         $323.28
            13101        Repair of wound or lesion           42         $323.28
            13102        Repair wound/lesion add-on          17          $91.24
            13120        Repair of wound or lesion           17          $91.24
            13121        Repair of wound or lesion           17          $91.24
            13122        Repair wound/lesion add-on          17          $91.24
            13131        Repair of wound or lesion           17          $91.24
            13132        Repair of wound or lesion           17          $91.24
            13133        Repair wound/lesion add-on          17          $91.24
            13150        Repair of wound or lesion           42         $323.28
            13151        Repair of wound or lesion           42         $323.28
            13152        Repair of wound or lesion           42         $323.28
            13153        Repair wound/lesion add-on          17          $91.24
            13160        Late closure of wound               02         $446.00
            14000        Skin tissue rearrangement           02         $446.00
            14001        Skin tissue rearrangement           03         $510.00
            14020        Skin tissue rearrangement           03         $510.00
            14021        Skin tissue rearrangement           03         $510.00
            14040        Skin tissue rearrangement           02         $446.00
            14041        Skin tissue rearrangement           03         $510.00
            14060        Skin tissue rearrangement           03         $510.00
            14061        Skin tissue rearrangement           03         $510.00
            14300        Skin tissue rearrangement           04         $630.00
            14350        Skin tissue rearrangement           03         $510.00
            15002        Wnd prep, ch/inf, trk/arm/lg        42         $323.28
            15003        Wnd prep, ch/inf addl 100 cm        42         $323.28
            15004        Wnd prep ch/inf, f/n/hf/g           42         $323.28
            15005        Wnd prep, f/n/hf/g, addl cm         42         $323.28
            15040        Harvest cultured skin graft         17          $91.24
            15050        Skin pinch graft                    42         $323.28
            15100        Skin splt grft, trnk/arm/leg        02         $446.00
            15101        Skin splt grft t/a/l, add-on        03         $510.00
            15110        Epidrm autogrft trnk/arm/leg        02         $446.00
            15111        Epidrm autogrft t/a/l add-on        01         $333.00
            15115        Epidrm a-grft face/nck/hf/g         02         $446.00
            15116        Epidrm a-grft f/n/hf/g addl         01         $333.00
            15120        Skn splt a-grft fac/nck/hf/g        02         $446.00
            15121        Skn splt a-grft f/n/hf/g add        03         $510.00
            15130        Derm autograft, trnk/arm/leg        02         $446.00
            15131        Derm autograft t/a/l add-on         01         $333.00
            15135        Derm autograft face/nck/hf/g        02         $446.00
            15136        Derm autograft, f/n/hf/g add        01         $333.00
            15150        Cult epiderm grft t/arm/leg         02         $446.00
            15151        Cult epiderm grft t/a/l addl        01         $333.00
            15152        Cult epiderm graft t/a/l +%         01         $333.00
            15155        Cult epiderm graft, f/n/hf/g        02         $446.00
            15156        Cult epidrm grft f/n/hfg add        01         $333.00
            15157        Cult epiderm grft f/n/hfg +%        01         $333.00


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                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            15200        Skin full graft, trunk              03         $510.00
            15201        Skin full graft trunk add-on        42         $323.28
            15220        Skin full graft sclp/arm/leg        02         $446.00
            15221        Skin full graft add-on              42         $323.28
            15240        Skin full grft face/genit/hf        03         $510.00
            15241        Skin full graft add-on              42         $323.28
            15260        Skin full graft een & lips          02         $446.00
            15261        Skin full graft add-on              42         $323.28
            15300        Apply skinallogrft, t/arm/lg        42         $323.28
            15301        Apply sknallogrft t/a/l addl        42         $323.28
            15320        Apply skin allogrft f/n/hf/g        42         $323.28
            15321        Aply sknallogrft f/n/hfg add        42         $323.28
            15330        Aply acell alogrft t/arm/leg        42         $323.28
            15331        Aply acell grft t/a/l add-on        42         $323.28
            15335        Apply acell graft, f/n/hf/g         42         $323.28
            15336        Aply acell grft f/n/hf/g add        42         $323.28
            15400        Apply skin xenograft, t/a/l         42         $323.28
            15401        Apply skn xenogrft t/a/l add        42         $323.28
            15420        Apply skin xgraft, f/n/hf/g         42         $323.28
            15421        Apply skn xgrft f/n/hf/g add        42         $323.28
            15430        Apply acellular xenograft           42         $323.28
            15431        Apply acellular xgraft add          42         $323.28
            15570        Form skin pedicle flap              03         $510.00
            15572        Form skin pedicle flap              03         $510.00
            15574        Form skin pedicle flap              03         $510.00
            15576        Form skin pedicle flap              03         $510.00
            15600        Skin graft                          03         $510.00
            15610        Skin graft                          03         $510.00
            15620        Skin graft                          04         $630.00
            15630        Skin graft                          03         $510.00
            15650        Transfer skin pedicle flap          05         $717.00
            15731        Forehead flap w/vasc pedicle        03         $510.00
            15732        Muscle-skin graft, head/neck        03         $510.00
            15734        Muscle-skin graft, trunk            03         $510.00
            15736        Muscle-skin graft, arm              03         $510.00
            15738        Muscle-skin graft, leg              03         $510.00
            15740        Island pedicle flap graft           02         $446.00
            15750        Neurovascular pedicle graft         02         $446.00
            15760        Composite skin graft                02         $446.00
            15770        Derma-fat-fascia graft              03         $510.00
            15775        Hair transplant punch grafts        42         $323.28
            15776        Hair transplant punch grafts        42         $323.28
            15820        Revision of lower eyelid            03         $510.00
            15821        Revision of lower eyelid            03         $510.00
            15822        Revision of upper eyelid            03         $510.00
            15823        Revision of upper eyelid            05         $717.00
            15824        Removal of forehead wrinkles        03         $510.00
            15825        Removal of neck wrinkles            03         $510.00
            15826        Removal of brow wrinkles            03         $510.00
            15828        Removal of face wrinkles            03         $510.00


4/22/2012                                  Page 3       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            15829        Removal of skin wrinkles            05         $717.00
            15830        Exc skin abd                        03         $510.00
            15832        Excise excessive skin tissue        03         $510.00
            15833        Excise excessive skin tissue        03         $510.00
            15834        Excise excessive skin tissue        03         $510.00
            15835        Excise excessive skin tissue        42         $323.28
            15836        Excise excessive skin tissue        03         $510.00
            15839        Excise excessive skin tissue        03         $510.00
            15840        Graft for face nerve palsy          04         $630.00
            15841        Graft for face nerve palsy          04         $630.00
            15845        Skin and muscle repair, face        04         $630.00
            15847        Exc skin abd add-on                 03         $510.00
            15876        Suction assisted lipectomy          03         $510.00
            15877        Suction assisted lipectomy          03         $510.00
            15878        Suction assisted lipectomy          03         $510.00
            15879        Suction assisted lipectomy          03         $510.00
            15920        Removal of tail bone ulcer          37         $251.52
            15922        Removal of tail bone ulcer          04         $630.00
            15931        Remove sacrum pressure sore         03         $510.00
            15933        Remove sacrum pressure sore         03         $510.00
            15934        Remove sacrum pressure sore         03         $510.00
            15935        Remove sacrum pressure sore         04         $630.00
            15936        Remove sacrum pressure sore         04         $630.00
            15937        Remove sacrum pressure sore         04         $630.00
            15940        Remove hip pressure sore            03         $510.00
            15941        Remove hip pressure sore            03         $510.00
            15944        Remove hip pressure sore            03         $510.00
            15945        Remove hip pressure sore            04         $630.00
            15946        Remove hip pressure sore            04         $630.00
            15950        Remove thigh pressure sore          03         $510.00
            15951        Remove thigh pressure sore          04         $630.00
            15952        Remove thigh pressure sore          03         $510.00
            15953        Remove thigh pressure sore          04         $630.00
            15956        Remove thigh pressure sore          03         $510.00
            15958        Remove thigh pressure sore          04         $630.00
            16025        Dress/debrid p-thick burn, m        13          $67.11
            16030        Dress/debrid p-thick burn, l        18          $99.83
            19020        Incision of breast lesion           02         $446.00
            19100        Bx breast percut w/o image          34         $240.00
            19101        Biopsy of breast, open              02         $446.00
            19102        Bx breast percut w/image            34         $240.00
            19103        Bx breast percut w/device           48         $395.77
            19110        Nipple exploration                  02         $446.00
            19112        Excise breast duct fistula          03         $510.00
            19120        Removal of breast lesion            03         $510.00
            19125        Excision, breast lesion             03         $510.00
            19126        Excision, addl breast lesion        03         $510.00
            19290        Place needle wire, breast           01         $333.00
            19291        Place needle wire, breast           01         $333.00
            19295        Place breast clip, percut           20         $106.76


4/22/2012                                 Page 4        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            19296        Place po breast cath for rad        09        $1,339.00
            19297        Place breast cath for rad           09        $1,339.00
            19298        Place breast rad tube/caths         09        $1,339.00
            19300        Removal of breast tissue            04          $630.00
            19301        Partical mastectomy                 03          $510.00
            19302        P-mastectomy w/ln removal           07          $995.00
            19303        Mast, simple, complete              04          $630.00
            19304        Mast, subq                          04          $630.00
            19316        Suspension of breast                04          $630.00
            19318        Reduction of large breast           04          $630.00
            19324        Enlarge breast                      04          $630.00
            19325        Enlarge breast with implant         09        $1,339.00
            19328        Removal of breast implant           01          $333.00
            19330        Removal of implant material         01          $333.00
            19340        Immediate breast prosthesis         02          $446.00
            19342        Delayed breast prosthesis           03          $510.00
            19350        Breast reconstruction               04          $630.00
            19355        Correct inverted nipple(s)          04          $630.00
            19357        Breast reconstruction               05          $717.00
            19366        Breast reconstruction               05          $717.00
            19370        Surgery of breast capsule           04          $630.00
            19371        Removal of breast capsule           04          $630.00
            19380        Revise breast reconstruction        05          $717.00
            20005        Incision of deep abscess            02          $446.00
            20200        Muscle biopsy                       02          $446.00
            20205        Deep muscle biopsy                  03          $510.00
            20206        Needle biopsy, muscle               34          $240.00
            20220        Bone biopsy, trocar/needle          37          $251.52
            20225        Bone biopsy, trocar/needle          51          $418.49
            20240        Bone biopsy, excisional             02          $446.00
            20245        Bone biopsy, excisional             03          $510.00
            20250        Open bone biopsy                    03          $510.00
            20251        Open bone biopsy                    03          $510.00
            20525        Removal of foreign body             03          $510.00
            20650        Insert and remove bone pin          03          $510.00
            20670        Removal of support implant          01          $333.00
            20680        Removal of support implant          03          $510.00
            20690        Apply bone fixation device          02          $446.00
            20692        Apply bone fixation device          03          $510.00
            20693        Adjust bone fixation device         03          $510.00
            20694        Remove bone fixation device         01          $333.00
            20900        Removal of bone for graft           03          $510.00
            20902        Removal of bone for graft           04          $630.00
            20910        Remove cartilage for graft          03          $510.00
            20912        Remove cartilage for graft          03          $510.00
            20920        Removal of fascia for graft         04          $630.00
            20922        Removal of fascia for graft         03          $510.00
            20924        Removal of tendon for graft         04          $630.00
            20926        Removal of tissue for graft         04          $630.00
            20975        Electrical bone stimulation         10           $37.51


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                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            21010        Incision of jaw joint               02          $446.00
            21015        Resection of facial tumor           03          $510.00
            21025        Excision of bone, lower jaw         02          $446.00
            21026        Excision of facial bone(s)          02          $446.00
            21029        Contour of face bone lesion         02          $446.00
            21034        Excise max/zygoma mlg tumor         03          $510.00
            21040        Excise mandible lesion              02          $446.00
            21044        Removal of jaw bone lesion          02          $446.00
            21046        Remove mandible cyst complex        02          $446.00
            21047        Excise lwr jaw cyst w/repair        02          $446.00
            21050        Removal of jaw joint                03          $510.00
            21060        Remove jaw joint cartilage          02          $446.00
            21070        Remove coronoid process             03          $510.00
            21100        Maxillofacial fixation              02          $446.00
            21120        Reconstruction of chin              07          $995.00
            21121        Reconstruction of chin              07          $995.00
            21122        Reconstruction of chin              07          $995.00
            21123        Reconstruction of chin              07          $995.00
            21125        Augmentation, lower jaw bone        07          $995.00
            21127        Augmentation, lower jaw bone        09        $1,339.00
            21181        Contour cranial bone lesion         07          $995.00
            21206        Reconstruct upper jaw bone          05          $717.00
            21208        Augmentation of facial bones        07          $995.00
            21209        Reduction of facial bones           05          $717.00
            21210        Face bone graft                     07          $995.00
            21215        Lower jaw bone graft                07          $995.00
            21230        Rib cartilage graft                 07          $995.00
            21235        Ear cartilage graft                 07          $995.00
            21240        Reconstruction of jaw joint         04          $630.00
            21242        Reconstruction of jaw joint         05          $717.00
            21243        Reconstruction of jaw joint         05          $717.00
            21244        Reconstruction of lower jaw         07          $995.00
            21245        Reconstruction of jaw               07          $995.00
            21246        Reconstruction of jaw               07          $995.00
            21248        Reconstruction of jaw               07          $995.00
            21249        Reconstruction of jaw               07          $995.00
            21267        Revise eye sockets                  07          $995.00
            21270        Augmentation, cheek bone            05          $717.00
            21275        Revision, orbitofacial bones        07          $995.00
            21280        Revision of eyelid                  05          $717.00
            21282        Revision of eyelid                  05          $717.00
            21295        Revision of jaw muscle/bone         01          $333.00
            21296        Revision of jaw muscle/bone         01          $333.00
            21310        Treatment of nose fracture          27          $150.72
            21315        Treatment of nose fracture          27          $150.72
            21320        Treatment of nose fracture          02          $446.00
            21325        Treatment of nose fracture          04          $630.00
            21330        Treatment of nose fracture          05          $717.00
            21335        Treatment of nose fracture          07          $995.00
            21336        Treat nasal septal fracture         04          $630.00


4/22/2012                                 Page 6        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            21337        Treat nasal septal fracture         02          $446.00
            21338        Treat nasoethmoid fracture          04          $630.00
            21339        Treat nasoethmoid fracture          05          $717.00
            21340        Treatment of nose fracture          04          $630.00
            21345        Treat nose/jaw fracture             07          $995.00
            21355        Treat cheek bone fracture           03          $510.00
            21356        Treat cheek bone fracture           03          $510.00
            21400        Treat eye socket fracture           02          $446.00
            21401        Treat eye socket fracture           03          $510.00
            21421        Treat mouth roof fracture           04          $630.00
            21445        Treat dental ridge fracture         04          $630.00
            21450        Treat lower jaw fracture            27          $150.72
            21451        Treat lower jaw fracture            53          $464.15
            21452        Treat lower jaw fracture            02          $446.00
            21453        Treat lower jaw fracture            03          $510.00
            21454        Treat lower jaw fracture            05          $717.00
            21461        Treat lower jaw fracture            04          $630.00
            21462        Treat lower jaw fracture            05          $717.00
            21465        Treat lower jaw fracture            04          $630.00
            21480        Reset dislocated jaw                27          $150.72
            21485        Reset dislocated jaw                02          $446.00
            21490        Repair dislocated jaw               03          $510.00
            21497        Interdental wiring                  02          $446.00
            21501        Drain neck/chest lesion             02          $446.00
            21502        Drain chest lesion                  02          $446.00
            21555        Remove lesion, neck/chest           02          $446.00
            21556        Remove lesion, neck/chest           02          $446.00
            21600        Partial removal of rib              02          $446.00
            21610        Partial removal of rib              02          $446.00
            21700        Revision of neck muscle             02          $446.00
            21720        Revision of neck muscle             03          $510.00
            21725        Revision of neck muscle             16           $88.46
            21800        Treatment of rib fracture           19          $103.62
            21805        Treatment of rib fracture           02          $446.00
            21820        Treat sternum fracture              19          $103.62
            21925        Biopsy soft tissue of back          02          $446.00
            21930        Remove lesion, back or flank        02          $446.00
            21935        Remove tumor, back                  03          $510.00
            22305        Treat spine process fracture        19          $103.62
            22310        Treat spine fracture                19          $103.62
            22315        Treat spine fracture                19          $103.62
            22505        Manipulation of spine               02          $446.00
            22520        Percut vertebroplasty thor          09        $1,339.00
            22521        Percut vertebroplasty lumb          09        $1,339.00
            22522        Percut vertebroplasty addÆl         09        $1,339.00
            22900        Remove abdominal wall lesion        04          $630.00
            23000        Removal of calcium deposits         02          $446.00
            23020        Release shoulder joint              02          $446.00
            23030        Drain shoulder lesion               01          $333.00
            23031        Drain shoulder bursa                03          $510.00


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                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            23035        Drain shoulder bone lesion          03         $510.00
            23040        Exploratory shoulder surgery        03         $510.00
            23044        Exploratory shoulder surgery        04         $630.00
            23066        Biopsy shoulder tissues             02         $446.00
            23075        Removal of shoulder lesion          02         $446.00
            23076        Removal of shoulder lesion          02         $446.00
            23077        Remove tumor of shoulder            03         $510.00
            23100        Biopsy of shoulder joint            02         $446.00
            23101        Shoulder joint surgery              07         $995.00
            23105        Remove shoulder joint lining        04         $630.00
            23106        Incision of collarbone joint        04         $630.00
            23107        Explore treat shoulder joint        04         $630.00
            23120        Partial removal, collar bone        05         $717.00
            23125        Removal of collar bone              05         $717.00
            23130        Remove shoulder bone, part          05         $717.00
            23140        Removal of bone lesion              04         $630.00
            23145        Removal of bone lesion              05         $717.00
            23146        Removal of bone lesion              05         $717.00
            23150        Removal of humerus lesion           04         $630.00
            23155        Removal of humerus lesion           05         $717.00
            23156        Removal of humerus lesion           05         $717.00
            23170        Remove collar bone lesion           02         $446.00
            23172        Remove shoulder blade lesion        02         $446.00
            23174        Remove humerus lesion               02         $446.00
            23180        Remove collar bone lesion           04         $630.00
            23182        Remove shoulder blade lesion        04         $630.00
            23184        Remove humerus lesion               04         $630.00
            23190        Partial removal of scapula          04         $630.00
            23195        Removal of head of humerus          05         $717.00
            23330        Remove shoulder foreign body        01         $333.00
            23331        Remove shoulder foreign body        01         $333.00
            23395        Muscle transfer,shoulder/arm        05         $717.00
            23397        Muscle transfers                    07         $995.00
            23400        Fixation of shoulder blade          07         $995.00
            23405        Incision of tendon & muscle         02         $446.00
            23406        Incise tendon(s) & muscle(s)        02         $446.00
            23410        Repair rotator cuff, acute          05         $717.00
            23412        Repair rotator cuff, chronic        07         $995.00
            23415        Release of shoulder ligament        05         $717.00
            23420        Repair of shoulder                  07         $995.00
            23430        Repair biceps tendon                04         $630.00
            23440        Remove/transplant tendon            04         $630.00
            23450        Repair shoulder capsule             05         $717.00
            23455        Repair shoulder capsule             07         $995.00
            23460        Repair shoulder capsule             05         $717.00
            23462        Repair shoulder capsule             07         $995.00
            23465        Repair shoulder capsule             05         $717.00
            23466        Repair shoulder capsule             07         $995.00
            23480        Revision of collar bone             04         $630.00
            23485        Revision of collar bone             07         $995.00


4/22/2012                                 Page 8        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            23490        Reinforce clavicle                  03         $510.00
            23491        Reinforce shoulder bones            03         $510.00
            23500        Treat clavicle fracture             19         $103.62
            23505        Treat clavicle fracture             19         $103.62
            23515        Treat clavicle fracture             03         $510.00
            23520        Treat clavicle dislocation          19         $103.62
            23525        Treat clavicle dislocation          19         $103.62
            23530        Treat clavicle dislocation          03         $510.00
            23532        Treat clavicle dislocation          04         $630.00
            23540        Treat clavicle dislocation          19         $103.62
            23545        Treat clavicle dislocation          19         $103.62
            23550        Treat clavicle dislocation          03         $510.00
            23552        Treat clavicle dislocation          04         $630.00
            23570        Treat shoulder blade fx             19         $103.62
            23575        Treat shoulder blade fx             19         $103.62
            23585        Treat scapula fracture              03         $510.00
            23605        Treat humerus fracture              19         $103.62
            23615        Treat humerus fracture              04         $630.00
            23616        Treat humerus fracture              04         $630.00
            23625        Treat humerus fracture              19         $103.62
            23630        Treat humerus fracture              05         $717.00
            23650        Treat shoulder dislocation          19         $103.62
            23655        Treat shoulder dislocation          01         $333.00
            23660        Treat shoulder dislocation          03         $510.00
            23665        Treat dislocation/fracture          19         $103.62
            23670        Treat dislocation/fracture          03         $510.00
            23675        Treat dislocation/fracture          19         $103.62
            23680        Treat dislocation/fracture          03         $510.00
            23700        Fixation of shoulder                01         $333.00
            23800        Fusion of shoulder joint            04         $630.00
            23802        Fusion of shoulder joint            07         $995.00
            23921        Amputation follow-up surgery        42         $323.28
            23930        Drainage of arm lesion              01         $333.00
            23931        Drainage of arm bursa               02         $446.00
            23935        Drain arm/elbow bone lesion         02         $446.00
            24000        Exploratory elbow surgery           04         $630.00
            24006        Release elbow joint                 04         $630.00
            24066        Biopsy arm/elbow soft tissue        02         $446.00
            24075        Remove arm/elbow lesion             02         $446.00
            24076        Remove arm/elbow lesion             02         $446.00
            24077        Remove tumor of arm/elbow           03         $510.00
            24100        Biopsy elbow joint lining           01         $333.00
            24101        Explore/treat elbow joint           04         $630.00
            24102        Remove elbow joint lining           04         $630.00
            24105        Removal of elbow bursa              03         $510.00
            24110        Remove humerus lesion               02         $446.00
            24115        Remove/graft bone lesion            03         $510.00
            24116        Remove/graft bone lesion            03         $510.00
            24120        Remove elbow lesion                 03         $510.00
            24125        Remove/graft bone lesion            03         $510.00


4/22/2012                                  Page 9       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            24126        Remove/graft bone lesion            03         $510.00
            24130        Removal of head of radius           03         $510.00
            24134        Removal of arm bone lesion          02         $446.00
            24136        Remove radius bone lesion           02         $446.00
            24138        Remove elbow bone lesion            02         $446.00
            24140        Partial removal of arm bone         03         $510.00
            24145        Partial removal of radius           03         $510.00
            24147        Partial removal of elbow            02         $446.00
            24155        Removal of elbow joint              03         $510.00
            24160        Remove elbow joint implant          02         $446.00
            24164        Remove radius head implant          03         $510.00
            24201        Removal of arm foreign body         02         $446.00
            24301        Muscle/tendon transfer              04         $630.00
            24305        Arm tendon lengthening              04         $630.00
            24310        Revision of arm tendon              03         $510.00
            24320        Repair of arm tendon                03         $510.00
            24330        Revision of arm muscles             03         $510.00
            24331        Revision of arm muscles             03         $510.00
            24340        Repair of biceps tendon             03         $510.00
            24341        Repair arm tendon/muscle            03         $510.00
            24342        Repair of ruptured tendon           03         $510.00
            24345        Repr elbw med ligmnt w/tissu        02         $446.00
            24350        Repair of tennis elbow              03         $510.00
            24351        Repair of tennis elbow              03         $510.00
            24352        Repair of tennis elbow              03         $510.00
            24354        Repair of tennis elbow              03         $510.00
            24356        Revision of tennis elbow            03         $510.00
            24360        Reconstruct elbow joint             05         $717.00
            24361        Reconstruct elbow joint             05         $717.00
            24362        Reconstruct elbow joint             05         $717.00
            24363        Replace elbow joint                 07         $995.00
            24365        Reconstruct head of radius          05         $717.00
            24366        Reconstruct head of radius          05         $717.00
            24400        Revision of humerus                 04         $630.00
            24410        Revision of humerus                 04         $630.00
            24420        Revision of humerus                 03         $510.00
            24430        Repair of humerus                   03         $510.00
            24435        Repair humerus with graft           04         $630.00
            24470        Revision of elbow joint             03         $510.00
            24495        Decompression of forearm            02         $446.00
            24498        Reinforce humerus                   03         $510.00
            24500        Treat humerus fracture              19         $103.62
            24505        Treat humerus fracture              19         $103.62
            24515        Treat humerus fracture              04         $630.00
            24516        Treat humerus fracture              04         $630.00
            24530        Treat humerus fracture              19         $103.62
            24535        Treat humerus fracture              19         $103.62
            24538        Treat humerus fracture              02         $446.00
            24545        Treat humerus fracture              04         $630.00
            24546        Treat humerus fracture              05         $717.00


4/22/2012                                 Page 10       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            24560        Treat humerus fracture              19         $103.62
            24565        Treat humerus fracture              19         $103.62
            24566        Treat humerus fracture              02         $446.00
            24575        Treat humerus fracture              03         $510.00
            24576        Treat humerus fracture              19         $103.62
            24577        Treat humerus fracture              19         $103.62
            24579        Treat humerus fracture              03         $510.00
            24582        Treat humerus fracture              02         $446.00
            24586        Treat elbow fracture                04         $630.00
            24587        Treat elbow fracture                05         $717.00
            24600        Treat elbow dislocation             19         $103.62
            24605        Treat elbow dislocation             02         $446.00
            24615        Treat elbow dislocation             03         $510.00
            24620        Treat elbow fracture                19         $103.62
            24635        Treat elbow fracture                03         $510.00
            24655        Treat radius fracture               19         $103.62
            24665        Treat radius fracture               04         $630.00
            24666        Treat radius fracture               04         $630.00
            24670        Treat ulnar fracture                19         $103.62
            24675        Treat ulnar fracture                19         $103.62
            24685        Treat ulnar fracture                03         $510.00
            24800        Fusion of elbow joint               04         $630.00
            24802        Fusion/graft of elbow joint         05         $717.00
            24925        Amputation follow-up surgery        03         $510.00
            25000        Incision of tendon sheath           03         $510.00
            25020        Decompress forearm 1 space          03         $510.00
            25023        Decompress forearm 1 space          03         $510.00
            25024        Decompress forearm 2 spaces         03         $510.00
            25025        Decompress forearm 2 spaces         03         $510.00
            25028        Drainage of forearm lesion          01         $333.00
            25031        Drainage of forearm bursa           02         $446.00
            25035        Treat forearm bone lesion           02         $446.00
            25040        Explore/treat wrist joint           05         $717.00
            25066        Biopsy forearm soft tissues         02         $446.00
            25075        Removal forearm lesion subcu        02         $446.00
            25076        Removal forearm lesion deep         03         $510.00
            25077        Remove tumor, forearm/wrist         03         $510.00
            25085        Incision of wrist capsule           03         $510.00
            25100        Biopsy of wrist joint               02         $446.00
            25101        Explore/treat wrist joint           03         $510.00
            25105        Remove wrist joint lining           04         $630.00
            25107        Remove wrist joint cartilage        03         $510.00
            25110        Remove wrist tendon lesion          03         $510.00
            25111        Remove wrist tendon lesion          03         $510.00
            25112        Reremove wrist tendon lesion        04         $630.00
            25115        Remove wrist/forearm lesion         04         $630.00
            25116        Remove wrist/forearm lesion         04         $630.00
            25118        Excise wrist tendon sheath          02         $446.00
            25119        Partial removal of ulna             03         $510.00
            25120        Removal of forearm lesion           03         $510.00


4/22/2012                                Page 11        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            25125        Remove/graft forearm lesion         03         $510.00
            25126        Remove/graft forearm lesion         03         $510.00
            25130        Removal of wrist lesion             03         $510.00
            25135        Remove & graft wrist lesion         03         $510.00
            25136        Remove & graft wrist lesion         03         $510.00
            25145        Remove forearm bone lesion          02         $446.00
            25150        Partial removal of ulna             02         $446.00
            25151        Partial removal of radius           02         $446.00
            25210        Removal of wrist bone               03         $510.00
            25215        Removal of wrist bones              04         $630.00
            25230        Partial removal of radius           04         $630.00
            25240        Partial removal of ulna             04         $630.00
            25248        Remove forearm foreign body         02         $446.00
            25250        Removal of wrist prosthesis         01         $333.00
            25251        Removal of wrist prosthesis         01         $333.00
            25260        Repair forearm tendon/muscle        04         $630.00
            25263        Repair forearm tendon/muscle        02         $446.00
            25265        Repair forearm tendon/muscle        03         $510.00
            25270        Repair forearm tendon/muscle        04         $630.00
            25272        Repair forearm tendon/muscle        03         $510.00
            25274        Repair forearm tendon/muscle        04         $630.00
            25275        Repair forearm tendon sheath        04         $630.00
            25280        Revise wrist/forearm tendon         04         $630.00
            25290        Incise wrist/forearm tendon         03         $510.00
            25295        Release wrist/forearm tendon        03         $510.00
            25300        Fusion of tendons at wrist          03         $510.00
            25301        Fusion of tendons at wrist          03         $510.00
            25310        Transplant forearm tendon           03         $510.00
            25312        Transplant forearm tendon           04         $630.00
            25315        Revise palsy hand tendon(s)         03         $510.00
            25316        Revise palsy hand tendon(s)         03         $510.00
            25320        Repair/revise wrist joint           03         $510.00
            25332        Revise wrist joint                  05         $717.00
            25335        Realignment of hand                 03         $510.00
            25337        Reconstruct ulna/radioulnar         05         $717.00
            25350        Revision of radius                  03         $510.00
            25355        Revision of radius                  03         $510.00
            25360        Revision of ulna                    03         $510.00
            25365        Revise radius & ulna                03         $510.00
            25370        Revise radius or ulna               03         $510.00
            25375        Revise radius & ulna                04         $630.00
            25390        Shorten radius or ulna              03         $510.00
            25391        Lengthen radius or ulna             04         $630.00
            25392        Shorten radius & ulna               03         $510.00
            25393        Lengthen radius & ulna              04         $630.00
            25400        Repair radius or ulna               03         $510.00
            25405        Repair/graft radius or ulna         04         $630.00
            25415        Repair radius & ulna                03         $510.00
            25420        Repair/graft radius & ulna          04         $630.00
            25425        Repair/graft radius or ulna         03         $510.00


4/22/2012                                 Page 12       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            25426        Repair/graft radius & ulna          04         $630.00
            25440        Repair/graft wrist bone             04         $630.00
            25441        Reconstruct wrist joint             05         $717.00
            25442        Reconstruct wrist joint             05         $717.00
            25443        Reconstruct wrist joint             05         $717.00
            25444        Reconstruct wrist joint             05         $717.00
            25445        Reconstruct wrist joint             05         $717.00
            25446        Wrist replacement                   07         $995.00
            25447        Repair wrist joint(s)               05         $717.00
            25449        Remove wrist joint implant          05         $717.00
            25450        Revision of wrist joint             03         $510.00
            25455        Revision of wrist joint             03         $510.00
            25490        Reinforce radius                    03         $510.00
            25491        Reinforce ulna                      03         $510.00
            25492        Reinforce radius and ulna           03         $510.00
            25505        Treat fracture of radius            19         $103.62
            25515        Treat fracture of radius            03         $510.00
            25520        Treat fracture of radius            19         $103.62
            25525        Treat fracture of radius            04         $630.00
            25526        Treat fracture of radius            05         $717.00
            25535        Treat fracture of ulna              19         $103.62
            25545        Treat fracture of ulna              03         $510.00
            25565        Treat fracture radius & ulna        19         $103.62
            25574        Treat fracture radius & ulna        03         $510.00
            25575        Treat fracture radius/ulna          03         $510.00
            25605        Treat fracture radius/ulna          19         $103.62
            25606        Treat fx distal radial              03         $510.00
            25607        Treat fx rad extra-articul          05         $717.00
            25608        Treat fx rad intra-articul          05         $717.00
            25609        Treat fx radial 3+ frag             05         $717.00
            25624        Treat wrist bone fracture           19         $103.62
            25628        Treat wrist bone fracture           03         $510.00
            25635        Treat wrist bone fracture           19         $103.62
            25645        Treat wrist bone fracture           03         $510.00
            25660        Treat wrist dislocation             19         $103.62
            25670        Treat wrist dislocation             03         $510.00
            25671        Pin radioulnar dislocation          01         $333.00
            25675        Treat wrist dislocation             19         $103.62
            25676        Treat wrist dislocation             02         $446.00
            25680        Treat wrist fracture                19         $103.62
            25685        Treat wrist fracture                03         $510.00
            25690        Treat wrist dislocation             19         $103.62
            25695        Treat wrist dislocation             02         $446.00
            25800        Fusion of wrist joint               04         $630.00
            25805        Fusion/graft of wrist joint         05         $717.00
            25810        Fusion/graft of wrist joint         05         $717.00
            25820        Fusion of hand bones                04         $630.00
            25825        Fuse hand bones with graft          05         $717.00
            25830        Fusion, radioulnar jnt/ulna         05         $717.00
            25907        Amputation follow-up surgery        03         $510.00


4/22/2012                                 Page 13       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            25922        Amputate hand at wrist              03         $510.00
            25929        Amputation follow-up surgery        03         $510.00
            26011        Drainage of finger abscess          01         $333.00
            26020        Drain hand tendon sheath            02         $446.00
            26025        Drainage of palm bursa              01         $333.00
            26030        Drainage of palm bursa(s)           02         $446.00
            26034        Treat hand bone lesion              02         $446.00
            26040        Release palm contracture            04         $630.00
            26045        Release palm contracture            03         $510.00
            26055        Incise finger tendon sheath         02         $446.00
            26060        Incision of finger tendon           02         $446.00
            26070        Explore/treat hand joint            02         $446.00
            26075        Explore/treat finger joint          04         $630.00
            26080        Explore/treat finger joint          04         $630.00
            26100        Biopsy hand joint lining            02         $446.00
            26105        Biopsy finger joint lining          01         $333.00
            26110        Biopsy finger joint lining          01         $333.00
            26115        Removal hand lesion subcut          02         $446.00
            26116        Removal hand lesion, deep           02         $446.00
            26117        Remove tumor, hand/finger           03         $510.00
            26121        Release palm contracture            04         $630.00
            26123        Release palm contracture            04         $630.00
            26125        Release palm contracture            04         $630.00
            26130        Remove wrist joint lining           03         $510.00
            26135        Revise finger joint, each           04         $630.00
            26140        Revise finger joint, each           02         $446.00
            26145        Tendon excision, palm/finger        03         $510.00
            26160        Remove tendon sheath lesion         03         $510.00
            26170        Removal of palm tendon, each        03         $510.00
            26180        Removal of finger tendon            03         $510.00
            26185        Remove finger bone                  04         $630.00
            26200        Remove hand bone lesion             02         $446.00
            26205        Remove/graft bone lesion            03         $510.00
            26210        Removal of finger lesion            02         $446.00
            26215        Remove/graft finger lesion          03         $510.00
            26230        Partial removal of hand bone        54         $992.95
            26235        Partial removal, finger bone        03         $510.00
            26236        Partial removal, finger bone        03         $510.00
            26250        Extensive hand surgery              03         $510.00
            26255        Extensive hand surgery              03         $510.00
            26260        Extensive finger surgery            03         $510.00
            26261        Extensive finger surgery            03         $510.00
            26262        Partial removal of finger           02         $446.00
            26320        Removal of implant from hand        02         $446.00
            26350        Repair finger/hand tendon           01         $333.00
            26352        Repair/graft hand tendon            04         $630.00
            26356        Repair finger/hand tendon           04         $630.00
            26357        Repair finger/hand tendon           04         $630.00
            26358        Repair/graft hand tendon            04         $630.00
            26370        Repair finger/hand tendon           04         $630.00


4/22/2012                                Page 14        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            26372        Repair/graft hand tendon            04         $630.00
            26373        Repair finger/hand tendon           03         $510.00
            26390        Revise hand/finger tendon           04         $630.00
            26392        Repair/graft hand tendon            03         $510.00
            26410        Repair hand tendon                  03         $510.00
            26412        Repair/graft hand tendon            03         $510.00
            26415        Excision, hand/finger tendon        04         $630.00
            26416        Graft hand or finger tendon         03         $510.00
            26418        Repair finger tendon                04         $630.00
            26420        Repair/graft finger tendon          04         $630.00
            26426        Repair finger/hand tendon           03         $510.00
            26428        Repair/graft finger tendon          03         $510.00
            26432        Repair finger tendon                03         $510.00
            26433        Repair finger tendon                03         $510.00
            26434        Repair/graft finger tendon          03         $510.00
            26437        Realignment of tendons              03         $510.00
            26440        Release palm/finger tendon          03         $510.00
            26442        Release palm & finger tendon        03         $510.00
            26445        Release hand/finger tendon          03         $510.00
            26449        Release forearm/hand tendon         03         $510.00
            26450        Incision of palm tendon             03         $510.00
            26455        Incision of finger tendon           03         $510.00
            26460        Incise hand/finger tendon           03         $510.00
            26471        Fusion of finger tendons            02         $446.00
            26474        Fusion of finger tendons            02         $446.00
            26476        Tendon lengthening                  01         $333.00
            26477        Tendon shortening                   01         $333.00
            26478        Lengthening of hand tendon          01         $333.00
            26479        Shortening of hand tendon           01         $333.00
            26480        Transplant hand tendon              03         $510.00
            26483        Transplant/graft hand tendon        03         $510.00
            26485        Transplant palm tendon              02         $446.00
            26489        Transplant/graft palm tendon        03         $510.00
            26490        Revise thumb tendon                 03         $510.00
            26492        Tendon transfer with graft          03         $510.00
            26494        Hand tendon/muscle transfer         03         $510.00
            26496        Revise thumb tendon                 03         $510.00
            26497        Finger tendon transfer              03         $510.00
            26498        Finger tendon transfer              04         $630.00
            26499        Revision of finger                  03         $510.00
            26500        Hand tendon reconstruction          04         $630.00
            26502        Hand tendon reconstruction          04         $630.00
            26508        Release thumb contracture           03         $510.00
            26510        Thumb tendon transfer               03         $510.00
            26516        Fusion of knuckle joint             01         $333.00
            26517        Fusion of knuckle joints            03         $510.00
            26518        Fusion of knuckle joints            03         $510.00
            26520        Release knuckle contracture         03         $510.00
            26525        Release finger contracture          03         $510.00
            26530        Revise knuckle joint                03         $510.00


4/22/2012                                 Page 15       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            26531        Revise knuckle with implant         07         $995.00
            26535        Revise finger joint                 05         $717.00
            26536        Revise/implant finger joint         05         $717.00
            26540        Repair hand joint                   04         $630.00
            26541        Repair hand joint with graft        07         $995.00
            26542        Repair hand joint with graft        04         $630.00
            26545        Reconstruct finger joint            04         $630.00
            26546        Repair nonunion hand                04         $630.00
            26548        Reconstruct finger joint            04         $630.00
            26550        Construct thumb replacement         02         $446.00
            26555        Positional change of finger         03         $510.00
            26560        Repair of web finger                02         $446.00
            26561        Repair of web finger                03         $510.00
            26562        Repair of web finger                04         $630.00
            26565        Correct metacarpal flaw             05         $717.00
            26567        Correct finger deformity            05         $717.00
            26568        Lengthen metacarpal/finger          03         $510.00
            26580        Repair hand deformity               05         $717.00
            26587        Reconstruct extra finger            05         $717.00
            26590        Repair finger deformity             05         $717.00
            26591        Repair muscles of hand              03         $510.00
            26593        Release muscles of hand             03         $510.00
            26596        Excision constricting tissue        02         $446.00
            26605        Treat metacarpal fracture           19         $103.62
            26607        Treat metacarpal fracture           19         $103.62
            26608        Treat metacarpal fracture           04         $630.00
            26615        Treat metacarpal fracture           04         $630.00
            26645        Treat thumb fracture                19         $103.62
            26650        Treat thumb fracture                02         $446.00
            26665        Treat thumb fracture                04         $630.00
            26675        Treat hand dislocation              19         $103.62
            26676        Pin hand dislocation                02         $446.00
            26685        Treat hand dislocation              03         $510.00
            26686        Treat hand dislocation              03         $510.00
            26705        Treat knuckle dislocation           19         $103.62
            26706        Pin knuckle dislocation             19         $103.62
            26715        Treat knuckle dislocation           04         $630.00
            26727        Treat finger fracture, each         07         $995.00
            26735        Treat finger fracture, each         04         $630.00
            26742        Treat finger fracture, each         19         $103.62
            26746        Treat finger fracture, each         05         $717.00
            26756        Pin finger fracture, each           02         $446.00
            26765        Treat finger fracture, each         04         $630.00
            26776        Pin finger dislocation              02         $446.00
            26785        Treat finger dislocation            02         $446.00
            26820        Thumb fusion with graft             05         $717.00
            26841        Fusion of thumb                     04         $630.00
            26842        Thumb fusion with graft             04         $630.00
            26843        Fusion of hand joint                03         $510.00
            26844        Fusion/graft of hand joint          03         $510.00


4/22/2012                                 Page 16       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            26850        Fusion of knuckle                   04         $630.00
            26852        Fusion of knuckle with graft        04         $630.00
            26860        Fusion of finger joint              03         $510.00
            26861        Fusion of finger jnt, add-on        02         $446.00
            26862        Fusion/graft of finger joint        04         $630.00
            26863        Fuse/graft added joint              03         $510.00
            26910        Amputate metacarpal bone            03         $510.00
            26951        Amputation of finger/thumb          02         $446.00
            26952        Amputation of finger/thumb          04         $630.00
            26990        Drainage of pelvis lesion           01         $333.00
            26991        Drainage of pelvis bursa            01         $333.00
            27000        Incision of hip tendon              02         $446.00
            27001        Incision of hip tendon              03         $510.00
            27003        Incision of hip tendon              03         $510.00
            27033        Exploration of hip joint            03         $510.00
            27035        Denervation of hip joint            04         $630.00
            27040        Biopsy of soft tissues              01         $333.00
            27041        Biopsy of soft tissues              51         $418.49
            27047        Remove hip/pelvis lesion            02         $446.00
            27048        Remove hip/pelvis lesion            03         $510.00
            27049        Remove tumor, hip/pelvis            03         $510.00
            27050        Biopsy of sacroiliac joint          03         $510.00
            27052        Biopsy of hip joint                 03         $510.00
            27060        Removal of ischial bursa            05         $717.00
            27062        Remove femur lesion/bursa           05         $717.00
            27065        Removal of hip bone lesion          05         $717.00
            27066        Removal of hip bone lesion          05         $717.00
            27067        Remove/graft hip bone lesion        05         $717.00
            27080        Removal of tail bone                02         $446.00
            27086        Remove hip foreign body             01         $333.00
            27087        Remove hip foreign body             03         $510.00
            27097        Revision of hip tendon              03         $510.00
            27098        Transfer tendon to pelvis           03         $510.00
            27100        Transfer of abdominal muscle        04         $630.00
            27105        Transfer of spinal muscle           04         $630.00
            27110        Transfer of iliopsoas muscle        04         $630.00
            27111        Transfer of iliopsoas muscle        04         $630.00
            27193        Treat pelvic ring fracture          19         $103.62
            27194        Treat pelvic ring fracture          02         $446.00
            27202        Treat tail bone fracture            02         $446.00
            27230        Treat thigh fracture                19         $103.62
            27238        Treat thigh fracture                19         $103.62
            27246        Treat thigh fracture                19         $103.62
            27250        Treat hip dislocation               19         $103.62
            27252        Treat hip dislocation               02         $446.00
            27257        Treat hip dislocation               03         $510.00
            27265        Treat hip dislocation               19         $103.62
            27266        Treat hip dislocation               02         $446.00
            27275        Manipulation of hip joint           02         $446.00
            27301        Drain thigh/knee lesion             03         $510.00


4/22/2012                                 Page 17       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            27305        Incise thigh tendon & fascia        02         $446.00
            27306        Incision of thigh tendon            03         $510.00
            27307        Incision of thigh tendons           03         $510.00
            27310        Exploration of knee joint           04         $630.00
            27323        Biopsy, thigh soft tissues          01         $333.00
            27324        Biopsy, thigh soft tissues          01         $333.00
            27325        Neurectomy, hamstring               02         $446.00
            27326        Neurectomy, popliteal               02         $446.00
            27327        Removal of thigh lesion             02         $446.00
            27328        Removal of thigh lesion             03         $510.00
            27329        Remove tumor, thigh/knee            04         $630.00
            27330        Biopsy, knee joint lining           04         $630.00
            27331        Explore/treat knee joint            04         $630.00
            27332        Removal of knee cartilage           04         $630.00
            27333        Removal of knee cartilage           04         $630.00
            27334        Remove knee joint lining            04         $630.00
            27335        Remove knee joint lining            04         $630.00
            27340        Removal of kneecap bursa            03         $510.00
            27345        Removal of knee cyst                04         $630.00
            27347        Remove knee cyst                    04         $630.00
            27350        Removal of kneecap                  04         $630.00
            27355        Remove femur lesion                 03         $510.00
            27356        Remove femur lesion/graft           04         $630.00
            27357        Remove femur lesion/graft           05         $717.00
            27358        Remove femur lesion/fixation        05         $717.00
            27360        Partial removal, leg bone(s)        05         $717.00
            27372        Removal of foreign body             07         $995.00
            27380        Repair of kneecap tendon            01         $333.00
            27381        Repair/graft kneecap tendon         03         $510.00
            27385        Repair of thigh muscle              03         $510.00
            27386        Repair/graft of thigh muscle        03         $510.00
            27390        Incision of thigh tendon            01         $333.00
            27391        Incision of thigh tendons           02         $446.00
            27392        Incision of thigh tendons           03         $510.00
            27393        Lengthening of thigh tendon         02         $446.00
            27394        Lengthening of thigh tendons        03         $510.00
            27395        Lengthening of thigh tendons        03         $510.00
            27396        Transplant of thigh tendon          03         $510.00
            27397        Transplants of thigh tendons        03         $510.00
            27400        Revise thigh muscles/tendons        03         $510.00
            27403        Repair of knee cartilage            04         $630.00
            27405        Repair of knee ligament             04         $630.00
            27407        Repair of knee ligament             04         $630.00
            27409        Repair of knee ligaments            04         $630.00
            27418        Repair degenerated kneecap          03         $510.00
            27420        Revision of unstable kneecap        03         $510.00
            27422        Revision of unstable kneecap        07         $995.00
            27424        Revision/removal of kneecap         03         $510.00
            27425        Lat retinacular release open        07         $995.00
            27427        Reconstruction, knee                03         $510.00


4/22/2012                                 Page 18       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            27428        Reconstruction, knee                04         $630.00
            27429        Reconstruction, knee                04         $630.00
            27430        Revision of thigh muscles           04         $630.00
            27435        Incision of knee joint              04         $630.00
            27437        Revise kneecap                      04         $630.00
            27438        Revise kneecap with implant         05         $717.00
            27441        Revision of knee joint              05         $717.00
            27442        Revision of knee joint              05         $717.00
            27443        Revision of knee joint              05         $717.00
            27496        Decompression of thigh/knee         05         $717.00
            27497        Decompression of thigh/knee         03         $510.00
            27498        Decompression of thigh/knee         03         $510.00
            27499        Decompression of thigh/knee         03         $510.00
            27500        Treatment of thigh fracture         19         $103.62
            27501        Treatment of thigh fracture         19         $103.62
            27502        Treatment of thigh fracture         19         $103.62
            27503        Treatment of thigh fracture         19         $103.62
            27508        Treatment of thigh fracture         19         $103.62
            27509        Treatment of thigh fracture         03         $510.00
            27510        Treatment of thigh fracture         19         $103.62
            27516        Treat thigh fx growth plate         19         $103.62
            27517        Treat thigh fx growth plate         19         $103.62
            27520        Treat kneecap fracture              19         $103.62
            27530        Treat knee fracture                 19         $103.62
            27532        Treat knee fracture                 19         $103.62
            27538        Treat knee fracture(s)              19         $103.62
            27550        Treat knee dislocation              19         $103.62
            27552        Treat knee dislocation              01         $333.00
            27560        Treat kneecap dislocation           19         $103.62
            27562        Treat kneecap dislocation           01         $333.00
            27566        Treat kneecap dislocation           02         $446.00
            27570        Fixation of knee joint              01         $333.00
            27594        Amputation follow-up surgery        03         $510.00
            27600        Decompression of lower leg          03         $510.00
            27601        Decompression of lower leg          03         $510.00
            27602        Decompression of lower leg          03         $510.00
            27603        Drain lower leg lesion              02         $446.00
            27604        Drain lower leg bursa               02         $446.00
            27605        Incision of achilles tendon         01         $333.00
            27606        Incision of achilles tendon         01         $333.00
            27607        Treat lower leg bone lesion         02         $446.00
            27610        Explore/treat ankle joint           02         $446.00
            27612        Exploration of ankle joint          03         $510.00
            27614        Biopsy lower leg soft tissue        02         $446.00
            27615        Remove tumor, lower leg             03         $510.00
            27618        Remove lower leg lesion             02         $446.00
            27619        Remove lower leg lesion             03         $510.00
            27620        Explore/treat ankle joint           04         $630.00
            27625        Remove ankle joint lining           04         $630.00
            27626        Remove ankle joint lining           04         $630.00


4/22/2012                                 Page 19       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            27630        Removal of tendon lesion            03         $510.00
            27635        Remove lower leg bone lesion        03         $510.00
            27637        Remove/graft leg bone lesion        03         $510.00
            27638        Remove/graft leg bone lesion        03         $510.00
            27640        Partial removal of tibia            02         $446.00
            27641        Partial removal of fibula           02         $446.00
            27647        Extensive ankle/heel surgery        03         $510.00
            27650        Repair achilles tendon              03         $510.00
            27652        Repair/graft achilles tendon        03         $510.00
            27654        Repair of achilles tendon           03         $510.00
            27656        Repair leg fascia defect            02         $446.00
            27658        Repair of leg tendon, each          01         $333.00
            27659        Repair of leg tendon, each          02         $446.00
            27664        Repair of leg tendon, each          02         $446.00
            27665        Repair of leg tendon, each          02         $446.00
            27675        Repair lower leg tendons            02         $446.00
            27676        Repair lower leg tendons            03         $510.00
            27680        Release of lower leg tendon         03         $510.00
            27681        Release of lower leg tendons        02         $446.00
            27685        Revision of lower leg tendon        03         $510.00
            27686        Revise lower leg tendons            03         $510.00
            27687        Revision of calf tendon             03         $510.00
            27690        Revise lower leg tendon             04         $630.00
            27691        Revise lower leg tendon             04         $630.00
            27692        Revise additional leg tendon        03         $510.00
            27695        Repair of ankle ligament            02         $446.00
            27696        Repair of ankle ligaments           02         $446.00
            27698        Repair of ankle ligament            02         $446.00
            27700        Revision of ankle joint             05         $717.00
            27704        Removal of ankle implant            02         $446.00
            27705        Incision of tibia                   02         $446.00
            27707        Incision of fibula                  02         $446.00
            27709        Incision of tibia & fibula          02         $446.00
            27730        Repair of tibia epiphysis           02         $446.00
            27732        Repair of fibula epiphysis          02         $446.00
            27734        Repair lower leg epiphyses          02         $446.00
            27740        Repair of leg epiphyses             02         $446.00
            27742        Repair of leg epiphyses             02         $446.00
            27745        Reinforce tibia                     03         $510.00
            27750        Treatment of tibia fracture         19         $103.62
            27752        Treatment of tibia fracture         19         $103.62
            27756        Treatment of tibia fracture         03         $510.00
            27758        Treatment of tibia fracture         04         $630.00
            27759        Treatment of tibia fracture         04         $630.00
            27760        Treatment of ankle fracture         19         $103.62
            27762        Treatment of ankle fracture         19         $103.62
            27766        Treatment of ankle fracture         03         $510.00
            27780        Treatment of fibula fracture        19         $103.62
            27781        Treatment of fibula fracture        19         $103.62
            27784        Treatment of fibula fracture        03         $510.00


4/22/2012                                 Page 20       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            27786        Treatment of ankle fracture         19         $103.62
            27788        Treatment of ankle fracture         19         $103.62
            27792        Treatment of ankle fracture         03         $510.00
            27808        Treatment of ankle fracture         19         $103.62
            27810        Treatment of ankle fracture         19         $103.62
            27814        Treatment of ankle fracture         03         $510.00
            27816        Treatment of ankle fracture         19         $103.62
            27818        Treatment of ankle fracture         19         $103.62
            27822        Treatment of ankle fracture         03         $510.00
            27823        Treatment of ankle fracture         03         $510.00
            27824        Treat lower leg fracture            19         $103.62
            27825        Treat lower leg fracture            19         $103.62
            27826        Treat lower leg fracture            03         $510.00
            27827        Treat lower leg fracture            03         $510.00
            27828        Treat lower leg fracture            04         $630.00
            27829        Treat lower leg joint               02         $446.00
            27830        Treat lower leg dislocation         19         $103.62
            27831        Treat lower leg dislocation         19         $103.62
            27832        Treat lower leg dislocation         02         $446.00
            27840        Treat ankle dislocation             19         $103.62
            27842        Treat ankle dislocation             01         $333.00
            27846        Treat ankle dislocation             03         $510.00
            27848        Treat ankle dislocation             03         $510.00
            27860        Fixation of ankle joint             01         $333.00
            27870        Fusion of ankle joint, open         04         $630.00
            27871        Fusion of tibiofibular joint        04         $630.00
            27884        Amputation follow-up surgery        03         $510.00
            27889        Amputation of foot at ankle         03         $510.00
            27892        Decompression of leg                03         $510.00
            27893        Decompression of leg                03         $510.00
            27894        Decompression of leg                03         $510.00
            28002        Treatment of foot infection         03         $510.00
            28003        Treatment of foot infection         03         $510.00
            28005        Treat foot bone lesion              03         $510.00
            28008        Incision of foot fascia             03         $510.00
            28011        Incision of toe tendons             03         $510.00
            28020        Exploration of foot joint           02         $446.00
            28022        Exploration of foot joint           02         $446.00
            28024        Exploration of toe joint            02         $446.00
            28035        Decompression of tibia nerve        04         $630.00
            28043        Excision of foot lesion             02         $446.00
            28045        Excision of foot lesion             03         $510.00
            28046        Resection of tumor, foot            03         $510.00
            28050        Biopsy of foot joint lining         02         $446.00
            28052        Biopsy of foot joint lining         02         $446.00
            28054        Biopsy of toe joint lining          02         $446.00
            28055        Neurectomy, foot                    04         $630.00
            28060        Partial removal, foot fascia        02         $446.00
            28062        Removal of foot fascia              03         $510.00
            28070        Removal of foot joint lining        03         $510.00


4/22/2012                                 Page 21       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            28072        Removal of foot joint lining        03         $510.00
            28080        Removal of foot lesion              03         $510.00
            28086        Excise foot tendon sheath           02         $446.00
            28088        Excise foot tendon sheath           02         $446.00
            28090        Removal of foot lesion              03         $510.00
            28092        Removal of toe lesions              03         $510.00
            28100        Removal of ankle/heel lesion        02         $446.00
            28102        Remove/graft foot lesion            03         $510.00
            28103        Remove/graft foot lesion            03         $510.00
            28104        Removal of foot lesion              02         $446.00
            28106        Remove/graft foot lesion            03         $510.00
            28107        Remove/graft foot lesion            03         $510.00
            28108        Removal of toe lesions              02         $446.00
            28110        Part removal of metatarsal          03         $510.00
            28111        Part removal of metatarsal          03         $510.00
            28112        Part removal of metatarsal          03         $510.00
            28113        Part removal of metatarsal          03         $510.00
            28114        Removal of metatarsal heads         03         $510.00
            28116        Revision of foot                    03         $510.00
            28118        Removal of heel bone                04         $630.00
            28119        Removal of heel spur                04         $630.00
            28120        Part removal of ankle/heel          07         $995.00
            28122        Partial removal of foot bone        03         $510.00
            28126        Partial removal of toe              03         $510.00
            28130        Removal of ankle bone               03         $510.00
            28140        Removal of metatarsal               03         $510.00
            28150        Removal of toe                      03         $510.00
            28153        Partial removal of toe              03         $510.00
            28160        Partial removal of toe              03         $510.00
            28171        Extensive foot surgery              03         $510.00
            28173        Extensive foot surgery              03         $510.00
            28175        Extensive foot surgery              03         $510.00
            28192        Removal of foot foreign body        02         $446.00
            28193        Removal of foot foreign body        51         $418.49
            28200        Repair of foot tendon               03         $510.00
            28202        Repair/graft of foot tendon         03         $510.00
            28208        Repair of foot tendon               03         $510.00
            28210        Repair/graft of foot tendon         03         $510.00
            28222        Release of foot tendons             01         $333.00
            28225        Release of foot tendon              01         $333.00
            28226        Release of foot tendons             01         $333.00
            28234        Incision of foot tendon             02         $446.00
            28238        Revision of foot tendon             03         $510.00
            28240        Release of big toe                  02         $446.00
            28250        Revision of foot fascia             03         $510.00
            28260        Release of midfoot joint            03         $510.00
            28261        Revision of foot tendon             03         $510.00
            28262        Revision of foot and ankle          04         $630.00
            28264        Release of midfoot joint            01         $333.00
            28270        Release of foot contracture         03         $510.00


4/22/2012                                 Page 22       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            28280        Fusion of toes                      02         $446.00
            28285        Repair of hammertoe                 03         $510.00
            28286        Repair of hammertoe                 04         $630.00
            28288        Partial removal of foot bone        03         $510.00
            28289        Repair hallux rigidus               03         $510.00
            28290        Correction of bunion                02         $446.00
            28292        Correction of bunion                02         $446.00
            28293        Correction of bunion                03         $510.00
            28294        Correction of bunion                03         $510.00
            28296        Correction of bunion                03         $510.00
            28297        Correction of bunion                03         $510.00
            28298        Correction of bunion                03         $510.00
            28299        Correction of bunion                05         $717.00
            28300        Incision of heel bone               02         $446.00
            28302        Incision of ankle bone              02         $446.00
            28304        Incision of midfoot bones           02         $446.00
            28305        Incise/graft midfoot bones          03         $510.00
            28306        Incision of metatarsal              04         $630.00
            28307        Incision of metatarsal              04         $630.00
            28308        Incision of metatarsal              02         $446.00
            28309        Incision of metatarsals             04         $630.00
            28310        Revision of big toe                 03         $510.00
            28312        Revision of toe                     03         $510.00
            28313        Repair deformity of toe             02         $446.00
            28315        Removal of sesamoid bone            04         $630.00
            28320        Repair of foot bones                04         $630.00
            28322        Repair of metatarsals               04         $630.00
            28340        Resect enlarged toe tissue          04         $630.00
            28341        Resect enlarged toe                 04         $630.00
            28344        Repair extra toe(s)                 04         $630.00
            28345        Repair webbed toe(s)                04         $630.00
            28400        Treatment of heel fracture          19         $103.62
            28405        Treatment of heel fracture          19         $103.62
            28406        Treatment of heel fracture          02         $446.00
            28415        Treat heel fracture                 03         $510.00
            28420        Treat/graft heel fracture           04         $630.00
            28435        Treatment of ankle fracture         19         $103.62
            28436        Treatment of ankle fracture         02         $446.00
            28445        Treat ankle fracture                03         $510.00
            28456        Treat midfoot fracture              02         $446.00
            28465        Treat midfoot fracture, each        03         $510.00
            28476        Treat metatarsal fracture           02         $446.00
            28485        Treat metatarsal fracture           04         $630.00
            28496        Treat big toe fracture              02         $446.00
            28505        Treat big toe fracture              03         $510.00
            28525        Treat toe fracture                  03         $510.00
            28531        Treat sesamoid bone fracture        03         $510.00
            28545        Treat foot dislocation              01         $333.00
            28546        Treat foot dislocation              02         $446.00
            28555        Repair foot dislocation             02         $446.00


4/22/2012                                 Page 23       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            28575        Treat foot dislocation              19         $103.62
            28576        Treat foot dislocation              03         $510.00
            28585        Repair foot dislocation             03         $510.00
            28605        Treat foot dislocation              19         $103.62
            28606        Treat foot dislocation              02         $446.00
            28615        Repair foot dislocation             03         $510.00
            28635        Treat toe dislocation               01         $333.00
            28636        Treat toe dislocation               03         $510.00
            28645        Repair toe dislocation              03         $510.00
            28665        Treat toe dislocation               01         $333.00
            28666        Treat toe dislocation               03         $510.00
            28675        Repair of toe dislocation           03         $510.00
            28705        Fusion of foot bones                04         $630.00
            28715        Fusion of foot bones                04         $630.00
            28725        Fusion of foot bones                04         $630.00
            28730        Fusion of foot bones                04         $630.00
            28735        Fusion of foot bones                04         $630.00
            28737        Revision of foot bones              05         $717.00
            28740        Fusion of foot bones                04         $630.00
            28750        Fusion of big toe joint             04         $630.00
            28755        Fusion of big toe joint             04         $630.00
            28760        Fusion of big toe joint             04         $630.00
            28810        Amputation toe & metatarsal         02         $446.00
            28820        Amputation of toe                   02         $446.00
            28825        Partial amputation of toe           02         $446.00
            29800        Jaw arthroscopy/surgery             03         $510.00
            29804        Jaw arthroscopy/surgery             03         $510.00
            29805        Shoulder arthroscopy, dx            03         $510.00
            29806        Shoulder arthroscopy/surgery        03         $510.00
            29807        Shoulder arthroscopy/surgery        03         $510.00
            29819        Shoulder arthroscopy/surgery        03         $510.00
            29820        Shoulder arthroscopy/surgery        03         $510.00
            29821        Shoulder arthroscopy/surgery        03         $510.00
            29822        Shoulder arthroscopy/surgery        03         $510.00
            29823        Shoulder arthroscopy/surgery        03         $510.00
            29824        Shoulder arthroscopy/surgery        05         $717.00
            29825        Shoulder arthroscopy/surgery        03         $510.00
            29826        Shoulder arthroscopy/surgery        03         $510.00
            29827        Arthroscop rotator cuff repr        05         $717.00
            29830        Elbow arthroscopy                   03         $510.00
            29834        Elbow arthroscopy/surgery           03         $510.00
            29835        Elbow arthroscopy/surgery           03         $510.00
            29836        Elbow arthroscopy/surgery           03         $510.00
            29837        Elbow arthroscopy/surgery           03         $510.00
            29838        Elbow arthroscopy/surgery           03         $510.00
            29840        Wrist arthroscopy                   03         $510.00
            29843        Wrist arthroscopy/surgery           03         $510.00
            29844        Wrist arthroscopy/surgery           03         $510.00
            29845        Wrist arthroscopy/surgery           03         $510.00
            29846        Wrist arthroscopy/surgery           03         $510.00


4/22/2012                                 Page 24       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                  Ambulatory Surgery Center


             Procedure                                         Pricer   07/01/08
               Code                Short Description           Group      Rate
            29847        Wrist arthroscopy/surgery            03          $510.00
            29848        Wrist endoscopy/surgery              09        $1,339.00
            29850        Knee arthroscopy/surgery             04          $630.00
            29851        Knee arthroscopy/surgery             04          $630.00
            29855        Tibial arthroscopy/surgery           04          $630.00
            29856        Tibial arthroscopy/surgery           04          $630.00
            29860        Hip arthroscopy, dx                  04          $630.00
            29861        Hip arthroscopy/surgery              04          $630.00
            29862        Hip arthroscopy/surgery              09        $1,339.00
            29863        Hip arthroscopy/surgery              04          $630.00
            29870        Knee arthroscopy, dx                 03          $510.00
            29871        Knee arthroscopy/drainage            03          $510.00
            29873        Knee arthroscopy/surgery             03          $510.00
            29874        Knee arthroscopy/surgery             03          $510.00
            29875        Knee arthroscopy/surgery             04          $630.00
            29876        Knee arthroscopy/surgery             04          $630.00
            29877        Knee arthroscopy/surgery             04          $630.00
            29879        Knee arthroscopy/surgery             03          $510.00
            29880        Knee arthroscopy/surgery             04          $630.00
            29881        Knee arthroscopy/surgery             04          $630.00
            29882        Knee arthroscopy/surgery             03          $510.00
            29883        Knee arthroscopy/surgery             03          $510.00
            29884        Knee arthroscopy/surgery             03          $510.00
            29885        Knee arthroscopy/surgery             03          $510.00
            29886        Knee arthroscopy/surgery             03          $510.00
            29887        Knee arthroscopy/surgery             03          $510.00
            29888        Knee arthroscopy/surgery             03          $510.00
            29889        Knee arthroscopy/surgery             03          $510.00
            29891        Ankle arthroscopy/surgery            03          $510.00
            29892        Ankle arthroscopy/surgery            03          $510.00
            29893        Scope, plantar fasciotomy            55        $1,255.56
            29894        Ankle arthroscopy/surgery            03          $510.00
            29895        Ankle arthroscopy/surgery            03          $510.00
            29897        Ankle arthroscopy/surgery            03          $510.00
            29898        Ankle arthroscopy/surgery            03          $510.00
            29899        Ankle arthroscopy/surgery            03          $510.00
            29900        Mcp joint arthroscopy, dx            03          $510.00
            29901        Mcp joint arthroscopy, surg          03          $510.00
            29902        Mcp joint arthroscopy, surg          03          $510.00
            30115        Removal of nose polyp(s)             02          $446.00
            30117        Removal of intranasal lesion         03          $510.00
            30118        Removal of intranasal lesion         03          $510.00
            30120        Revision of nose                     01          $333.00
            30125        Removal of nose lesion               02          $446.00
            30130        Excise inferior turbinate            03          $510.00
            30140        Resect inferior turbinate            02          $446.00
            30150        Partial removal of nose              03          $510.00
            30160        Removal of nose                      04          $630.00
            30220        Insert nasal septal button           53          $464.15
            30310        Remove nasal foreign body            01          $333.00


4/22/2012                                  Page 25      ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            30320        Remove nasal foreign body           02          $446.00
            30400        Reconstruction of nose              04          $630.00
            30410        Reconstruction of nose              05          $717.00
            30420        Reconstruction of nose              05          $717.00
            30430        Revision of nose                    03          $510.00
            30435        Revision of nose                    05          $717.00
            30450        Revision of nose                    07          $995.00
            30460        Revision of nose                    07          $995.00
            30462        Revision of nose                    09        $1,339.00
            30465        Repair nasal stenosis               09        $1,339.00
            30520        Repair of nasal septum              04          $630.00
            30540        Repair nasal defect                 05          $717.00
            30545        Repair nasal defect                 05          $717.00
            30560        Release of nasal adhesions          27          $150.72
            30580        Repair upper jaw fistula            04          $630.00
            30600        Repair mouth/nose fistula           04          $630.00
            30620        Intranasal reconstruction           07          $995.00
            30630        Repair nasal septum defect          07          $995.00
            30801        Ablate inf turbinate, superf        01          $333.00
            30802        Cauterization, inner nose           01          $333.00
            30903        Control of nosebleed                14           $72.48
            30905        Control of nosebleed                14           $72.48
            30906        Repeat control of nosebleed         14           $72.48
            30915        Ligation, nasal sinus artery        02          $446.00
            30920        Ligation, upper jaw artery          03          $510.00
            30930        Ther fx, nasal inf turbinate        04          $630.00
            31020        Exploration, maxillary sinus        02          $446.00
            31030        Exploration, maxillary sinus        03          $510.00
            31032        Explore sinus, remove polyps        04          $630.00
            31050        Exploration, sphenoid sinus         02          $446.00
            31051        Sphenoid sinus surgery              04          $630.00
            31070        Exploration of frontal sinus        02          $446.00
            31075        Exploration of frontal sinus        04          $630.00
            31080        Removal of frontal sinus            04          $630.00
            31081        Removal of frontal sinus            04          $630.00
            31084        Removal of frontal sinus            04          $630.00
            31085        Removal of frontal sinus            04          $630.00
            31086        Removal of frontal sinus            04          $630.00
            31087        Removal of frontal sinus            04          $630.00
            31090        Exploration of sinuses              05          $717.00
            31200        Removal of ethmoid sinus            02          $446.00
            31201        Removal of ethmoid sinus            05          $717.00
            31205        Removal of ethmoid sinus            03          $510.00
            31233        Nasal/sinus endoscopy, dx           15           $86.39
            31235        Nasal/sinus endoscopy, dx           01          $333.00
            31237        Nasal/sinus endoscopy, surg         02          $446.00
            31238        Nasal/sinus endoscopy, surg         01          $333.00
            31239        Nasal/sinus endoscopy, surg         04          $630.00
            31240        Nasal/sinus endoscopy, surg         02          $446.00
            31254        Revision of ethmoid sinus           03          $510.00


4/22/2012                                 Page 26       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            31255        Removal of ethmoid sinus            05         $717.00
            31256        Exploration maxillary sinus         03         $510.00
            31267        Endoscopy, maxillary sinus          03         $510.00
            31276        Sinus endoscopy, surgical           03         $510.00
            31287        Nasal/sinus endoscopy, surg         03         $510.00
            31288        Nasal/sinus endoscopy, surg         03         $510.00
            31300        Removal of larynx lesion            05         $717.00
            31320        Diagnostic incision, larynx         02         $446.00
            31400        Revision of larynx                  02         $446.00
            31420        Removal of epiglottis               02         $446.00
            31510        Laryngoscopy with biopsy            02         $446.00
            31511        Remove foreign body, larynx         15          $86.39
            31512        Removal of larynx lesion            02         $446.00
            31513        Injection into vocal cord           15          $86.39
            31515        Laryngoscopy for aspiration         01         $333.00
            31525        Dx laryngoscopy excl nb             01         $333.00
            31526        Dx laryngoscopy w/oper scope        02         $446.00
            31527        Laryngoscopy for treatment          01         $333.00
            31528        Laryngoscopy and dilation           02         $446.00
            31529        Laryngoscopy and dilation           02         $446.00
            31530        Laryngoscopy w/fb removal           02         $446.00
            31531        Laryngoscopy w/fb & op scope        03         $510.00
            31535        Laryngoscopy w/biopsy               02         $446.00
            31536        Laryngoscopy w/bx & op scope        03         $510.00
            31540        Laryngoscopy w/exc of tumor         03         $510.00
            31541        Larynscop w/tumr exc + scope        04         $630.00
            31545        Remove vc lesion w/scope            04         $630.00
            31546        Remove vc lesion scope/graft        04         $630.00
            31560        Laryngoscop w/arytenoidectom        05         $717.00
            31561        Larynscop, remve cart + scop        05         $717.00
            31570        Laryngoscope w/vc inj               02         $446.00
            31571        Laryngoscop w/vc inj + scope        02         $446.00
            31576        Laryngoscopy with biopsy            02         $446.00
            31577        Remove foreign body, larynx         33         $236.42
            31578        Removal of larynx lesion            02         $446.00
            31580        Revision of larynx                  05         $717.00
            31582        Revision of larynx                  05         $717.00
            31588        Revision of larynx                  05         $717.00
            31590        Reinnervate larynx                  05         $717.00
            31595        Larynx nerve surgery                02         $446.00
            31603        Incision of windpipe                01         $333.00
            31611        Surgery/speech prosthesis           03         $510.00
            31612        Puncture/clear windpipe             01         $333.00
            31613        Repair windpipe opening             02         $446.00
            31614        Repair windpipe opening             02         $446.00
            31615        Visualization of windpipe           01         $333.00
            31620        Endobronchial us add-on             01         $333.00
            31622        Dx bronchoscope/wash                01         $333.00
            31623        Dx bronchoscope/brush               02         $446.00
            31624        Dx bronchoscope/lavage              02         $446.00


4/22/2012                                Page 27        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            31625        Bronchoscopy w/biopsy(s)            02          $446.00
            31628        Bronchoscopy/lung bx, each          02          $446.00
            31629        Bronchoscopy/needle bx, each        02          $446.00
            31630        Bronchoscopy dilate/fx repr         02          $446.00
            31631        Bronchoscopy, dilate w/stent        02          $446.00
            31635        Bronchoscopy w/fb removal           02          $446.00
            31636        Bronchoscopy, bronch stents         02          $446.00
            31637        Bronchoscopy, stent add-on          01          $333.00
            31638        Bronchoscopy, revise stent          02          $446.00
            31640        Bronchoscopy w/tumor excise         02          $446.00
            31641        Bronchoscopy, treat blockage        02          $446.00
            31643        Diag bronchoscope/catheter          02          $446.00
            31645        Bronchoscopy, clear airways         01          $333.00
            31646        Bronchoscopy, reclear airway        01          $333.00
            31656        Bronchoscopy, inj for x-ray         01          $333.00
            31717        Bronchial brush biopsy              33          $236.42
            31720        Clearance of airways                11           $47.32
            31730        Intro, windpipe wire/tube           33          $236.42
            31750        Repair of windpipe                  05          $717.00
            31755        Repair of windpipe                  02          $446.00
            31820        Closure of windpipe lesion          01          $333.00
            31825        Repair of windpipe defect           02          $446.00
            31830        Revise windpipe scar                02          $446.00
            32000        Drainage of chest                   32          $222.78
            32400        Needle biopsy chest lining          01          $333.00
            32405        Biopsy, lung or mediastinum         01          $333.00
            32420        Puncture/clear lung                 32          $222.78
            33010        Drainage of heart sac               32          $222.78
            33011        Repeat drainage of heart sac        32          $222.78
            33212        Insertion of pulse generator        03          $510.00
            33213        Insertion of pulse generator        03          $510.00
            33222        Revise pocket, pacemaker            02          $446.00
            33223        Revise pocket, pacing-defib         02          $446.00
            33233        Removal of pacemaker system         02          $446.00
            35188        Repair blood vessel lesion          04          $630.00
            35207        Repair blood vessel lesion          04          $630.00
            35875        Removal of clot in graft            09        $1,339.00
            35876        Removal of clot in graft            09        $1,339.00
            36260        Insertion of infusion pump          03          $510.00
            36261        Revision of infusion pump           02          $446.00
            36262        Removal of infusion pump            01          $333.00
            36475        Endovenous rf, 1st vein             09        $1,339.00
            36476        Endovenous rf, vein add-on          09        $1,339.00
            36478        Endovenous laser, 1st vein          09        $1,339.00
            36479        Endovenous laser vein addon         09        $1,339.00
            36555        Insert non-tunnel cv cath           01          $333.00
            36556        Insert non-tunnel cv cath           01          $333.00
            36557        Insert tunneled cv cath             02          $446.00
            36558        Insert tunneled cv cath             02          $446.00
            36560        Insert tunneled cv cath             03          $510.00


4/22/2012                                Page 28        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            36561        Insert tunneled cv cath             03          $510.00
            36563        Insert tunneled cv cath             03          $510.00
            36565        Insert tunneled cv cath             03          $510.00
            36566        Insert tunneled cv cath             03          $510.00
            36568        Insert picc cath                    01          $333.00
            36569        Insert picc cath                    01          $333.00
            36570        Insert picvad cath                  03          $510.00
            36571        Insert picvad cath                  03          $510.00
            36575        Repair tunneled cv cath             02          $446.00
            36576        Repair tunneled cv cath             02          $446.00
            36578        Replace tunneled cv cath            02          $446.00
            36580        Replace cvad cath                   01          $333.00
            36581        Replace tunneled cv cath            02          $446.00
            36582        Replace tunneled cv cath            03          $510.00
            36583        Replace tunneled cv cath            03          $510.00
            36584        Replace picc cath                   01          $333.00
            36585        Replace picvad cath                 03          $510.00
            36589        Removal tunneled cv cath            01          $333.00
            36590        Removal tunneled cv cath            01          $333.00
            36640        Insertion catheter, artery          01          $333.00
            36800        Insertion of cannula                03          $510.00
            36810        Insertion of cannula                03          $510.00
            36815        Insertion of cannula                03          $510.00
            36818        Av fuse, uppr arm, cephalic         03          $510.00
            36819        Av fuse, uppr arm, basilic          03          $510.00
            36820        Av fusion/forearm vein              03          $510.00
            36821        Av fusion direct any site           03          $510.00
            36825        Artery-vein autograft               04          $630.00
            36830        Artery-vein nonautograft            04          $630.00
            36831        Open thrombect av fistula           09        $1,339.00
            36832        Av fistula revision, open           04          $630.00
            36833        Av fistula revision                 04          $630.00
            36834        Repair A-V aneurysm                 03          $510.00
            36835        Artery to vein shunt                04          $630.00
            36860        External cannula declotting         22          $127.40
            36861        Cannula declotting                  03          $510.00
            36870        Percut thrombect av fistula         09        $1,339.00
            37500        Endoscopy ligate perf veins         03          $510.00
            37607        Ligation of a-v fistula             03          $510.00
            37609        Temporal artery procedure           02          $446.00
            37650        Revision of major vein              02          $446.00
            37700        Revise leg vein                     02          $446.00
            37718        Ligate/strip short leg vein         03          $510.00
            37722        Ligate/strip long leg vein          03          $510.00
            37735        Removal of leg veins/lesion         03          $510.00
            37760        Ligation, leg veins, open           03          $510.00
            37780        Revision of leg vein                03          $510.00
            37785        Ligate/divide/excise vein           03          $510.00
            37790        Penile venous occlusion             03          $510.00
            38300        Drainage, lymph node lesion         01          $333.00


4/22/2012                                 Page 29      ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                Ambulatory Surgery Center


             Procedure                                       Pricer   07/01/08
               Code                Short Description         Group      Rate
            38305        Drainage, lymph node lesion        02          $446.00
            38308        Incision of lymph channels         02          $446.00
            38500        Biopsy/removal, lymph nodes        02          $446.00
            38505        Needle biopsy, lymph nodes         34          $240.00
            38510        Biopsy/removal, lymph nodes        02          $446.00
            38520        Biopsy/removal, lymph nodes        02          $446.00
            38525        Biopsy/removal, lymph nodes        02          $446.00
            38530        Biopsy/removal, lymph nodes        02          $446.00
            38542        Explore deep node(s), neck         02          $446.00
            38550        Removal, neck/armpit lesion        03          $510.00
            38555        Removal, neck/armpit lesion        04          $630.00
            38570        Laparoscopy, lymph node biop       09        $1,339.00
            38571        Laparoscopy, lymphadenectomy       09        $1,339.00
            38572        Laparoscopy, lymphadenectomy       09        $1,339.00
            38740        Remove armpit lymph nodes          02          $446.00
            38745        Remove armpit lymph nodes          04          $630.00
            38760        Remove groin lymph nodes           02          $446.00
            40500        Partial excision of lip            02          $446.00
            40510        Partial excision of lip            02          $446.00
            40520        Partial excision of lip            02          $446.00
            40525        Reconstruct lip with flap          02          $446.00
            40527        Reconstruct lip with flap          02          $446.00
            40530        Partial removal of lip             02          $446.00
            40650        Repair lip                         53          $464.15
            40652        Repair lip                         53          $464.15
            40654        Repair lip                         53          $464.15
            40700        Repair cleft lip/nasal             07          $995.00
            40701        Repair cleft lip/nasal             07          $995.00
            40720        Repair cleft lip/nasal             07          $995.00
            40761        Repair cleft lip/nasal             03          $510.00
            40801        Drainage of mouth lesion           02          $446.00
            40814        Excise/repair mouth lesion         02          $446.00
            40816        Excision of mouth lesion           02          $446.00
            40818        Excise oral mucosa for graft       27          $150.72
            40819        Excise lip or cheek fold           01          $333.00
            40831        Repair mouth laceration            01          $333.00
            40840        Reconstruction of mouth            02          $446.00
            40842        Reconstruction of mouth            03          $510.00
            40843        Reconstruction of mouth            03          $510.00
            40844        Reconstruction of mouth            05          $717.00
            40845        Reconstruction of mouth            05          $717.00
            41005        Drainage of mouth lesion           27          $150.72
            41006        Drainage of mouth lesion           01          $333.00
            41007        Drainage of mouth lesion           01          $333.00
            41008        Drainage of mouth lesion           01          $333.00
            41009        Drainage of mouth lesion           27          $150.72
            41010        Incision of tongue fold            01          $333.00
            41015        Drainage of mouth lesion           27          $150.72
            41016        Drainage of mouth lesion           01          $333.00
            41017        Drainage of mouth lesion           01          $333.00


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                                  Ambulatory Surgery Center


             Procedure                                         Pricer   07/01/08
               Code                Short Description           Group      Rate
            41018        Drainage of mouth lesion             01         $333.00
            41112        Excision of tongue lesion            02         $446.00
            41113        Excision of tongue lesion            02         $446.00
            41114        Excision of tongue lesion            02         $446.00
            41116        Excision of mouth lesion             01         $333.00
            41120        Partial removal of tongue            05         $717.00
            41250        Repair tongue laceration             27         $150.72
            41251        Repair tongue laceration             27         $150.72
            41252        Repair tongue laceration             02         $446.00
            41500        Fixation of tongue                   01         $333.00
            41510        Tongue to lip surgery                01         $333.00
            41520        Reconstruction, tongue fold          02         $446.00
            41800        Drainage of gum lesion               16          $88.46
            41827        Excision of gum lesion               02         $446.00
            42000        Drainage mouth roof lesion           27         $150.72
            42107        Excision lesion, mouth roof          02         $446.00
            42120        Remove palate/lesion                 04         $630.00
            42140        Excision of uvula                    02         $446.00
            42145        Repair palate, pharynx/uvula         05         $717.00
            42180        Repair palate                        27         $150.72
            42182        Repair palate                        02         $446.00
            42200        Reconstruct cleft palate             05         $717.00
            42205        Reconstruct cleft palate             05         $717.00
            42210        Reconstruct cleft palate             05         $717.00
            42215        Reconstruct cleft palate             07         $995.00
            42220        Reconstruct cleft palate             05         $717.00
            42226        Lengthening of palate                05         $717.00
            42235        Repair palate                        05         $717.00
            42260        Repair nose to lip fistula           04         $630.00
            42300        Drainage of salivary gland           01         $333.00
            42305        Drainage of salivary gland           02         $446.00
            42310        Drainage of salivary gland           27         $150.72
            42320        Drainage of salivary gland           27         $150.72
            42340        Removal of salivary stone            02         $446.00
            42405        Biopsy of salivary gland             02         $446.00
            42408        Excision of salivary cyst            03         $510.00
            42409        Drainage of salivary cyst            03         $510.00
            42410        Excise parotid gland/lesion          03         $510.00
            42415        Excise parotid gland/lesion          07         $995.00
            42420        Excise parotid gland/lesion          07         $995.00
            42425        Excise parotid gland/lesion          07         $995.00
            42440        Excise submaxillary gland            03         $510.00
            42450        Excise sublingual gland              02         $446.00
            42500        Repair salivary duct                 03         $510.00
            42505        Repair salivary duct                 04         $630.00
            42507        Parotid duct diversion               03         $510.00
            42508        Parotid duct diversion               04         $630.00
            42509        Parotid duct diversion               04         $630.00
            42510        Parotid duct diversion               04         $630.00
            42600        Closure of salivary fistula          01         $333.00


4/22/2012                                  Page 31      ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            42665        Ligation of salivary duct           07         $995.00
            42700        Drainage of tonsil abscess          27         $150.72
            42720        Drainage of throat abscess          01         $333.00
            42725        Drainage of throat abscess          02         $446.00
            42802        Biopsy of throat                    01         $333.00
            42804        Biopsy of upper nose/throat         01         $333.00
            42806        Biopsy of upper nose/throat         02         $446.00
            42808        Excise pharynx lesion               02         $446.00
            42810        Excision of neck cyst               03         $510.00
            42815        Excision of neck cyst               05         $717.00
            42820        Remove tonsils and adenoids         03         $510.00
            42821        Remove tonsils and adenoids         05         $717.00
            42825        Removal of tonsils                  04         $630.00
            42826        Removal of tonsils                  04         $630.00
            42830        Removal of adenoids                 04         $630.00
            42831        Removal of adenoids                 04         $630.00
            42835        Removal of adenoids                 04         $630.00
            42836        Removal of adenoids                 04         $630.00
            42860        Excision of tonsil tags             03         $510.00
            42870        Excision of lingual tonsil          03         $510.00
            42890        Partial removal of pharynx          07         $995.00
            42892        Revision of pharyngeal walls        07         $995.00
            42900        Repair throat wound                 01         $333.00
            42950        Reconstruction of throat            02         $446.00
            42955        Surgical opening of throat          02         $446.00
            42960        Control throat bleeding             14          $72.48
            42962        Control throat bleeding             02         $446.00
            42972        Control nose/throat bleeding        03         $510.00
            43200        Esophagus endoscopy                 01         $333.00
            43201        Esoph scope w/submucous inj         01         $333.00
            43202        Esophagus endoscopy, biopsy         01         $333.00
            43204        Esoph scope w/sclerosis inj         01         $333.00
            43205        Esophagus endoscopy/ligation        01         $333.00
            43215        Esophagus endoscopy                 01         $333.00
            43216        Esophagus endoscopy/lesion          01         $333.00
            43217        Esophagus endoscopy                 01         $333.00
            43219        Esophagus endoscopy                 01         $333.00
            43220        Esoph endoscopy, dilation           01         $333.00
            43226        Esoph endoscopy, dilation           01         $333.00
            43227        Esoph endoscopy, repair             02         $446.00
            43228        Esoph endoscopy, ablation           02         $446.00
            43231        Esoph endoscopy w/us exam           02         $446.00
            43232        Esoph endoscopy w/us fn bx          02         $446.00
            43234        Upper GI endoscopy, exam            01         $333.00
            43235        Uppr gi endoscopy, diagnosis        01         $333.00
            43236        Uppr gi scope w/submuc inj          02         $446.00
            43237        Endoscopic us exam, esoph           02         $446.00
            43238        Uppr gi endoscopy w/us fn bx        02         $446.00
            43239        Upper GI endoscopy, biopsy          02         $446.00
            43240        Esoph endoscope w/drain cyst        02         $446.00


4/22/2012                                 Page 32       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            43241        Upper GI endoscopy with tube        02          $446.00
            43242        Uppr gi endoscopy w/us fn bx        02          $446.00
            43243        Upper gi endoscopy & inject         02          $446.00
            43244        Upper GI endoscopy/ligation         02          $446.00
            43245        Uppr gi scope dilate strictr        02          $446.00
            43246        Place gastrostomy tube              02          $446.00
            43247        Operative upper GI endoscopy        02          $446.00
            43248        Uppr gi endoscopy/guide wire        02          $446.00
            43249        Esoph endoscopy, dilation           02          $446.00
            43250        Upper GI endoscopy/tumor            02          $446.00
            43251        Operative upper GI endoscopy        02          $446.00
            43255        Operative upper GI endoscopy        02          $446.00
            43256        Uppr gi endoscopy w/stent           03          $510.00
            43257        Uppr gi scope w/thrml txmnt         03          $510.00
            43258        Operative upper GI endoscopy        03          $510.00
            43259        Endoscopic ultrasound exam          03          $510.00
            43260        Endo cholangiopancreatograph        02          $446.00
            43261        Endo cholangiopancreatograph        02          $446.00
            43262        Endo cholangiopancreatograph        02          $446.00
            43263        Endo cholangiopancreatograph        02          $446.00
            43264        Endo cholangiopancreatograph        02          $446.00
            43265        Endo cholangiopancreatograph        02          $446.00
            43267        Endo cholangiopancreatograph        02          $446.00
            43268        Endo cholangiopancreatograph        02          $446.00
            43269        Endo cholangiopancreatograph        02          $446.00
            43271        Endo cholangiopancreatograph        02          $446.00
            43272        Endo cholangiopancreatograph        02          $446.00
            43450        Dilate esophagus                    01          $333.00
            43453        Dilate esophagus                    01          $333.00
            43456        Dilate esophagus                    43          $335.41
            43458        Dilate esophagus                    43          $335.41
            43600        Biopsy of stomach                   01          $333.00
            43653        Laparoscopy, gastrostomy            09        $1,339.00
            43750        Place gastrostomy tube              02          $446.00
            43760        Change gastrostomy tube             26          $144.98
            43761        Reposition gastrostomy tube         01          $333.00
            43870        Repair stomach opening              01          $333.00
            44100        Biopsy of bowel                     01          $333.00
            44312        Revision of ileostomy               01          $333.00
            44340        Revision of colostomy               03          $510.00
            44360        Small bowel endoscopy               02          $446.00
            44361        Small bowel endoscopy/biopsy        02          $446.00
            44363        Small bowel endoscopy               02          $446.00
            44364        Small bowel endoscopy               02          $446.00
            44365        Small bowel endoscopy               02          $446.00
            44366        Small bowel endoscopy               02          $446.00
            44369        Small bowel endoscopy               02          $446.00
            44370        Small bowel endoscopy/stent         09        $1,339.00
            44372        Small bowel endoscopy               02          $446.00
            44373        Small bowel endoscopy               02          $446.00


4/22/2012                                Page 33        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            44376        Small bowel endoscopy               02          $446.00
            44377        Small bowel endoscopy/biopsy        02          $446.00
            44378        Small bowel endoscopy               02          $446.00
            44379        Sbowel endoscope w/stent            09        $1,339.00
            44380        Small bowel endoscopy               01          $333.00
            44382        Small bowel endoscopy               01          $333.00
            44383        Ileoscopy w/stent                   09        $1,339.00
            44385        Endoscopy of bowel pouch            01          $333.00
            44386        Endoscopy, bowel pouch/biop         01          $333.00
            44388        Colonoscopy                         01          $333.00
            44389        Colonoscopy with biopsy             01          $333.00
            44390        Colonoscopy for foreign body        01          $333.00
            44391        Colonoscopy for bleeding            01          $333.00
            44392        Colonoscopy & polypectomy           01          $333.00
            44393        Colonoscopy, lesion removal         01          $333.00
            44394        Colonoscopy w/snare                 01          $333.00
            44397        Colonoscopy w/stent                 01          $333.00
            45000        Drainage of pelvic abscess          40          $312.07
            45005        Drainage of rectal abscess          02          $446.00
            45020        Drainage of rectal abscess          02          $446.00
            45100        Biopsy of rectum                    01          $333.00
            45108        Removal of anorectal lesion         02          $446.00
            45150        Excision of rectal stricture        02          $446.00
            45160        Excision of rectal lesion           02          $446.00
            45170        Excision of rectal lesion           02          $446.00
            45190        Destruction, rectal tumor           09        $1,339.00
            45305        Proctosigmoidoscopy w/bx            01          $333.00
            45307        Proctosigmoidoscopy fb              01          $333.00
            45308        Proctosigmoidoscopy removal         01          $333.00
            45309        Proctosigmoidoscopy removal         01          $333.00
            45315        Proctosigmoidoscopy removal         01          $333.00
            45317        Proctosigmoidoscopy bleed           01          $333.00
            45320        Proctosigmoidoscopy ablate          01          $333.00
            45321        Proctosigmoidoscopy volvul          01          $333.00
            45327        Proctosigmoidoscopy w/stent         01          $333.00
            45331        Sigmoidoscopy and biopsy            38          $299.24
            45332        Sigmoidoscopy w/fb removal          38          $299.24
            45333        Sigmoidoscopy & polypectomy         01          $333.00
            45334        Sigmoidoscopy for bleeding          01          $333.00
            45335        Sigmoidoscopy w/submuc inj          38          $299.24
            45337        Sigmoidoscopy & decompress          38          $299.24
            45338        Sigmoidoscopy w/tumr remove         01          $333.00
            45339        Sigmoidoscopy w/ablate tumr         01          $333.00
            45340        Sig w/balloon dilation              01          $333.00
            45341        Sigmoidoscopy w/ultrasound          01          $333.00
            45342        Sigmoidoscopy w/us guide bx         01          $333.00
            45345        Sigmoidoscopy w/stent               01          $333.00
            45355        Surgical colonoscopy                01          $333.00
            45378        Diagnostic colonoscopy              02          $446.00
            45379        Colonoscopy w/fb removal            02          $446.00


4/22/2012                                Page 34        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            45380        Colonoscopy and biopsy              02         $446.00
            45381        Colonoscopy, submucous inj          02         $446.00
            45382        Colonoscopy/control bleeding        02         $446.00
            45383        Lesion removal colonoscopy          02         $446.00
            45384        Lesion remove colonoscopy           02         $446.00
            45385        Lesion removal colonoscopy          02         $446.00
            45386        Colonoscopy dilate stricture        02         $446.00
            45387        Colonoscopy w/stent                 01         $333.00
            45391        Colonoscopy w/endoscope us          02         $446.00
            45392        Colonoscopy w/endoscopic fnb        02         $446.00
            45500        Repair of rectum                    02         $446.00
            45505        Repair of rectum                    02         $446.00
            45560        Repair of rectocele                 02         $446.00
            45900        Reduction of rectal prolapse        40         $312.07
            45905        Dilation of anal sphincter          01         $333.00
            45910        Dilation of rectal narrowing        01         $333.00
            45915        Remove rectal obstruction           40         $312.07
            45990        Surg dx exam, anorectal             40         $312.07
            46020        Placement of seton                  03         $510.00
            46030        Removal of rectal marker            40         $312.07
            46040        Incision of rectal abscess          03         $510.00
            46045        Incision of rectal abscess          02         $446.00
            46050        Incision of anal abscess            40         $312.07
            46060        Incision of rectal abscess          02         $446.00
            46080        Incision of anal sphincter          03         $510.00
            46200        Removal of anal fissure             02         $446.00
            46210        Removal of anal crypt               02         $446.00
            46211        Removal of anal crypts              02         $446.00
            46220        Removal of anal tag                 01         $333.00
            46230        Removal of anal tags                01         $333.00
            46250        Hemorrhoidectomy                    03         $510.00
            46255        Hemorrhoidectomy                    03         $510.00
            46257        Remove hemorrhoids & fissure        03         $510.00
            46258        Remove hemorrhoids & fistula        03         $510.00
            46260        Hemorrhoidectomy                    03         $510.00
            46261        Remove hemorrhoids & fissure        04         $630.00
            46262        Remove hemorrhoids & fistula        04         $630.00
            46270        Removal of anal fistula             03         $510.00
            46275        Removal of anal fistula             03         $510.00
            46280        Removal of anal fistula             04         $630.00
            46285        Removal of anal fistula             01         $333.00
            46288        Repair anal fistula                 04         $630.00
            46608        Anoscopy, remove for body           01         $333.00
            46610        Anoscopy, remove lesion             01         $333.00
            46611        Anoscopy                            01         $333.00
            46612        Anoscopy, remove lesions            01         $333.00
            46615        Anoscopy                            02         $446.00
            46700        Repair of anal stricture            03         $510.00
            46706        Repr of anal fistula w/glue         01         $333.00
            46750        Repair of anal sphincter            03         $510.00


4/22/2012                                Page 35        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            46753        Reconstruction of anus              03          $510.00
            46754        Removal of suture from anus         02          $446.00
            46760        Repair of anal sphincter            02          $446.00
            46761        Repair of anal sphincter            03          $510.00
            46762        Implant artificial sphincter        07          $995.00
            46917        Laser surgery, anal lesions         01          $333.00
            46922        Excision of anal lesion(s)          01          $333.00
            46924        Destruction, anal lesion(s)         01          $333.00
            46937        Cryotherapy of rectal lesion        02          $446.00
            46938        Cryotherapy of rectal lesion        02          $446.00
            46946        Ligation of hemorrhoids             01          $333.00
            46947        Hemorrhoidopexy by stapling         07          $995.00
            47000        Needle biopsy of liver              01          $333.00
            47510        Insert catheter, bile duct          02          $446.00
            47511        Insert bile duct drain              56        $1,245.85
            47525        Change bile duct catheter           01          $333.00
            47530        Revise/reinsert bile tube           01          $333.00
            47552        Biliary endoscopy thru skin         02          $446.00
            47553        Biliary endoscopy thru skin         03          $510.00
            47554        Biliary endoscopy thru skin         03          $510.00
            47555        Biliary endoscopy thru skin         03          $510.00
            47556        Biliary endoscopy thru skin         56        $1,245.85
            47560        Laparoscopy w/cholangio             03          $510.00
            47561        Laparo w/cholangio/biopsy           03          $510.00
            47630        Remove bile duct stone              03          $510.00
            48102        Needle biopsy, pancreas             01          $333.00
            49080        Puncture, peritoneal cavity         32          $222.78
            49081        Removal of abdominal fluid          32          $222.78
            49180        Biopsy, abdominal mass              01          $333.00
            49250        Excision of umbilicus               04          $630.00
            49320        Diag laparo separate proc           03          $510.00
            49321        Laparoscopy, biopsy                 04          $630.00
            49322        Laparoscopy, aspiration             04          $630.00
            49402        Remove foreign body, adbomen        02          $446.00
            49419        Insrt abdom cath for chemotx        01          $333.00
            49420        Insert abdom drain, temp            01          $333.00
            49421        Insert abdom drain, perm            01          $333.00
            49422        Remove perm cannula/catheter        01          $333.00
            49426        Revise abdomen-venous shunt         02          $446.00
            49495        Rpr ing hernia baby, reduc          04          $630.00
            49496        Rpr ing hernia baby, blocked        04          $630.00
            49500        Rpr ing hernia, init, reduce        04          $630.00
            49501        Rpr ing hernia, init blocked        09        $1,339.00
            49505        Prp i/hern init reduc >5 yr         04          $630.00
            49507        Prp i/hern init block >5 yr         09        $1,339.00
            49520        Rerepair ing hernia, reduce         07          $995.00
            49521        Rerepair ing hernia, blocked        09        $1,339.00
            49525        Repair ing hernia, sliding          04          $630.00
            49540        Repair lumbar hernia                02          $446.00
            49550        Rpr rem hernia, init, reduce        05          $717.00


4/22/2012                                Page 36        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            49553        Rpr fem hernia, init blocked        09        $1,339.00
            49555        Rerepair fem hernia, reduce         05          $717.00
            49557        Rerepair fem hernia, blocked        09        $1,339.00
            49560        Rpr ventral hern init, reduc        04          $630.00
            49561        Rpr ventral hern init, block        09        $1,339.00
            49565        Rerepair ventrl hern, reduce        04          $630.00
            49566        Rerepair ventrl hern, block         09        $1,339.00
            49568        Hernia repair w/mesh                07          $995.00
            49570        Rpr epigastric hern, reduce         04          $630.00
            49572        Rpr epigastric hern, blocked        09        $1,339.00
            49580        Rpr umbil hern, reduc < 5 yr        04          $630.00
            49582        Rpr umbil hern, block < 5 yr        09        $1,339.00
            49585        Rpr umbil hern, reduc > 5 yr        04          $630.00
            49587        Rpr umbil hern, block > 5 yr        09        $1,339.00
            49590        Repair spigelian hernia             03          $510.00
            49600        Repair umbilical lesion             04          $630.00
            49650        Laparo hernia repair initial        04          $630.00
            49651        Laparo hernia repair recur          07          $995.00
            50200        Biopsy of kidney                    01          $333.00
            50390        Drainage of kidney lesion           01          $333.00
            50392        Insert kidney drain                 01          $333.00
            50393        Insert ureteral tube                01          $333.00
            50395        Create passage to kidney            01          $333.00
            50396        Measure kidney pressure             23          $131.50
            50398        Change kidney tube                  01          $333.00
            50551        Kidney endoscopy                    01          $333.00
            50553        Kidney endoscopy                    01          $333.00
            50555        Kidney endoscopy & biopsy           01          $333.00
            50557        Kidney endoscopy & treatment        01          $333.00
            50561        Kidney endoscopy & treatment        01          $333.00
            50688        Change of ureter tube/stent         01          $333.00
            50947        Laparo new ureter/bladder           09        $1,339.00
            50948        Laparo new ureter/bladder           09        $1,339.00
            50951        Endoscopy of ureter                 01          $333.00
            50953        Endoscopy of ureter                 01          $333.00
            50955        Ureter endoscopy & biopsy           01          $333.00
            50957        Ureter endoscopy & treatment        01          $333.00
            50961        Ureter endoscopy & treatment        01          $333.00
            50970        Ureter endoscopy                    01          $333.00
            50972        Ureter endoscopy & catheter         01          $333.00
            50974        Ureter endoscopy & biopsy           01          $333.00
            50976        Ureter endoscopy & treatment        01          $333.00
            50980        Ureter endoscopy & treatment        01          $333.00
            51010        Drainage of bladder                 01          $333.00
            51020        Incise & treat bladder              04          $630.00
            51030        Incise & treat bladder              04          $630.00
            51040        Incise & drain bladder              04          $630.00
            51045        Incise bladder/drain ureter         49          $399.24
            51050        Removal of bladder stone            04          $630.00
            51065        Remove ureter calculus              04          $630.00


4/22/2012                                 Page 37       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            51080        Drainage of bladder abscess         01          $333.00
            51500        Removal of bladder cyst             04          $630.00
            51520        Removal of bladder lesion           04          $630.00
            51710        Change of bladder tube              01          $333.00
            51715        Endoscopic injection/implant        03          $510.00
            51726        Complex cystometrogram              31          $209.48
            51772        Urethra pressure profile            23          $131.50
            51785        Anal/urinary muscle study           12           $66.92
            51880        Repair of bladder opening           01          $333.00
            51992        Laparo sling operation              05          $717.00
            52000        Cystoscopy                          01          $333.00
            52001        Cystoscopy, removal of clots        49          $399.24
            52005        Cystoscopy & ureter catheter        02          $446.00
            52007        Cystoscopy and biopsy               02          $446.00
            52010        Cystoscopy & duct catheter          49          $399.24
            52204        Cystoscopy w/biopsy(s)              02          $446.00
            52214        Cystoscopy and treatment            02          $446.00
            52224        Cystoscopy and treatment            02          $446.00
            52234        Cystoscopy and treatment            02          $446.00
            52235        Cystoscopy and treatment            03          $510.00
            52240        Cystoscopy and treatment            03          $510.00
            52250        Cystoscopy and radiotracer          04          $630.00
            52260        Cystoscopy and treatment            02          $446.00
            52270        Cystoscopy & revise urethra         02          $446.00
            52275        Cystoscopy & revise urethra         02          $446.00
            52276        Cystoscopy and treatment            03          $510.00
            52277        Cystoscopy and treatment            02          $446.00
            52281        Cystoscopy and treatment            02          $446.00
            52282        Cystoscopy, implant stent           09        $1,339.00
            52283        Cystoscopy and treatment            02          $446.00
            52285        Cystoscopy and treatment            02          $446.00
            52290        Cystoscopy and treatment            02          $446.00
            52300        Cystoscopy and treatment            02          $446.00
            52301        Cystoscopy and treatment            03          $510.00
            52305        Cystoscopy and treatment            02          $446.00
            52310        Cystoscopy and treatment            49          $399.24
            52315        Cystoscopy and treatment            02          $446.00
            52317        Remove bladder stone                01          $333.00
            52318        Remove bladder stone                02          $446.00
            52320        Cystoscopy and treatment            05          $717.00
            52325        Cystoscopy, stone removal           04          $630.00
            52327        Cystoscopy, inject material         02          $446.00
            52330        Cystoscopy and treatment            02          $446.00
            52332        Cystoscopy and treatment            02          $446.00
            52334        Create passage to kidney            03          $510.00
            52341        Cysto w/ureter stricture tx         03          $510.00
            52342        Cysto w/up stricture tx             03          $510.00
            52343        Cysto w/renal stricture tx          03          $510.00
            52344        Cysto/uretero, stricture tx         03          $510.00
            52345        Cysto/uretero w/up stricture        03          $510.00


4/22/2012                                 Page 38       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            52346        Cystouretero w/renal strict         03          $510.00
            52351        Cystouretero & or pyeloscope        03          $510.00
            52352        Cystouretero w/stone remove         04          $630.00
            52353        Cystouretero w/lithotripsy          04          $630.00
            52354        Cystouretero w/biopsy               04          $630.00
            52355        Cystouretero w/excise tumor         04          $630.00
            52400        Cystouretero w/congen repr          03          $510.00
            52402        Cystourethro cut ejacul duct        03          $510.00
            52450        Incision of prostate                03          $510.00
            52500        Revision of bladder neck            03          $510.00
            52510        Dilation prostatic urethra          03          $510.00
            52601        Prostatectomy (TURP)                04          $630.00
            52606        Control postop bleeding             01          $333.00
            52612        Prostatectomy, first stage          02          $446.00
            52614        Prostatectomy, second stage         01          $333.00
            52620        Remove residual prostate            01          $333.00
            52630        Remove prostate regrowth            02          $446.00
            52640        Relieve bladder contracture         02          $446.00
            52647        Laser surgery of prostate           09        $1,339.00
            52648        Laser surgery of prostate           09        $1,339.00
            52700        Drainage of prostate abscess        02          $446.00
            53000        Incision of urethra                 01          $333.00
            53010        Incision of urethra                 01          $333.00
            53020        Incision of urethra                 01          $333.00
            53040        Drainage of urethra abscess         02          $446.00
            53080        Drainage of urinary leakage         03          $510.00
            53200        Biopsy of urethra                   01          $333.00
            53210        Removal of urethra                  05          $717.00
            53215        Removal of urethra                  05          $717.00
            53220        Treatment of urethra lesion         02          $446.00
            53230        Removal of urethra lesion           02          $446.00
            53235        Removal of urethra lesion           03          $510.00
            53240        Surgery for urethra pouch           02          $446.00
            53250        Removal of urethra gland            02          $446.00
            53260        Treatment of urethra lesion         02          $446.00
            53265        Treatment of urethra lesion         02          $446.00
            53270        Removal of urethra gland            02          $446.00
            53275        Repair of urethra defect            02          $446.00
            53400        Revise urethra, stage 1             03          $510.00
            53405        Revise urethra, stage 2             02          $446.00
            53410        Reconstruction of urethra           02          $446.00
            53420        Reconstruct urethra, stage 1        03          $510.00
            53425        Reconstruct urethra, stage 2        02          $446.00
            53430        Reconstruction of urethra           02          $446.00
            53431        Reconstruct urethra/bladder         02          $446.00
            53440        Male sling procedure                02          $446.00
            53442        Remove/revise male sling            01          $333.00
            53444        Insert tandem cuff                  02          $446.00
            53445        Insert uro/ves nck sphincter        01          $333.00
            53446        Remove uro sphincter                01          $333.00


4/22/2012                                 Page 39       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            53447        Remove/replace ur sphincter         01         $333.00
            53449        Repair uro sphincter                01         $333.00
            53450        Revision of urethra                 01         $333.00
            53460        Revision of urethra                 01         $333.00
            53502        Repair of urethra injury            02         $446.00
            53505        Repair of urethra injury            02         $446.00
            53510        Repair of urethra injury            02         $446.00
            53515        Repair of urethra injury            02         $446.00
            53520        Repair of urethra defect            02         $446.00
            53605        Dilate urethra stricture            02         $446.00
            53665        Dilation of urethra                 01         $333.00
            54000        Slitting of prepuce                 02         $446.00
            54001        Slitting of prepuce                 02         $446.00
            54015        Drain penis lesion                  04         $630.00
            54057        Laser surg, penis lesion(s)         01         $333.00
            54060        Excision of penis lesion(s)         01         $333.00
            54065        Destruction, penis lesion(s)        01         $333.00
            54100        Biopsy of penis                     01         $333.00
            54105        Biopsy of penis                     01         $333.00
            54110        Treatment of penis lesion           02         $446.00
            54111        Treat penis lesion, graft           02         $446.00
            54112        Treat penis lesion, graft           02         $446.00
            54115        Treatment of penis lesion           01         $333.00
            54120        Partial removal of penis            02         $446.00
            54150        Circumcision w/regionl block        01         $333.00
            54160        Circumcision, neonate               02         $446.00
            54161        Circum 28 days or older             02         $446.00
            54162        Lysis penil circumic lesion         02         $446.00
            54163        Repair of circumcision              02         $446.00
            54164        Frenulotomy of penis                02         $446.00
            54205        Treatment of penis lesion           04         $630.00
            54220        Treatment of penis lesion           23         $131.50
            54300        Revision of penis                   03         $510.00
            54304        Revision of penis                   03         $510.00
            54308        Reconstruction of urethra           03         $510.00
            54312        Reconstruction of urethra           03         $510.00
            54316        Reconstruction of urethra           03         $510.00
            54318        Reconstruction of urethra           03         $510.00
            54322        Reconstruction of urethra           03         $510.00
            54324        Reconstruction of urethra           03         $510.00
            54326        Reconstruction of urethra           03         $510.00
            54328        Revise penis/urethra                03         $510.00
            54340        Secondary urethral surgery          03         $510.00
            54344        Secondary urethral surgery          03         $510.00
            54348        Secondary urethral surgery          03         $510.00
            54352        Reconstruct urethra/penis           03         $510.00
            54360        Penis plastic surgery               03         $510.00
            54380        Repair penis                        03         $510.00
            54385        Repair penis                        03         $510.00
            54400        Insert semi-rigid prosthesis        03         $510.00


4/22/2012                                  Page 40      ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            54401        Insert self-contd prosthesis        03          $510.00
            54405        Insert multi-comp penis pros        03          $510.00
            54406        Remove muti-comp penis pros         03          $510.00
            54408        Repair multi-comp penis pros        03          $510.00
            54410        Remove/replace penis prosth         03          $510.00
            54415        Remove self-contd penis pros        03          $510.00
            54416        Remv/repl penis contain pros        03          $510.00
            54420        Revision of penis                   04          $630.00
            54435        Revision of penis                   04          $630.00
            54440        Repair of penis                     04          $630.00
            54450        Preputial stretching                31          $209.48
            54500        Biopsy of testis                    01          $333.00
            54505        Biopsy of testis                    01          $333.00
            54512        Excise lesion testis                02          $446.00
            54520        Removal of testis                   03          $510.00
            54522        Orchiectomy, partial                03          $510.00
            54530        Removal of testis                   04          $630.00
            54550        Exploration for testis              04          $630.00
            54600        Reduce testis torsion               04          $630.00
            54620        Suspension of testis                03          $510.00
            54640        Suspension of testis                04          $630.00
            54660        Revision of testis                  02          $446.00
            54670        Repair testis injury                03          $510.00
            54680        Relocation of testis(es)            03          $510.00
            54690        Laparoscopy, orchiectomy            09        $1,339.00
            54700        Drainage of scrotum                 02          $446.00
            54800        Biopsy of epididymis                21          $127.16
            54830        Remove epididymis lesion            03          $510.00
            54840        Remove epididymis lesion            04          $630.00
            54860        Removal of epididymis               03          $510.00
            54861        Removal of epididymis               04          $630.00
            54865        Explore epididymis                  01          $333.00
            54900        Fusion of spermatic ducts           04          $630.00
            54901        Fusion of spermatic ducts           04          $630.00
            55040        Removal of hydrocele                03          $510.00
            55041        Removal of hydroceles               05          $717.00
            55060        Repair of hydrocele                 04          $630.00
            55100        Drainage of scrotum abscess         01          $333.00
            55110        Explore scrotum                     02          $446.00
            55120        Removal of scrotum lesion           02          $446.00
            55150        Removal of scrotum                  01          $333.00
            55175        Revision of scrotum                 01          $333.00
            55180        Revision of scrotum                 02          $446.00
            55200        Incision of sperm duct              02          $446.00
            55250        Removal of sperm duct(s)            02          $446.00
            55400        Repair of sperm duct                01          $333.00
            55500        Removal of hydrocele                03          $510.00
            55520        Removal of sperm cord lesion        04          $630.00
            55530        Revise spermatic cord veins         04          $630.00
            55535        Revise spermatic cord veins         04          $630.00


4/22/2012                                Page 41        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            55540        Revise hernia & sperm veins         05          $717.00
            55550        Laparo ligate spermatic vein        09        $1,339.00
            55680        Remove sperm pouch lesion           01          $333.00
            55700        Biopsy of prostate                  44          $345.83
            55705        Biopsy of prostate                  44          $345.83
            55720        Drainage of prostate abscess        01          $333.00
            55725        Drainage of prostate abscess        02          $446.00
            55873        Cryoablate prostate                 09        $1,339.00
            55875        Transperi needle place, pros        09        $1,339.00
            56440        Surgery for vulva lesion            02          $446.00
            56441        Lysis of labial lesion(s)           01          $333.00
            56442        Hymenotomy                          01          $333.00
            56515        Destroy vulva lesion/s compl        03          $510.00
            56620        Partial removal of vulva            05          $717.00
            56625        Complete removal of vulva           07          $995.00
            56700        Partial removal of hymen            01          $333.00
            56740        Remove vagina gland lesion          03          $510.00
            56800        Repair of vagina                    03          $510.00
            56810        Repair of perineum                  05          $717.00
            57000        Exploration of vagina               01          $333.00
            57010        Drainage of pelvic abscess          02          $446.00
            57020        Drainage of pelvic fluid            50          $409.33
            57023        I & d vag hematoma, non-ob          01          $333.00
            57065        Destroy vag lesions, complex        01          $333.00
            57105        Biopsy of vagina                    02          $446.00
            57130        Remove vagina lesion                02          $446.00
            57135        Remove vagina lesion                02          $446.00
            57155        Insert uteri tandems/ovoids         50          $409.33
            57180        Treat vaginal bleeding              29          $178.05
            57200        Repair of vagina                    01          $333.00
            57210        Repair vagina/perineum              02          $446.00
            57220        Revision of urethra                 03          $510.00
            57230        Repair of urethral lesion           03          $510.00
            57240        Repair bladder & vagina             05          $717.00
            57250        Repair rectum & vagina              05          $717.00
            57260        Repair of vagina                    05          $717.00
            57265        Extensive repair of vagina          07          $995.00
            57267        Insert mesh/pelvic flr addon        07          $995.00
            57268        Repair of bowel bulge               03          $510.00
            57288        Repair bladder defect               05          $717.00
            57289        Repair bladder & vagina             05          $717.00
            57291        Construction of vagina              05          $717.00
            57300        Repair rectum-vagina fistula        03          $510.00
            57400        Dilation of vagina                  02          $446.00
            57410        Pelvic examination                  02          $446.00
            57415        Remove vaginal foreign body         02          $446.00
            57513        Laser surgery of cervix             02          $446.00
            57520        Conization of cervix                02          $446.00
            57522        Conization of cervix                02          $446.00
            57530        Removal of cervix                   03          $510.00


4/22/2012                                 Page 42       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            57550        Removal of residual cervix          03          $510.00
            57556        Remove cervix, repair bowel         05          $717.00
            57558        D&c of cervical stump               03          $510.00
            57700        Revision of cervix                  01          $333.00
            57720        Revision of cervix                  03          $510.00
            58120        Dilation and curettage              02          $446.00
            58145        Myomectomy vag method               05          $717.00
            58346        Insert heyman uteri capsule         02          $446.00
            58350        Reopen fallopian tube               03          $510.00
            58353        Endometr ablate, thermal            07          $995.00
            58545        Laparoscopic myomectomy             09        $1,339.00
            58546        Laparo-myomectomy, complex          09        $1,339.00
            58550        Laparo-asst vag hysterectomy        09        $1,339.00
            58555        Hysteroscopy, dx, sep proc          01          $333.00
            58558        Hysteroscopy, biopsy                03          $510.00
            58559        Hysteroscopy, lysis                 02          $446.00
            58560        Hysteroscopy, resect septum         03          $510.00
            58561        Hysteroscopy, remove myoma          03          $510.00
            58562        Hysteroscopy, remove fb             03          $510.00
            58563        Hysteroscopy, ablation              09        $1,339.00
            58565        Hysteroscopy, sterilization         09        $1,339.00
            58660        Laparoscopy, lysis                  05          $717.00
            58661        Laparoscopy, remove adnexa          05          $717.00
            58662        Laparoscopy, excise lesions         05          $717.00
            58670        Laparoscopy, tubal cautery          03          $510.00
            58671        Laparoscopy, tubal block            03          $510.00
            58672        Laparoscopy, fimbrioplasty          05          $717.00
            58673        Laparoscopy, salpingostomy          05          $717.00
            58800        Drainage of ovarian cyst(s)         03          $510.00
            58820        Drain ovary abscess, open           03          $510.00
            58900        Biopsy of ovary(s)                  03          $510.00
            58970        Retrieval of oocyte                 36          $245.92
            58974        Transfer of embryo                  36          $245.92
            58976        Transfer of embryo                  36          $245.92
            59160        D& c after delivery                 03          $510.00
            59320        Revision of cervix                  01          $333.00
            59812        Treatment of miscarriage            05          $717.00
            59820        Care of miscarriage                 05          $717.00
            59821        Treatment of miscarriage            05          $717.00
            59840        Abortion                            05          $717.00
            59841        Abortion                            05          $717.00
            59870        Evacuate mole of uterus             05          $717.00
            59871        Remove cerclage suture              05          $717.00
            60000        Drain thyroid/tongue cyst           01          $333.00
            60200        Remove thyroid lesion               02          $446.00
            60280        Remove thyroid duct lesion          04          $630.00
            60281        Remove thyroid duct lesion          04          $630.00
            61020        Remove brain cavity fluid           30          $183.83
            61026        Injection into brain canal          30          $183.83
            61050        Remove brain canal fluid            30          $183.83


4/22/2012                                Page 43        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            61055        Injection into brain canal          30          $183.83
            61070        Brain canal shunt procedure         30          $183.83
            61215        Insert brain-fluid device           03          $510.00
            61790        Treat trigeminal nerve              03          $510.00
            61791        Treat trigeminal tract              45          $351.92
            61795        Brain surgery using computer        39          $302.04
            61885        Insrt/redo neurostim 1 array        02          $446.00
            61886        Implant neurostim arrays            03          $510.00
            61888        Revise/remove neuroreceiver         01          $333.00
            62194        Replace/irrigate catheter           01          $333.00
            62225        Replace/irrigate catheter           01          $333.00
            62230        Replace/revise brain shunt          02          $446.00
            62263        Epidural lysis mult sessions        01          $333.00
            62264        Epidural lysis on single day        01          $333.00
            62268        Drain spinal cord cyst              30          $183.83
            62269        Needle biopsy, spinal cord          01          $333.00
            62270        Spinal fluid tap, diagnostic        25          $139.00
            62272        Drain cerebro spinal fluid          25          $139.00
            62273        Inject epidural patch               01          $333.00
            62280        Treat spinal cord lesion            01          $333.00
            62281        Treat spinal cord lesion            01          $333.00
            62282        Treat spinal canal lesion           01          $333.00
            62287        Percutaneous diskectomy             09        $1,339.00
            62294        Injection into spinal artery        30          $183.83
            62310        Inject spine c/t                    01          $333.00
            62311        Inject spine l/s (cd)               01          $333.00
            62318        Inject spine w/cath, c/t            01          $333.00
            62319        Inject spine w/cath l/s (cd)        01          $333.00
            62350        Implant spinal canal cath           02          $446.00
            62355        Remove spinal canal catheter        02          $446.00
            62360        Insert spine infusion device        02          $446.00
            62361        Implant spine infusion pump         02          $446.00
            62362        Implant spine infusion pump         02          $446.00
            62365        Remove spine infusion device        02          $446.00
            63600        Remove spinal cord lesion           02          $446.00
            63610        Stimulation of spinal cord          01          $333.00
            63650        Implant neuroelectrodes             02          $446.00
            63660        Revise/remove neuroelectrode        01          $333.00
            63685        Insrt/redo spine n generator        02          $446.00
            63688        Revise/remove neuroreceiver         01          $333.00
            63744        Revision of spinal shunt            03          $510.00
            63746        Removal of spinal shunt             02          $446.00
            64410        Nblock inj, phrenic                 01          $333.00
            64415        Nblock inj, brachial plexus         25          $139.00
            64417        Nblock inj, axillary                25          $139.00
            64420        Nblock inj, intercost, sng          25          $139.00
            64421        Nblock inj, intercost, mlt          01          $333.00
            64430        Nblock inj, pudendal                25          $139.00
            64470        Inj paravertebral c/t               01          $333.00
            64472        Inj paravertebral c/t add-on        01          $333.00


4/22/2012                                Page 44        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            64475        Inj paravertebral l/s               01         $333.00
            64476        Inj paravertebral l/s add-on        01         $333.00
            64479        Inj foramen epidural c/t            01         $333.00
            64480        Inj foramen epidural add-on         01         $333.00
            64483        Inj foramen epidural l/s            01         $333.00
            64484        Inj foramen epidural add-on         01         $333.00
            64510        Nblock, stellate ganglion           01         $333.00
            64517        Nblock inj, hypogas plxs            25         $139.00
            64520        Nblock, lumbar/thoracic             01         $333.00
            64530        Nblock inj, celiac pelus            01         $333.00
            64553        Implant neuroelectrodes             01         $333.00
            64561        Implant neuroelectrodes             03         $510.00
            64573        Implant neuroelectrodes             01         $333.00
            64575        Implant neuroelectrodes             01         $333.00
            64577        Implant neuroelectrodes             01         $333.00
            64580        Implant neuroelectrodes             01         $333.00
            64581        Implant neuroelectrodes             03         $510.00
            64585        Revise/remove neuroelectrode        01         $333.00
            64590        Insrt/redo pn/gastr stimul          02         $446.00
            64595        Revise/rmv pn/gastr stimul          01         $333.00
            64600        Injection treatment of nerve        01         $333.00
            64605        Injection treatment of nerve        01         $333.00
            64610        Injection treatment of nerve        01         $333.00
            64620        Injection treatment of nerve        01         $333.00
            64622        Destr paravertebrl nerve l/s        01         $333.00
            64623        Destr paravertebral n add-on        01         $333.00
            64626        Destr paravertebrl nerve c/t        01         $333.00
            64627        Destr paravertebral n add-on        01         $333.00
            64630        Injection treatment of nerve        45         $351.92
            64680        Injection treatment of nerve        47         $390.95
            64681        Injection treatment of nerve        02         $446.00
            64702        Revise finger/toe nerve             01         $333.00
            64704        Revise hand/foot nerve              01         $333.00
            64708        Revise arm/leg nerve                02         $446.00
            64712        Revision of sciatic nerve           02         $446.00
            64713        Revision of arm nerve(s)            02         $446.00
            64714        Revise low back nerve(s)            02         $446.00
            64716        Revision of cranial nerve           03         $510.00
            64718        Revise ulnar nerve at elbow         02         $446.00
            64719        Revise ulnar nerve at wrist         02         $446.00
            64721        Carpal tunnel surgery               02         $446.00
            64722        Relieve pressure on nerve(s)        01         $333.00
            64726        Release foot/toe nerve              01         $333.00
            64727        Internal nerve revision             01         $333.00
            64732        Incision of brow nerve              02         $446.00
            64734        Incision of cheek nerve             02         $446.00
            64736        Incision of chin nerve              02         $446.00
            64738        Incision of jaw nerve               02         $446.00
            64740        Incision of tongue nerve            02         $446.00
            64742        Incision of facial nerve            02         $446.00


4/22/2012                                Page 45        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            64744        Incise nerve, back of head          02         $446.00
            64746        Incise diaphragm nerve              02         $446.00
            64771        Sever cranial nerve                 02         $446.00
            64772        Incision of spinal nerve            02         $446.00
            64774        Remove skin nerve lesion            02         $446.00
            64776        Remove digit nerve lesion           03         $510.00
            64778        Digit nerve surgery add-on          02         $446.00
            64782        Remove limb nerve lesion            03         $510.00
            64783        Limb nerve surgery add-on           02         $446.00
            64784        Remove nerve lesion                 03         $510.00
            64786        Remove sciatic nerve lesion         03         $510.00
            64787        Implant nerve end                   02         $446.00
            64788        Remove skin nerve lesion            03         $510.00
            64790        Removal of nerve lesion             03         $510.00
            64792        Removal of nerve lesion             03         $510.00
            64795        Biopsy of nerve                     02         $446.00
            64802        Remove sympathetic nerves           02         $446.00
            64821        Remove sympathetic nerves           04         $630.00
            64831        Repair of digit nerve               04         $630.00
            64832        Repair nerve add-on                 01         $333.00
            64834        Repair of hand or foot nerve        02         $446.00
            64835        Repair of hand or foot nerve        03         $510.00
            64836        Repair of hand or foot nerve        03         $510.00
            64837        Repair nerve add-on                 01         $333.00
            64840        Repair of leg nerve                 02         $446.00
            64856        Repair/transpose nerve              02         $446.00
            64857        Repair arm/leg nerve                02         $446.00
            64858        Repair sciatic nerve                02         $446.00
            64859        Nerve surgery                       01         $333.00
            64861        Repair of arm nerves                03         $510.00
            64862        Repair of low back nerves           03         $510.00
            64864        Repair of facial nerve              03         $510.00
            64865        Repair of facial nerve              04         $630.00
            64870        Fusion of facial/other nerve        04         $630.00
            64872        Subsequent repair of nerve          02         $446.00
            64874        Repair & revise nerve add-on        03         $510.00
            64876        Repair nerve/shorten bone           03         $510.00
            64885        Nerve graft, head or neck           02         $446.00
            64886        Nerve graft, head or neck           02         $446.00
            64890        Nerve graft, hand or foot           02         $446.00
            64891        Nerve graft, hand or foot           02         $446.00
            64892        Nerve graft, arm or leg             02         $446.00
            64893        Nerve graft, arm or leg             02         $446.00
            64895        Nerve graft, hand or foot           03         $510.00
            64896        Nerve graft, hand or foot           03         $510.00
            64897        Nerve graft, arm or leg             03         $510.00
            64898        Nerve graft, arm or leg             03         $510.00
            64901        Nerve graft add-on                  02         $446.00
            64902        Nerve graft add-on                  02         $446.00
            64905        Nerve pedicle transfer              02         $446.00


4/22/2012                                 Page 46       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            64907        Nerve pedicle transfer              01         $333.00
            65091        Revise eye                          03         $510.00
            65093        Revise eye with implant             03         $510.00
            65101        Removal of eye                      03         $510.00
            65103        Remove eye/insert implant           03         $510.00
            65105        Remove eye/attach implant           04         $630.00
            65110        Removal of eye                      05         $717.00
            65112        Remove eye/revise socket            07         $995.00
            65114        Remove eye/revise socket            07         $995.00
            65130        Insert ocular implant               03         $510.00
            65135        Insert ocular implant               02         $446.00
            65140        Attach ocular implant               03         $510.00
            65150        Revise ocular implant               02         $446.00
            65155        Reinsert ocular implant             03         $510.00
            65175        Removal of ocular implant           01         $333.00
            65235        Remove foreign body from eye        02         $446.00
            65260        Remove foreign body from eye        03         $510.00
            65265        Remove foreign body from eye        04         $630.00
            65270        Repair of eye wound                 02         $446.00
            65272        Repair of eye wound                 02         $446.00
            65275        Repair of eye wound                 04         $630.00
            65280        Repair of eye wound                 04         $630.00
            65285        Repair of eye wound                 04         $630.00
            65290        Repair of eye socket wound          03         $510.00
            65400        Removal of eye lesion               01         $333.00
            65410        Biopsy of cornea                    02         $446.00
            65420        Removal of eye lesion               02         $446.00
            65426        Removal of eye lesion               05         $717.00
            65710        Corneal transplant                  07         $995.00
            65730        Corneal transplant                  07         $995.00
            65750        Corneal transplant                  07         $995.00
            65755        Corneal transplant                  07         $995.00
            65770        Revise cornea with implant          07         $995.00
            65772        Correction of astigmatism           04         $630.00
            65775        Correction of astigmatism           04         $630.00
            65780        Ocular reconst, transplant          05         $717.00
            65781        Ocular reconst, transplant          05         $717.00
            65782        Ocular reconst, transplant          05         $717.00
            65800        Drainage of eye                     01         $333.00
            65805        Drainage of eye                     01         $333.00
            65810        Drainage of eye                     03         $510.00
            65815        Drainage of eye                     02         $446.00
            65820        Relieve inner eye pressure          01         $333.00
            65850        Incision of eye                     04         $630.00
            65865        Incise inner eye adhesions          01         $333.00
            65870        Incise inner eye adhesions          04         $630.00
            65875        Incise inner eye adhesions          04         $630.00
            65880        Incise inner eye adhesions          04         $630.00
            65900        Remove eye lesion                   05         $717.00
            65920        Remove implant of eye               07         $995.00


4/22/2012                                Page 47        ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                  Ambulatory Surgery Center


             Procedure                                         Pricer   07/01/08
               Code                Short Description           Group      Rate
            65930        Remove blood clot from eye           05         $717.00
            66020        Injection treatment of eye           01         $333.00
            66030        Injection treatment of eye           01         $333.00
            66130        Remove eye lesion                    07         $995.00
            66150        Glaucoma surgery                     04         $630.00
            66155        Glaucoma surgery                     04         $630.00
            66160        Glaucoma surgery                     02         $446.00
            66165        Glaucoma surgery                     04         $630.00
            66170        Glaucoma surgery                     04         $630.00
            66172        Incision of eye                      04         $630.00
            66180        Implant eye shunt                    05         $717.00
            66185        Revise eye shunt                     02         $446.00
            66220        Repair eye lesion                    03         $510.00
            66225        Repair/graft eye lesion              04         $630.00
            66250        Follow-up surgery of eye             02         $446.00
            66500        Incision of iris                     01         $333.00
            66505        Incision of iris                     01         $333.00
            66600        Remove iris and lesion               03         $510.00
            66605        Removal of iris                      03         $510.00
            66625        Removal of iris                      46         $372.94
            66630        Removal of iris                      03         $510.00
            66635        Removal of iris                      03         $510.00
            66680        Repair iris & ciliary body           03         $510.00
            66682        Repair iris & ciliary body           02         $446.00
            66700        Destruction, ciliary body            02         $446.00
            66710        Ciliary transsleral therapy          02         $446.00
            66711        Ciliary endoscopic ablation          02         $446.00
            66720        Destruction, ciliary body            02         $446.00
            66740        Destruction, ciliary body            02         $446.00
            66821        After cataract laser surgery         41         $312.50
            66825        Reposition intraocular lens          04         $630.00
            66830        Removal of lens lesion               46         $372.94
            66840        Removal of lens material             04         $630.00
            66850        Removal of lens material             07         $995.00
            66852        Removal of lens material             04         $630.00
            66920        Extraction of lens                   04         $630.00
            66930        Extraction of lens                   05         $717.00
            66940        Extraction of lens                   05         $717.00
            66982        Cataract surgery, complex            08         $973.00
            66983        Cataract surg w/iol, 1 stage         08         $973.00
            66984        Cataract surg w/iol, 1 stage         08         $973.00
            66985        Insert lens prosthesis               06         $826.00
            66986        Exchange lens prosthesis             06         $826.00
            67005        Partial removal of eye fluid         04         $630.00
            67010        Partial removal of eye fluid         04         $630.00
            67015        Release of eye fluid                 01         $333.00
            67025        Replace eye fluid                    01         $333.00
            67027        Implant eye drug system              04         $630.00
            67030        Incise inner eye strands             01         $333.00
            67031        Laser surgery, eye strands           41         $312.50


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                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            67036        Removal of inner eye fluid          04         $630.00
            67038        Strip retinal membrane              05         $717.00
            67039        Laser treatment of retina           07         $995.00
            67040        Laser treatment of retina           07         $995.00
            67107        Repair detached retina              05         $717.00
            67108        Repair detached retina              07         $995.00
            67112        Rerepair detached retina            07         $995.00
            67115        Release encircling material         02         $446.00
            67120        Remove eye implant material         02         $446.00
            67121        Remove eye implant material         02         $446.00
            67141        Treatment of retina                 35         $241.77
            67218        Treatment of retinal lesion         05         $717.00
            67227        Treatment of retinal lesion         01         $333.00
            67250        Reinforce eye wall                  03         $510.00
            67255        Reinforce/graft eye wall            03         $510.00
            67311        Revise eye muscle                   03         $510.00
            67312        Revise two eye muscles              04         $630.00
            67314        Revise eye muscle                   04         $630.00
            67316        Revise two eye muscles              04         $630.00
            67318        Revise eye muscle(s)                04         $630.00
            67320        Revise eye muscle(s) add-on         04         $630.00
            67331        Eye surgery follow-up add-on        04         $630.00
            67332        Rerevise eye muscles add-on         04         $630.00
            67334        Revise eye muscle w/suture          04         $630.00
            67335        Eye suture during surgery           04         $630.00
            67340        Revise eye muscle add-on            04         $630.00
            67343        Release eye tissue                  07         $995.00
            67346        Biopsy, eye muscle                  01         $333.00
            67400        Explore/biopsy eye socket           03         $510.00
            67405        Explore/drain eye socket            04         $630.00
            67412        Explore/treat eye socket            05         $717.00
            67413        Explore/treat eye socket            05         $717.00
            67415        Aspiration, orbital contents        01         $333.00
            67420        Explore/treat eye socket            05         $717.00
            67430        Explore/treat eye socket            05         $717.00
            67440        Explore/drain eye socket            05         $717.00
            67445        Explr/decompress eye socket         05         $717.00
            67450        Explore/biopsy eye socket           05         $717.00
            67550        Insert eye socket implant           04         $630.00
            67560        Revise eye socket implant           02         $446.00
            67570        Decompress optic nerve              04         $630.00
            67715        Incision of eyelid fold             01         $333.00
            67808        Remove eyelid lesion(s)             02         $446.00
            67830        Revise eyelashes                    02         $446.00
            67835        Revise eyelashes                    02         $446.00
            67880        Revision of eyelid                  03         $510.00
            67882        Revision of eyelid                  03         $510.00
            67900        Repair brow defect                  04         $630.00
            67901        Repair eyelid defect                05         $717.00
            67902        Repair eyelid defect                05         $717.00


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                                  Ambulatory Surgery Center


             Procedure                                         Pricer   07/01/08
               Code                Short Description           Group      Rate
            67903        Repair eyelid defect                 04         $630.00
            67904        Repair eyelid defect                 04         $630.00
            67906        Repair eyelid defect                 05         $717.00
            67908        Repair eyelid defect                 04         $630.00
            67909        Revise eyelid defect                 04         $630.00
            67911        Revise eyelid defect                 03         $510.00
            67912        Correction eyelid w/implant          03         $510.00
            67914        Repair eyelid defect                 03         $510.00
            67916        Repair eyelid defect                 04         $630.00
            67917        Repair eyelid defect                 04         $630.00
            67921        Repair eyelid defect                 03         $510.00
            67923        Repair eyelid defect                 04         $630.00
            67924        Repair eyelid defect                 04         $630.00
            67935        Repair eyelid wound                  02         $446.00
            67950        Revision of eyelid                   02         $446.00
            67961        Revision of eyelid                   03         $510.00
            67966        Revision of eyelid                   03         $510.00
            67971        Reconstruction of eyelid             03         $510.00
            67973        Reconstruction of eyelid             03         $510.00
            67974        Reconstruction of eyelid             03         $510.00
            67975        Reconstruction of eyelid             03         $510.00
            68115        Remove eyelid lining lesion          02         $446.00
            68130        Remove eyelid lining lesion          02         $446.00
            68320        Revise/graft eyelid lining           04         $630.00
            68325        Revise/graft eyelid lining           04         $630.00
            68326        Revise/graft eyelid lining           04         $630.00
            68328        Revise/graft eyelid lining           04         $630.00
            68330        Revise eyelid lining                 04         $630.00
            68335        Revise/graft eyelid lining           04         $630.00
            68340        Separate eyelid adhesions            04         $630.00
            68360        Revise eyelid lining                 02         $446.00
            68362        Revise eyelid lining                 02         $446.00
            68371        Harvest eye tissue, alograft         02         $446.00
            68500        Removal of tear gland                03         $510.00
            68505        Partial removal, tear gland          03         $510.00
            68510        Biopsy of tear gland                 01         $333.00
            68520        Removal of tear sac                  03         $510.00
            68525        Biopsy of tear sac                   01         $333.00
            68540        Remove tear gland lesion             03         $510.00
            68550        Remove tear gland lesion             03         $510.00
            68700        Repair tear ducts                    02         $446.00
            68720        Create tear sac drain                04         $630.00
            68745        Create tear duct drain               04         $630.00
            68750        Create tear duct drain               04         $630.00
            68770        Close tear system fistula            04         $630.00
            68810        Probe nasolacrimal duct              24         $131.86
            68811        Probe nasolacrimal duct              02         $446.00
            68815        Probe nasolacrimal duct              02         $446.00
            69110        Remove external ear, partial         01         $333.00
            69120        Removal of external ear              02         $446.00


4/22/2012                                  Page 50      ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code               Short Description           Group      Rate
            69140        Remove ear canal lesion(s)          02          $446.00
            69145        Remove ear canal lesion(s)          02          $446.00
            69150        Extensive ear canal surgery         53          $464.15
            69205        Clear outer ear canal               01          $333.00
            69300        Revise external ear                 03          $510.00
            69310        Rebuild outer ear canal             03          $510.00
            69320        Rebuild outer ear canal             07          $995.00
            69421        Incision of eardrum                 03          $510.00
            69436        Create eardrum opening              03          $510.00
            69440        Exploration of middle ear           03          $510.00
            69450        Eardrum revision                    01          $333.00
            69501        Mastoidectomy                       07          $995.00
            69502        Mastoidectomy                       07          $995.00
            69505        Remove mastoid structures           07          $995.00
            69511        Extensive mastoid surgery           07          $995.00
            69530        Extensive mastoid surgery           07          $995.00
            69550        Remove ear lesion                   05          $717.00
            69552        Remove ear lesion                   07          $995.00
            69601        Mastoid surgery revision            07          $995.00
            69602        Mastoid surgery revision            07          $995.00
            69603        Mastoid surgery revision            07          $995.00
            69604        Mastoid surgery revision            07          $995.00
            69605        Mastoid surgery revision            07          $995.00
            69620        Repair of eardrum                   02          $446.00
            69631        Repair eardrum structures           05          $717.00
            69632        Rebuild eardrum structures          05          $717.00
            69633        Rebuild eardrum structures          05          $717.00
            69635        Repair eardrum structures           07          $995.00
            69636        Rebuild eardrum structures          07          $995.00
            69637        Rebuild eardrum structures          07          $995.00
            69641        Revise middle ear & mastoid         07          $995.00
            69642        Revise middle ear & mastoid         07          $995.00
            69643        Revise middle ear & mastoid         07          $995.00
            69644        Revise middle ear & mastoid         07          $995.00
            69645        Revise middle ear & mastoid         07          $995.00
            69646        Revise middle ear & mastoid         07          $995.00
            69650        Release middle ear bone             07          $995.00
            69660        Revise middle ear bone              05          $717.00
            69661        Revise middle ear bone              05          $717.00
            69662        Revise middle ear bone              05          $717.00
            69666        Repair middle ear structures        04          $630.00
            69667        Repair middle ear structures        04          $630.00
            69670        Remove mastoid air cells            03          $510.00
            69676        Remove middle ear nerve             03          $510.00
            69700        Close mastoid fistula               03          $510.00
            69711        Remove/repair hearing aid           01          $333.00
            69714        Implant temple bone w/stimul        09        $1,339.00
            69715        Temple bne implnt w/stimulat        09        $1,339.00
            69717        Temple bone implant revision        09        $1,339.00
            69718        Revise temple bone implant          09        $1,339.00


4/22/2012                                 Page 51       ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                 Ambulatory Surgery Center


             Procedure                                        Pricer   07/01/08
               Code                Short Description          Group      Rate
            69720        Release facial nerve                05          $717.00
            69740        Repair facial nerve                 05          $717.00
            69745        Repair facial nerve                 05          $717.00
            69801        Incise inner ear                    05          $717.00
            69802        Incise inner ear                    07          $995.00
            69805        Explore inner ear                   07          $995.00
            69806        Explore inner ear                   07          $995.00
            69820        Establish inner ear window          05          $717.00
            69840        Revise inner ear window             05          $717.00
            69905        Remove inner ear                    07          $995.00
            69910        Remove inner ear & mastoid          07          $995.00
            69915        Incise inner ear nerve              07          $995.00
            69930        Implant cochlear device             07          $995.00
            0176T        Aqu canal dilat w/o retent          09        $1,339.00
            0177T        Aqu canal dilat w retent            09        $1,339.00
            G0105        Colorectal scrn; hi risk ind        02          $446.00
            G0121        Colon ca scrn not hi rsk ind        02          $446.00
            G0260        Inj for sacroiliac jt anesth        01          $333.00
            G0392        AV fistula or graft arterial        09        $1,339.00
            G0393        AV fistula or graft venous          09        $1,339.00




4/22/2012                                  Page 52      ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH      Pricing    Charge
5 - Independent Laboratory        36415                                                 M
                                               36415 - COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE     07/01/2006           $2.85
                                  36415
H - Laboratory Billed by Outpatient Hospital                                            M
                                               36415 - COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE     07/01/2006           $2.85
I - Laboratory Billed by Physician36415                                                 M
                                               36415 - COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE     07/01/2006           $2.85
5 - Independent Laboratory        78267                                                 M             FOR ANALYSIS
                                               78267 - UREA BREATH TEST, C-14 (ISOTOPIC); ACQUISITION 07/01/2006         $10.43
                                  78267
H - Laboratory Billed by Outpatient Hospital                                            M             FOR ANALYSIS
                                               78267 - UREA BREATH TEST, C-14 (ISOTOPIC); ACQUISITION 07/01/2006         $10.43
I - Laboratory Billed by Physician78267                                                 M             FOR ANALYSIS
                                               78267 - UREA BREATH TEST, C-14 (ISOTOPIC); ACQUISITION 07/01/2006         $10.43
5 - Independent Laboratory        78268                                                 M
                                               78268 - UREA BREATH TEST, C-14 (ISOTOPIC); ANALYSIS    07/01/2006         $89.40
                                  78268
H - Laboratory Billed by Outpatient Hospital                                            M
                                               78268 - UREA BREATH TEST, C-14 (ISOTOPIC); ANALYSIS    07/01/2006         $89.40
I - Laboratory Billed by Physician78268                                                 M
                                               78268 - UREA BREATH TEST, C-14 (ISOTOPIC); ANALYSIS    07/01/2006         $89.40
5 - Independent Laboratory        80048        80048 - BASIC METABOLIC PANEL            M             07/01/2006         $11.24
                                  80048
H - Laboratory Billed by Outpatient Hospital   80048 - BASIC METABOLIC PANEL            M             07/01/2006         $11.24
I - Laboratory Billed by Physician80048        80048 - BASIC METABOLIC PANEL            M             07/01/2006         $11.24
                                  80049
H - Laboratory Billed by Outpatient Hospital   80049 - BASIC METABOLIC PANEL            M             07/01/2000         $18.83
5 - Independent Laboratory        80050        80050 - GENERAL HEALTH PANEL             M             07/01/2006         $48.56
                                  80050
H - Laboratory Billed by Outpatient Hospital   80050 - GENERAL HEALTH PANEL             M             07/01/2006         $48.56
I - Laboratory Billed by Physician80050        80050 - GENERAL HEALTH PANEL             M             07/01/2006         $48.56
5 - Independent Laboratory        80051        80051 - ELECTROLYTE PANEL                M             07/01/2006           $9.31
                                  80051
H - Laboratory Billed by Outpatient Hospital   80051 - ELECTROLYTE PANEL                M             07/01/2006           $9.31
I - Laboratory Billed by Physician80051        80051 - ELECTROLYTE PANEL                M             07/01/2006           $9.31
5 - Independent Laboratory        80053        80053 - COMPREHENSIVE METABOLIC PANELM                 07/01/2006         $14.03
                                  80053
H - Laboratory Billed by Outpatient Hospital   80053 - COMPREHENSIVE METABOLIC PANELM                 07/01/2006         $14.03
I - Laboratory Billed by Physician80053        80053 - COMPREHENSIVE METABOLIC PANELM                 07/01/2006         $14.03
                                  80054
H - Laboratory Billed by Outpatient Hospital   80054 - COMPREHENSIVE METABOLIC PANELM                 07/01/2000         $24.36
5 - Independent Laboratory        80055        80055 - OBSTETRIC PANEL                  M             07/01/2006         $19.81
                                  80055
H - Laboratory Billed by Outpatient Hospital   80055 - OBSTETRIC PANEL                  M             07/01/2006         $19.81
I - Laboratory Billed by Physician80055        80055 - OBSTETRIC PANEL                  M             07/01/2006         $19.81
5 - Independent Laboratory        80061        80061 - LIPID PANEL                      M             07/01/2006         $17.78
                                  80061
H - Laboratory Billed by Outpatient Hospital   80061 - LIPID PANEL                      M             07/01/2006         $17.78
I - Laboratory Billed by Physician80061        80061 - LIPID PANEL                      M             07/01/2006         $17.78
5 - Independent Laboratory        80069        80069 - RENAL FUNCTION PANEL             M             07/01/2006         $11.52
                                  80069
H - Laboratory Billed by Outpatient Hospital   80069 - RENAL FUNCTION PANEL             M             07/01/2006         $11.52
I - Laboratory Billed by Physician80069        80069 - RENAL FUNCTION PANEL             M             07/01/2006         $11.52
5 - Independent Laboratory        80074        80074 - ACUTE HEPATITIS PANEL            M             07/01/2006         $63.21
                                  80074
H - Laboratory Billed by Outpatient Hospital   80074 - ACUTE HEPATITIS PANEL            M             07/01/2006         $63.21
I - Laboratory Billed by Physician80074        80074 - ACUTE HEPATITIS PANEL            M             07/01/2006         $63.21
5 - Independent Laboratory        80076        80076 - HEPATIC FUNCTION PANEL           M             07/01/2006         $10.85
                                  80076
H - Laboratory Billed by Outpatient Hospital   80076 - HEPATIC FUNCTION PANEL           M             07/01/2006         $10.85
I - Laboratory Billed by Physician80076        80076 - HEPATIC FUNCTION PANEL           M             07/01/2006         $10.85
5 - Independent Laboratory        80100                                                 M             07/01/2006           $5.00
                                               80100 - DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES CHROMATOGRAPHIC METHOD, EAC
                                  80100
H - Laboratory Billed by Outpatient Hospital                                            M             07/01/2006           $5.00
                                               80100 - DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES CHROMATOGRAPHIC METHOD, EAC
I - Laboratory Billed by Physician80100                                                 M             07/01/2006           $5.00
                                               80100 - DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES CHROMATOGRAPHIC METHOD, EAC
5 - Independent Laboratory        80101                                                 M             METHOD (EG, IMMUNOASSAY, ENZYME AS
                                               80101 - DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS 07/01/2006              $5.00
                                  80101
H - Laboratory Billed by Outpatient Hospital                                            M             METHOD (EG, IMMUNOASSAY, ENZYME AS
                                               80101 - DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS 07/01/2006              $5.00
I - Laboratory Billed by Physician80101                                                 M             METHOD (EG, IMMUNOASSAY, ENZYME AS
                                               80101 - DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS 07/01/2006              $5.00
5 - Independent Laboratory        80102        80102 - DRUG CONFIRMATION, EACH PROCEDUREM             07/01/2006         $17.58
                                  80102
H - Laboratory Billed by Outpatient Hospital   80102 - DRUG CONFIRMATION, EACH PROCEDUREM             07/01/2006         $17.58
I - Laboratory Billed by Physician80102        80102 - DRUG CONFIRMATION, EACH PROCEDUREM             07/01/2006         $17.58
5 - Independent Laboratory        80103                                                 M
                                               80103 - TISSUE PREPARATION FOR DRUG ANALYSIS           07/01/2006         $25.00
                                  80103
H - Laboratory Billed by Outpatient Hospital                                            M
                                               80103 - TISSUE PREPARATION FOR DRUG ANALYSIS           07/01/2006         $25.00
I - Laboratory Billed by Physician80103                                                 M
                                               80103 - TISSUE PREPARATION FOR DRUG ANALYSIS           07/01/2006         $25.00
5 - Independent Laboratory        80150        80150 - AMIKACIN                         M             07/01/2006         $20.01
                                  80150
H - Laboratory Billed by Outpatient Hospital   80150 - AMIKACIN                         M             07/01/2006         $20.01
I - Laboratory Billed by Physician80150        80150 - AMIKACIN                         M             07/01/2006         $20.01
5 - Independent Laboratory        80152        80152 - AMITRIPTYLINE                    M             07/01/2006         $23.76
                                  80152
H - Laboratory Billed by Outpatient Hospital   80152 - AMITRIPTYLINE                    M             07/01/2006         $23.76
I - Laboratory Billed by Physician80152        80152 - AMITRIPTYLINE                    M             07/01/2006         $23.76
5 - Independent Laboratory        80154        80154 - BENZODIAZEPINES                  M             07/01/2006         $24.55
                                  80154
H - Laboratory Billed by Outpatient Hospital   80154 - BENZODIAZEPINES                  M             07/01/2006         $24.55
I - Laboratory Billed by Physician80154        80154 - BENZODIAZEPINES                  M             07/01/2006         $24.55
5 - Independent Laboratory        80156        80156 - CARBAMAZEPINE; TOTAL             M             07/01/2006         $19.32
                                  80156
H - Laboratory Billed by Outpatient Hospital   80156 - CARBAMAZEPINE; TOTAL             M             07/01/2006         $19.32
I - Laboratory Billed by Physician80156        80156 - CARBAMAZEPINE; TOTAL             M             07/01/2006         $19.32
5 - Independent Laboratory        80157        80157 - CARBAMAZEPINE; FREE              M             07/01/2006         $17.59
                                  80157
H - Laboratory Billed by Outpatient Hospital   80157 - CARBAMAZEPINE; FREE              M             07/01/2006         $17.59
I - Laboratory Billed by Physician80157        80157 - CARBAMAZEPINE; FREE              M             07/01/2006         $17.59
5 - Independent Laboratory        80158        80158 - CYCLOSPORINE                     M             07/01/2006         $23.97


 4/22/2012                                                     53 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3      Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing    Charge
                                  80158
H - Laboratory Billed by Outpatient Hospital   80158 - CYCLOSPORINE                    M            07/01/2006        $23.97
I - Laboratory Billed by Physician80158        80158 - CYCLOSPORINE                    M            07/01/2006        $23.97
5 - Independent Laboratory        80160        80160 - DESIPRAMINE                     M            07/01/2006        $22.85
                                  80160
H - Laboratory Billed by Outpatient Hospital   80160 - DESIPRAMINE                     M            07/01/2006        $22.85
I - Laboratory Billed by Physician80160        80160 - DESIPRAMINE                     M            07/01/2006        $22.85
5 - Independent Laboratory        80162        80162 - DIGOXIN                         M            07/01/2006        $17.62
                                  80162
H - Laboratory Billed by Outpatient Hospital   80162 - DIGOXIN                         M            07/01/2006        $17.62
I - Laboratory Billed by Physician80162        80162 - DIGOXIN                         M            07/01/2006        $17.62
5 - Independent Laboratory        80164                                                M
                                               80164 - DIPROPYLACETIC ACID (VALPROIC ACID)          07/01/2006        $17.98
                                  80164
H - Laboratory Billed by Outpatient Hospital                                           M
                                               80164 - DIPROPYLACETIC ACID (VALPROIC ACID)          07/01/2006        $17.98
I - Laboratory Billed by Physician80164                                                M
                                               80164 - DIPROPYLACETIC ACID (VALPROIC ACID)          07/01/2006        $17.98
5 - Independent Laboratory        80166        80166 - DOXEPIN                         M            07/01/2006        $20.58
                                  80166
H - Laboratory Billed by Outpatient Hospital   80166 - DOXEPIN                         M            07/01/2006        $20.58
I - Laboratory Billed by Physician80166        80166 - DOXEPIN                         M            07/01/2006        $20.58
5 - Independent Laboratory        80168        80168 - ETHOSUXIMIDE                    M            07/01/2006        $21.69
                                  80168
H - Laboratory Billed by Outpatient Hospital   80168 - ETHOSUXIMIDE                    M            07/01/2006        $21.69
I - Laboratory Billed by Physician80168        80168 - ETHOSUXIMIDE                    M            07/01/2006        $21.69
5 - Independent Laboratory        80170        80170 - GENTAMICIN                      M            07/01/2006        $21.76
                                  80170
H - Laboratory Billed by Outpatient Hospital   80170 - GENTAMICIN                      M            07/01/2006        $21.76
I - Laboratory Billed by Physician80170        80170 - GENTAMICIN                      M            07/01/2006        $21.76
5 - Independent Laboratory        80172        80172 - GOLD                            M            07/01/2006        $21.62
                                  80172
H - Laboratory Billed by Outpatient Hospital   80172 - GOLD                            M            07/01/2006        $21.62
I - Laboratory Billed by Physician80172        80172 - GOLD                            M            07/01/2006        $21.62
5 - Independent Laboratory        80173        80173 - HALOPERIDOL                     M            07/01/2006        $19.32
                                  80173
H - Laboratory Billed by Outpatient Hospital   80173 - HALOPERIDOL                     M            07/01/2006        $19.32
I - Laboratory Billed by Physician80173        80173 - HALOPERIDOL                     M            07/01/2006        $19.32
5 - Independent Laboratory        80174        80174 - IMIPRAMINE                      M            07/01/2006        $22.85
                                  80174
H - Laboratory Billed by Outpatient Hospital   80174 - IMIPRAMINE                      M            07/01/2006        $22.85
I - Laboratory Billed by Physician80174        80174 - IMIPRAMINE                      M            07/01/2006        $22.85
5 - Independent Laboratory        80176        80176 - LIDOCAINE                       M            07/01/2006        $19.49
                                  80176
H - Laboratory Billed by Outpatient Hospital   80176 - LIDOCAINE                       M            07/01/2006        $19.49
I - Laboratory Billed by Physician80176        80176 - LIDOCAINE                       M            07/01/2006        $19.49
5 - Independent Laboratory        80178        80178 - LITHIUM                         M            07/01/2006          $8.78
                                  80178
H - Laboratory Billed by Outpatient Hospital   80178 - LITHIUM                         M            07/01/2006          $8.78
I - Laboratory Billed by Physician80178        80178 - LITHIUM                         M            07/01/2006          $8.78
5 - Independent Laboratory        80182        80182 - NORTRIPTYLINE                   M            07/01/2006        $17.98
                                  80182
H - Laboratory Billed by Outpatient Hospital   80182 - NORTRIPTYLINE                   M            07/01/2006        $17.98
I - Laboratory Billed by Physician80182        80182 - NORTRIPTYLINE                   M            07/01/2006        $17.98
5 - Independent Laboratory        80184        80184 - PHENOBARBITAL                   M            07/01/2006        $15.21
                                  80184
H - Laboratory Billed by Outpatient Hospital   80184 - PHENOBARBITAL                   M            07/01/2006        $15.21
I - Laboratory Billed by Physician80184        80184 - PHENOBARBITAL                   M            07/01/2006        $15.21
5 - Independent Laboratory        80185        80185 - PHENYTOIN; TOTAL                M            07/01/2006        $17.59
                                  80185
H - Laboratory Billed by Outpatient Hospital   80185 - PHENYTOIN; TOTAL                M            07/01/2006        $17.59
I - Laboratory Billed by Physician80185        80185 - PHENYTOIN; TOTAL                M            07/01/2006        $17.59
5 - Independent Laboratory        80186        80186 - PHENYTOIN; FREE                 M            07/01/2006        $18.27
                                  80186
H - Laboratory Billed by Outpatient Hospital   80186 - PHENYTOIN; FREE                 M            07/01/2006        $18.27
I - Laboratory Billed by Physician80186        80186 - PHENYTOIN; FREE                 M            07/01/2006        $18.27
5 - Independent Laboratory        80188        80188 - PRIMIDONE                       M            07/01/2006        $22.02
                                  80188
H - Laboratory Billed by Outpatient Hospital   80188 - PRIMIDONE                       M            07/01/2006        $22.02
I - Laboratory Billed by Physician80188        80188 - PRIMIDONE                       M            07/01/2006        $22.02
5 - Independent Laboratory        80190        80190 - PROCAINAMIDE;                   M            07/01/2006        $22.24
                                  80190
H - Laboratory Billed by Outpatient Hospital   80190 - PROCAINAMIDE;                   M            07/01/2006        $22.24
I - Laboratory Billed by Physician80190        80190 - PROCAINAMIDE;                   M            07/01/2006        $22.24
5 - Independent Laboratory        80192        80192 - PROCAINAMIDE; WITH METABOLITES M              PROCAINAMIDE)
                                                                                       (EG, N-ACETYL07/01/2006        $22.24
                                  80192
H - Laboratory Billed by Outpatient Hospital   80192 - PROCAINAMIDE; WITH METABOLITES M              PROCAINAMIDE)
                                                                                       (EG, N-ACETYL07/01/2006        $22.24
I - Laboratory Billed by Physician80192        80192 - PROCAINAMIDE; WITH METABOLITES M              PROCAINAMIDE)
                                                                                       (EG, N-ACETYL07/01/2006        $22.24
5 - Independent Laboratory        80194        80194 - QUINIDINE                       M            07/01/2006        $19.37
                                  80194
H - Laboratory Billed by Outpatient Hospital   80194 - QUINIDINE                       M            07/01/2006        $19.37
I - Laboratory Billed by Physician80194        80194 - QUINIDINE                       M            07/01/2006        $19.37
5 - Independent Laboratory        80195        80195 - SIROLIMUS                       M            07/01/2006        $18.02
                                  80195
H - Laboratory Billed by Outpatient Hospital   80195 - SIROLIMUS                       M            07/01/2006        $18.02
I - Laboratory Billed by Physician80195        80195 - SIROLIMUS                       M            07/01/2006        $18.02
5 - Independent Laboratory        80196        80196 - SALICYLATE                      M            07/01/2006          $9.42
                                  80196
H - Laboratory Billed by Outpatient Hospital   80196 - SALICYLATE                      M            07/01/2006          $9.42
I - Laboratory Billed by Physician80196        80196 - SALICYLATE                      M            07/01/2006          $9.42
5 - Independent Laboratory        80197        80197 - TACROLIMUS                      M            07/01/2006        $18.21


 4/22/2012                                                     54 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing   Charge
                                  80197
H - Laboratory Billed by Outpatient Hospital   80197 - TACROLIMUS                      M            07/01/2006        $18.21
I - Laboratory Billed by Physician80197        80197 - TACROLIMUS                      M            07/01/2006        $18.21
5 - Independent Laboratory        80198        80198 - THEOPHYLLINE                    M            07/01/2006        $18.78
                                  80198
H - Laboratory Billed by Outpatient Hospital   80198 - THEOPHYLLINE                    M            07/01/2006        $18.78
I - Laboratory Billed by Physician80198        80198 - THEOPHYLLINE                    M            07/01/2006        $18.78
5 - Independent Laboratory        80200        80200 - TOBRAMYCIN                      M            07/01/2006        $21.39
                                  80200
H - Laboratory Billed by Outpatient Hospital   80200 - TOBRAMYCIN                      M            07/01/2006        $21.39
I - Laboratory Billed by Physician80200        80200 - TOBRAMYCIN                      M            07/01/2006        $21.39
5 - Independent Laboratory        80201        80201 - TOPIRAMATE                      M            07/01/2006        $15.83
                                  80201
H - Laboratory Billed by Outpatient Hospital   80201 - TOPIRAMATE                      M            07/01/2006        $15.83
I - Laboratory Billed by Physician80201        80201 - TOPIRAMATE                      M            07/01/2006        $15.83
5 - Independent Laboratory        80202        80202 - VANCOMYCIN                      M            07/01/2006        $17.98
                                  80202
H - Laboratory Billed by Outpatient Hospital   80202 - VANCOMYCIN                      M            07/01/2006        $17.98
I - Laboratory Billed by Physician80202        80202 - VANCOMYCIN                      M            07/01/2006        $17.98
5 - Independent Laboratory        80299                                                M
                                               80299 - QUANTITATION OF DRUG, NOT ELSEWHERE SPECIFIED07/01/2006        $18.17
                                  80299
H - Laboratory Billed by Outpatient Hospital                                           M
                                               80299 - QUANTITATION OF DRUG, NOT ELSEWHERE SPECIFIED07/01/2006        $18.17
I - Laboratory Billed by Physician80299                                                M
                                               80299 - QUANTITATION OF DRUG, NOT ELSEWHERE SPECIFIED07/01/2006        $18.17
5 - Independent Laboratory        80400                                                M            07/01/2006
                                               80400 - ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY              $43.28
                                  80400
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80400 - ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY              $43.28
I - Laboratory Billed by Physician80400                                                M            07/01/2006
                                               80400 - ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY              $43.28
5 - Independent Laboratory        80402                                                M            07/01/2006
                                               80402 - ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY         $115.39
                                  80402
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80402 - ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY         $115.39
I - Laboratory Billed by Physician80402                                                M            07/01/2006
                                               80402 - ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY         $115.39
5 - Independent Laboratory        80406                                                M            07/01/2006       $103.87
                                               80406 - ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE DEFICIENCY
                                  80406
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006       $103.87
                                               80406 - ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE DEFICIENCY
I - Laboratory Billed by Physician80406                                                M            07/01/2006       $103.87
                                               80406 - ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE DEFICIENCY
5 - Independent Laboratory        80408                                                M            07/01/2006
                                               80408 - ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE INFUSION)$166.57
                                  80408
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80408 - ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE INFUSION)$166.57
I - Laboratory Billed by Physician80408                                                M            07/01/2006
                                               80408 - ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE INFUSION)$166.57
5 - Independent Laboratory        80410                                                M            07/01/2006
                                               80410 - CALCITONIN STIMULATION PANEL (EG, CALCIUM, PENTAGASTRIN)      $106.62
                                  80410
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80410 - CALCITONIN STIMULATION PANEL (EG, CALCIUM, PENTAGASTRIN)      $106.62
I - Laboratory Billed by Physician80410                                                M            07/01/2006
                                               80410 - CALCITONIN STIMULATION PANEL (EG, CALCIUM, PENTAGASTRIN)      $106.62
5 - Independent Laboratory        80412                                                M            07/01/2006
                                               80412 - CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL       $437.48
                                  80412
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80412 - CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL       $437.48
I - Laboratory Billed by Physician80412                                                M            07/01/2006
                                               80412 - CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL       $437.48
5 - Independent Laboratory        80414                                                M            07/01/2006
                                               80414 - CHORIONIC GONADOTROPIN STIMULATION PANEL; TESTOSTERONE RESPONSE$68.55
                                  80414
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80414 - CHORIONIC GONADOTROPIN STIMULATION PANEL; TESTOSTERONE RESPONSE$68.55
I - Laboratory Billed by Physician80414                                                M            07/01/2006
                                               80414 - CHORIONIC GONADOTROPIN STIMULATION PANEL; TESTOSTERONE RESPONSE$68.55
5 - Independent Laboratory        80415                                                M            07/01/2006
                                               80415 - CHORIONIC GONADOTROPIN STIMULATION PANEL; ESTRADIOL RESPONSE   $74.18
                                  80415
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80415 - CHORIONIC GONADOTROPIN STIMULATION PANEL; ESTRADIOL RESPONSE   $74.18
I - Laboratory Billed by Physician80415                                                M            07/01/2006
                                               80415 - CHORIONIC GONADOTROPIN STIMULATION PANEL; ESTRADIOL RESPONSE   $74.18
5 - Independent Laboratory        80416                                                M            07/01/2006
                                               80416 - RENAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL)            $175.16
                                  80416
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80416 - RENAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL)            $175.16
I - Laboratory Billed by Physician80416                                                M            07/01/2006
                                               80416 - RENAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL)            $175.16
5 - Independent Laboratory        80417                                                M            07/01/2006
                                               80417 - PERIPHERAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL)        $58.39
                                  80417
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80417 - PERIPHERAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL)        $58.39
I - Laboratory Billed by Physician80417                                                M            07/01/2006
                                               80417 - PERIPHERAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL)        $58.39
5 - Independent Laboratory        80418                                                M            07/01/2006
                                               80418 - COMBINED RAPID ANTERIOR PITUITARY EVALUATION PANEL            $769.27
                                  80418
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80418 - COMBINED RAPID ANTERIOR PITUITARY EVALUATION PANEL            $769.27
I - Laboratory Billed by Physician80418                                                M            07/01/2006
                                               80418 - COMBINED RAPID ANTERIOR PITUITARY EVALUATION PANEL            $769.27
5 - Independent Laboratory        80420                                                M
                                               80420 - DEXAMETHASONE SUPPRESSION PANEL, 48 HOUR 07/01/2006            $95.61
                                  80420
H - Laboratory Billed by Outpatient Hospital                                           M
                                               80420 - DEXAMETHASONE SUPPRESSION PANEL, 48 HOUR 07/01/2006            $95.61
I - Laboratory Billed by Physician80420                                                M
                                               80420 - DEXAMETHASONE SUPPRESSION PANEL, 48 HOUR 07/01/2006            $95.61
5 - Independent Laboratory        80422        80422 - GLUCAGON TOLERANCE PANEL; FOR M INSULINOMA 07/01/2006          $61.16
                                  80422
H - Laboratory Billed by Outpatient Hospital   80422 - GLUCAGON TOLERANCE PANEL; FOR M INSULINOMA 07/01/2006          $61.16
I - Laboratory Billed by Physician80422        80422 - GLUCAGON TOLERANCE PANEL; FOR M INSULINOMA 07/01/2006          $61.16
5 - Independent Laboratory        80424        80424 - GLUCAGON TOLERANCE PANEL; FOR M              07/01/2006
                                                                                       PHEOCHROMOCYTOMA               $67.03
                                  80424
H - Laboratory Billed by Outpatient Hospital   80424 - GLUCAGON TOLERANCE PANEL; FOR M              07/01/2006
                                                                                       PHEOCHROMOCYTOMA               $67.03
I - Laboratory Billed by Physician80424        80424 - GLUCAGON TOLERANCE PANEL; FOR M              07/01/2006
                                                                                       PHEOCHROMOCYTOMA               $67.03
5 - Independent Laboratory        80426                                                M            07/01/2006
                                               80426 - GONADOTROPIN RELEASING HORMONE STIMULATION PANEL              $197.03
                                  80426
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               80426 - GONADOTROPIN RELEASING HORMONE STIMULATION PANEL              $197.03
I - Laboratory Billed by Physician80426                                                M            07/01/2006
                                               80426 - GONADOTROPIN RELEASING HORMONE STIMULATION PANEL              $197.03
5 - Independent Laboratory        80428                                                M            07/01/2006        $88.50
                                               80428 - GROWTH HORMONE STIMULATION PANEL (EG, ARGININE INFUSION, L-DOPA ADMINISTRATION
                                  80428
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006        $88.50
                                               80428 - GROWTH HORMONE STIMULATION PANEL (EG, ARGININE INFUSION, L-DOPA ADMINISTRATION
I - Laboratory Billed by Physician80428                                                M            07/01/2006        $88.50
                                               80428 - GROWTH HORMONE STIMULATION PANEL (EG, ARGININE INFUSION, L-DOPA ADMINISTRATION
5 - Independent Laboratory        80430                                                M            07/01/2006
                                               80430 - GROWTH HORMONE SUPPRESSION PANEL (GLUCOSE ADMINISTRATION)$104.12


 4/22/2012                                                    55 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing    Charge
                                  80430
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               80430 - GROWTH HORMONE SUPPRESSION PANEL (GLUCOSE ADMINISTRATION)$104.12
I - Laboratory Billed by Physician80430                                                 M            07/01/2006
                                               80430 - GROWTH HORMONE SUPPRESSION PANEL (GLUCOSE ADMINISTRATION)$104.12
5 - Independent Laboratory        80432                                                 M
                                               80432 - INSULIN-INDUCED C-PEPTIDE SUPPRESSION PANEL07/01/2006           $179.29
                                  80432
H - Laboratory Billed by Outpatient Hospital                                            M
                                               80432 - INSULIN-INDUCED C-PEPTIDE SUPPRESSION PANEL07/01/2006           $179.29
I - Laboratory Billed by Physician80432                                                 M
                                               80432 - INSULIN-INDUCED C-PEPTIDE SUPPRESSION PANEL07/01/2006           $179.29
5 - Independent Laboratory        80434                                                 M            07/01/2006
                                               80434 - INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY                 $134.24
                                  80434
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               80434 - INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY                 $134.24
I - Laboratory Billed by Physician80434                                                 M            07/01/2006
                                               80434 - INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY                 $134.24
5 - Independent Laboratory        80435                                                 M            07/01/2006
                                               80435 - INSULIN TOLERANCE PANEL; FOR GROWTH HORMONE DEFICIENCY          $136.66
                                  80435
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               80435 - INSULIN TOLERANCE PANEL; FOR GROWTH HORMONE DEFICIENCY          $136.66
I - Laboratory Billed by Physician80435                                                 M            07/01/2006
                                               80435 - INSULIN TOLERANCE PANEL; FOR GROWTH HORMONE DEFICIENCY          $136.66
5 - Independent Laboratory        80436        80436 - METYRAPONE PANEL                 M            07/01/2006        $120.99
                                  80436
H - Laboratory Billed by Outpatient Hospital   80436 - METYRAPONE PANEL                 M            07/01/2006        $120.99
I - Laboratory Billed by Physician80436        80436 - METYRAPONE PANEL                 M            07/01/2006        $120.99
5 - Independent Laboratory        80438                                                 M            07/01/2006
                                               80438 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; ONE HOUR  $66.89
                                  80438
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               80438 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; ONE HOUR  $66.89
I - Laboratory Billed by Physician80438                                                 M            07/01/2006
                                               80438 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; ONE HOUR  $66.89
5 - Independent Laboratory        80439                                                 M            07/01/2006
                                               80439 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; TWO HOUR  $89.19
                                  80439
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               80439 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; TWO HOUR  $89.19
I - Laboratory Billed by Physician80439                                                 M            07/01/2006
                                               80439 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; TWO HOUR  $89.19
5 - Independent Laboratory        80440                                                 M            07/01/2006         $77.18
                                               80440 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; FOR HYPERPROLACTINEM
                                  80440
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $77.18
                                               80440 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; FOR HYPERPROLACTINEM
I - Laboratory Billed by Physician80440                                                 M            07/01/2006         $77.18
                                               80440 - THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; FOR HYPERPROLACTINEM
5 - Independent Laboratory        80500                                                 M            07/01/2006         $14.04
                                               80500 - CLINICAL PATHOLOGY CONSULTATION; LIMITED, WITHOUT REVIEW OF PATIENT'S HISTORY AN
                                  80500
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $14.04
                                               80500 - CLINICAL PATHOLOGY CONSULTATION; LIMITED, WITHOUT REVIEW OF PATIENT'S HISTORY AN
5 - Independent Laboratory        80502                                                 M            07/01/2006         $31.46
                                               80502 - CLINICAL PATHOLOGY CONSULTATION; COMPREHENSIVE, FOR A COMPLEX DIAGNOSTIC PRO
                                  80502
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $31.46
                                               80502 - CLINICAL PATHOLOGY CONSULTATION; COMPREHENSIVE, FOR A COMPLEX DIAGNOSTIC PRO
5 - Independent Laboratory        81000                                                 M            07/01/2006           $4.21
                                               81000 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
                                  81000
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $4.21
                                               81000 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
I - Laboratory Billed by Physician81000                                                 M            07/01/2006           $4.21
                                               81000 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
5 - Independent Laboratory        81001                                                 M            07/01/2006           $4.21
                                               81001 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
                                  81001
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $4.21
                                               81001 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
I - Laboratory Billed by Physician81001                                                 M            07/01/2006           $4.21
                                               81001 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
5 - Independent Laboratory        81002                                                 M            07/01/2006           $3.39
                                               81002 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
                                  81002
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $3.39
                                               81002 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
I - Laboratory Billed by Physician81002                                                 M            07/01/2006           $3.39
                                               81002 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
5 - Independent Laboratory        81003                                                 M            07/01/2006           $2.98
                                               81003 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
                                  81003
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $2.98
                                               81003 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
I - Laboratory Billed by Physician81003                                                 M            07/01/2006           $2.98
                                               81003 - URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
5 - Independent Laboratory        81005                                                 M            07/01/2006
                                               81005 - URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS   $2.88
                                  81005
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               81005 - URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS   $2.88
I - Laboratory Billed by Physician81005                                                 M            07/01/2006
                                               81005 - URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS   $2.88
5 - Independent Laboratory        81007                                                 M            07/01/2006
                                               81007 - URINALYSIS; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR DIPSTICK $3.41
                                  81007
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               81007 - URINALYSIS; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR DIPSTICK $3.41
I - Laboratory Billed by Physician81007                                                 M            07/01/2006
                                               81007 - URINALYSIS; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR DIPSTICK $3.41
5 - Independent Laboratory        81015        81015 - URINALYSIS; MICROSCOPIC ONLY     M            07/01/2006           $4.03
                                  81015
H - Laboratory Billed by Outpatient Hospital   81015 - URINALYSIS; MICROSCOPIC ONLY     M            07/01/2006           $4.03
I - Laboratory Billed by Physician81015        81015 - URINALYSIS; MICROSCOPIC ONLY     M            07/01/2006           $4.03
5 - Independent Laboratory        81020                                                 M
                                               81020 - URINALYSIS; TWO OR THREE GLASS TEST           07/01/2006           $4.89
                                  81020
H - Laboratory Billed by Outpatient Hospital                                            M
                                               81020 - URINALYSIS; TWO OR THREE GLASS TEST           07/01/2006           $4.89
I - Laboratory Billed by Physician81020                                                 M
                                               81020 - URINALYSIS; TWO OR THREE GLASS TEST           07/01/2006           $4.89
5 - Independent Laboratory        81025        81025 - URINE PREGNANCY TEST, BY VISUAL M             07/01/2006
                                                                                         COLOR COMPARISON METHODS         $8.40
                                  81025
H - Laboratory Billed by Outpatient Hospital   81025 - URINE PREGNANCY TEST, BY VISUAL M             07/01/2006
                                                                                         COLOR COMPARISON METHODS         $8.40
I - Laboratory Billed by Physician81025        81025 - URINE PREGNANCY TEST, BY VISUAL M             07/01/2006
                                                                                         COLOR COMPARISON METHODS         $8.40
5 - Independent Laboratory        81050                                                 M
                                               81050 - VOLUME MEASUREMENT FOR TIMED COLLECTION, EACH 07/01/2006           $3.98
                                  81050
H - Laboratory Billed by Outpatient Hospital                                            M
                                               81050 - VOLUME MEASUREMENT FOR TIMED COLLECTION, EACH 07/01/2006           $3.98
I - Laboratory Billed by Physician81050                                                 M
                                               81050 - VOLUME MEASUREMENT FOR TIMED COLLECTION, EACH 07/01/2006           $3.98
5 - Independent Laboratory        82000        82000 - ACETALDEHYDE, BLOOD              M            07/01/2006         $16.44
                                  82000
H - Laboratory Billed by Outpatient Hospital   82000 - ACETALDEHYDE, BLOOD              M            07/01/2006         $16.44
I - Laboratory Billed by Physician82000        82000 - ACETALDEHYDE, BLOOD              M            07/01/2006         $16.44
5 - Independent Laboratory        82003        82003 - ACETAMINOPHEN                    M            07/01/2006         $26.87
                                  82003
H - Laboratory Billed by Outpatient Hospital   82003 - ACETAMINOPHEN                    M            07/01/2006         $26.87
I - Laboratory Billed by Physician82003        82003 - ACETAMINOPHEN                    M            07/01/2006         $26.87
5 - Independent Laboratory        82009                                                 M            07/01/2006
                                               82009 - ACETONE OR OTHER KETONE BODIES, SERUM; QUALITATIVE                 $5.99
                                  82009
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               82009 - ACETONE OR OTHER KETONE BODIES, SERUM; QUALITATIVE                 $5.99
I - Laboratory Billed by Physician82009                                                 M            07/01/2006
                                               82009 - ACETONE OR OTHER KETONE BODIES, SERUM; QUALITATIVE                 $5.99


 4/22/2012                                                    56 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        82010                                                 M            07/01/2006
                                               82010 - ACETONE OR OTHER KETONE BODIES, SERUM; QUANTITATIVE             $10.85
                                  82010
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               82010 - ACETONE OR OTHER KETONE BODIES, SERUM; QUANTITATIVE             $10.85
I - Laboratory Billed by Physician82010                                                 M            07/01/2006
                                               82010 - ACETONE OR OTHER KETONE BODIES, SERUM; QUANTITATIVE             $10.85
5 - Independent Laboratory        82013        82013 - ACETYLCHOLINESTERASE             M            07/01/2006        $14.83
                                  82013
H - Laboratory Billed by Outpatient Hospital   82013 - ACETYLCHOLINESTERASE             M            07/01/2006        $14.83
I - Laboratory Billed by Physician82013        82013 - ACETYLCHOLINESTERASE             M            07/01/2006        $14.83
5 - Independent Laboratory        82016                                                 M
                                               82016 - ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN 07/01/2006           $18.40
                                  82016
H - Laboratory Billed by Outpatient Hospital                                            M
                                               82016 - ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN 07/01/2006           $18.40
I - Laboratory Billed by Physician82016                                                 M
                                               82016 - ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN 07/01/2006           $18.40
5 - Independent Laboratory        82017                                                 M
                                               82017 - ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN 07/01/2006          $22.39
                                  82017
H - Laboratory Billed by Outpatient Hospital                                            M
                                               82017 - ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN 07/01/2006          $22.39
I - Laboratory Billed by Physician82017                                                 M
                                               82017 - ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN 07/01/2006          $22.39
5 - Independent Laboratory        82024        82024 - ADRENOCORTICOTROPIC HORMONE M    (ACTH)       07/01/2006        $51.27
                                  82024
H - Laboratory Billed by Outpatient Hospital   82024 - ADRENOCORTICOTROPIC HORMONE M    (ACTH)       07/01/2006        $51.27
I - Laboratory Billed by Physician82024        82024 - ADRENOCORTICOTROPIC HORMONE M    (ACTH)       07/01/2006        $51.27
5 - Independent Laboratory        82030                                                 M            07/01/2006
                                               82030 - ADENOSINE, 5-MONOPHOSPHATE, CYCLIC (CYCLIC AMP)                 $34.25
                                  82030
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               82030 - ADENOSINE, 5-MONOPHOSPHATE, CYCLIC (CYCLIC AMP)                 $34.25
I - Laboratory Billed by Physician82030                                                 M            07/01/2006
                                               82030 - ADENOSINE, 5-MONOPHOSPHATE, CYCLIC (CYCLIC AMP)                 $34.25
5 - Independent Laboratory        82040        82040 - ALBUMIN; SERUM                   M            07/01/2006          $6.05
                                  82040
H - Laboratory Billed by Outpatient Hospital   82040 - ALBUMIN; SERUM                   M            07/01/2006          $6.05
I - Laboratory Billed by Physician82040        82040 - ALBUMIN; SERUM                   M            07/01/2006          $6.05
5 - Independent Laboratory        82042        82042 - ALBUMIN; URINE OR OTHER SOURCE,M              07/01/2006
                                                                                         QUANTITATIVE, EACH SPECIMEN     $6.87
                                  82042
H - Laboratory Billed by Outpatient Hospital   82042 - ALBUMIN; URINE OR OTHER SOURCE,M              07/01/2006
                                                                                         QUANTITATIVE, EACH SPECIMEN     $6.87
I - Laboratory Billed by Physician82042        82042 - ALBUMIN; URINE OR OTHER SOURCE,M              07/01/2006
                                                                                         QUANTITATIVE, EACH SPECIMEN     $6.87
5 - Independent Laboratory        82043                                                 M
                                               82043 - ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE 07/01/2006             $7.69
                                  82043
H - Laboratory Billed by Outpatient Hospital                                            M
                                               82043 - ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE 07/01/2006             $7.69
I - Laboratory Billed by Physician82043                                                 M
                                               82043 - ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE 07/01/2006             $7.69
5 - Independent Laboratory        82044                                                 M            07/01/2006          $6.07
                                               82044 - ALBUMIN; URINE, MICROALBUMIN, SEMIQUANTITATIVE (EG, REAGENT STRIP ASSAY)
                                  82044
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $6.07
                                               82044 - ALBUMIN; URINE, MICROALBUMIN, SEMIQUANTITATIVE (EG, REAGENT STRIP ASSAY)
I - Laboratory Billed by Physician82044                                                 M            07/01/2006          $6.07
                                               82044 - ALBUMIN; URINE, MICROALBUMIN, SEMIQUANTITATIVE (EG, REAGENT STRIP ASSAY)
5 - Independent Laboratory        82045        82045 - ALBUMIN; ISCHEMIA MODIFIED       M            07/01/2006        $45.06
                                  82045
H - Laboratory Billed by Outpatient Hospital   82045 - ALBUMIN; ISCHEMIA MODIFIED       M            07/01/2006        $45.06
I - Laboratory Billed by Physician82045        82045 - ALBUMIN; ISCHEMIA MODIFIED       M            07/01/2006        $45.06
5 - Independent Laboratory        82055        82055 - ALCOHOL (ETHANOL); ANY SPECIMENM              07/01/2006
                                                                                         EXCEPT BREATH                 $14.35
                                  82055
H - Laboratory Billed by Outpatient Hospital   82055 - ALCOHOL (ETHANOL); ANY SPECIMENM              07/01/2006
                                                                                         EXCEPT BREATH                 $14.35
I - Laboratory Billed by Physician82055        82055 - ALCOHOL (ETHANOL); ANY SPECIMENM              07/01/2006
                                                                                         EXCEPT BREATH                 $14.35
5 - Independent Laboratory        82075        82075 - ALCOHOL (ETHANOL); BREATH        M            07/01/2006        $16.00
                                  82075
H - Laboratory Billed by Outpatient Hospital   82075 - ALCOHOL (ETHANOL); BREATH        M            07/01/2006        $16.00
I - Laboratory Billed by Physician82075        82075 - ALCOHOL (ETHANOL); BREATH        M            07/01/2006        $16.00
5 - Independent Laboratory        82085        82085 - ALDOLASE                         M            07/01/2006        $12.88
                                  82085
H - Laboratory Billed by Outpatient Hospital   82085 - ALDOLASE                         M            07/01/2006        $12.88
I - Laboratory Billed by Physician82085        82085 - ALDOLASE                         M            07/01/2006        $12.88
5 - Independent Laboratory        82088        82088 - ALDOSTERONE                      M            07/01/2006        $54.09
                                  82088
H - Laboratory Billed by Outpatient Hospital   82088 - ALDOSTERONE                      M            07/01/2006        $54.09
I - Laboratory Billed by Physician82088        82088 - ALDOSTERONE                      M            07/01/2006        $54.09
5 - Independent Laboratory        82101        82101 - ALKALOIDS, URINE, QUANTITATIVE M              07/01/2006        $30.88
                                  82101
H - Laboratory Billed by Outpatient Hospital   82101 - ALKALOIDS, URINE, QUANTITATIVE M              07/01/2006        $30.88
I - Laboratory Billed by Physician82101        82101 - ALKALOIDS, URINE, QUANTITATIVE M              07/01/2006        $30.88
5 - Independent Laboratory        82103        82103 - ALPHA-1-ANTITRYPSIN; TOTAL       M            07/01/2006        $17.83
                                  82103
H - Laboratory Billed by Outpatient Hospital   82103 - ALPHA-1-ANTITRYPSIN; TOTAL       M            07/01/2006        $17.83
I - Laboratory Billed by Physician82103        82103 - ALPHA-1-ANTITRYPSIN; TOTAL       M            07/01/2006        $17.83
5 - Independent Laboratory        82104        82104 - ALPHA-1-ANTITRYPSIN; PHENOTYPE M              07/01/2006        $12.08
                                  82104
H - Laboratory Billed by Outpatient Hospital   82104 - ALPHA-1-ANTITRYPSIN; PHENOTYPE M              07/01/2006        $12.08
I - Laboratory Billed by Physician82104        82104 - ALPHA-1-ANTITRYPSIN; PHENOTYPE M              07/01/2006        $12.08
5 - Independent Laboratory        82105        82105 - ALPHA-FETOPROTEIN; SERUM         M            07/01/2006        $22.27
                                  82105
H - Laboratory Billed by Outpatient Hospital   82105 - ALPHA-FETOPROTEIN; SERUM         M            07/01/2006        $22.27
I - Laboratory Billed by Physician82105        82105 - ALPHA-FETOPROTEIN; SERUM         M            07/01/2006        $22.27
5 - Independent Laboratory        82106        82106 - ALPHA-FETOPROTEIN; AMNIOTIC FLUIDM            07/01/2006        $22.27
                                  82106
H - Laboratory Billed by Outpatient Hospital   82106 - ALPHA-FETOPROTEIN; AMNIOTIC FLUIDM            07/01/2006        $22.27
I - Laboratory Billed by Physician82106        82106 - ALPHA-FETOPROTEIN; AMNIOTIC FLUIDM            07/01/2006        $22.27
5 - Independent Laboratory        82107                                                 M            01/01/2007        $85.49
                                               82107 - ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL AFP (INCLUDING RATIO)
                                  82107
H - Laboratory Billed by Outpatient Hospital                                            M            01/01/2007        $85.49
                                               82107 - ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL AFP (INCLUDING RATIO)
I - Laboratory Billed by Physician82107                                                 M            01/01/2007        $85.49
                                               82107 - ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL AFP (INCLUDING RATIO)
5 - Independent Laboratory        82108        82108 - ALUMINUM                         M            07/01/2006        $33.82
                                  82108
H - Laboratory Billed by Outpatient Hospital   82108 - ALUMINUM                         M            07/01/2006        $33.82
I - Laboratory Billed by Physician82108        82108 - ALUMINUM                         M            07/01/2006        $33.82


 4/22/2012                                                     57 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        82120        82120 - AMINES, VAGINAL FLUID, QUALITATIVEM            07/01/2006          $4.99
                                  82120
H - Laboratory Billed by Outpatient Hospital   82120 - AMINES, VAGINAL FLUID, QUALITATIVEM            07/01/2006          $4.99
I - Laboratory Billed by Physician82120        82120 - AMINES, VAGINAL FLUID, QUALITATIVEM            07/01/2006          $4.99
5 - Independent Laboratory        82127                                                  EACH SPECIMEN
                                               82127 - AMINO ACIDS; SINGLE, QUALITATIVE, M            07/01/2006        $18.40
                                  82127
H - Laboratory Billed by Outpatient Hospital                                             EACH SPECIMEN
                                               82127 - AMINO ACIDS; SINGLE, QUALITATIVE, M            07/01/2006        $18.40
I - Laboratory Billed by Physician82127                                                  EACH SPECIMEN
                                               82127 - AMINO ACIDS; SINGLE, QUALITATIVE, M            07/01/2006        $18.40
5 - Independent Laboratory        82128                                                  M            07/01/2006
                                               82128 - AMINO ACIDS; MULTIPLE, QUALITATIVE, EACH SPECIMEN                $18.40
                                  82128
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               82128 - AMINO ACIDS; MULTIPLE, QUALITATIVE, EACH SPECIMEN                $18.40
I - Laboratory Billed by Physician82128                                                  M            07/01/2006
                                               82128 - AMINO ACIDS; MULTIPLE, QUALITATIVE, EACH SPECIMEN                $18.40
5 - Independent Laboratory        82131                                                  M            07/01/2006
                                               82131 - AMINO ACIDS; SINGLE, QUANTITATIVE, EACH SPECIMEN                 $22.39
                                  82131
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               82131 - AMINO ACIDS; SINGLE, QUANTITATIVE, EACH SPECIMEN                 $22.39
I - Laboratory Billed by Physician82131                                                  M            07/01/2006
                                               82131 - AMINO ACIDS; SINGLE, QUANTITATIVE, EACH SPECIMEN                 $22.39
5 - Independent Laboratory        82135        82135 - AMINOLEVULINIC ACID, DELTA (ALA) M             07/01/2006        $16.05
                                  82135
H - Laboratory Billed by Outpatient Hospital   82135 - AMINOLEVULINIC ACID, DELTA (ALA) M             07/01/2006        $16.05
I - Laboratory Billed by Physician82135        82135 - AMINOLEVULINIC ACID, DELTA (ALA) M             07/01/2006        $16.05
5 - Independent Laboratory        82136                                                  M            07/01/2006
                                               82136 - AMINO ACIDS, 2 TO 5 AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN     $22.39
                                  82136
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               82136 - AMINO ACIDS, 2 TO 5 AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN     $22.39
I - Laboratory Billed by Physician82136                                                  M            07/01/2006
                                               82136 - AMINO ACIDS, 2 TO 5 AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN     $22.39
5 - Independent Laboratory        82139                                                  M            07/01/2006
                                               82139 - AMINO ACIDS, 6 OR MORE AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN $22.39
                                  82139
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               82139 - AMINO ACIDS, 6 OR MORE AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN $22.39
I - Laboratory Billed by Physician82139                                                  M            07/01/2006
                                               82139 - AMINO ACIDS, 6 OR MORE AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN $22.39
5 - Independent Laboratory        82140        82140 - AMMONIA                           M            07/01/2006        $19.34
                                  82140
H - Laboratory Billed by Outpatient Hospital   82140 - AMMONIA                           M            07/01/2006        $19.34
I - Laboratory Billed by Physician82140        82140 - AMMONIA                           M            07/01/2006        $19.34
5 - Independent Laboratory        82143                                                  M
                                               82143 - AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) 07/01/2006                $9.13
                                  82143
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82143 - AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) 07/01/2006                $9.13
I - Laboratory Billed by Physician82143                                                  M
                                               82143 - AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) 07/01/2006                $9.13
5 - Independent Laboratory        82145        82145 - AMPHETAMINE OR METHAMPHETAMINE    M            07/01/2006        $12.73
                                  82145
H - Laboratory Billed by Outpatient Hospital   82145 - AMPHETAMINE OR METHAMPHETAMINE    M            07/01/2006        $12.73
I - Laboratory Billed by Physician82145        82145 - AMPHETAMINE OR METHAMPHETAMINE    M            07/01/2006        $12.73
5 - Independent Laboratory        82150        82150 - AMYLASE                           M            07/01/2006          $8.61
                                  82150
H - Laboratory Billed by Outpatient Hospital   82150 - AMYLASE                           M            07/01/2006          $8.61
I - Laboratory Billed by Physician82150        82150 - AMYLASE                           M            07/01/2006          $8.61
5 - Independent Laboratory        82154        82154 - ANDROSTANEDIOL GLUCURONIDE M                   07/01/2006        $38.28
                                  82154
H - Laboratory Billed by Outpatient Hospital   82154 - ANDROSTANEDIOL GLUCURONIDE M                   07/01/2006        $38.28
I - Laboratory Billed by Physician82154        82154 - ANDROSTANEDIOL GLUCURONIDE M                   07/01/2006        $38.28
5 - Independent Laboratory        82157        82157 - ANDROSTENEDIONE                   M            07/01/2006        $38.86
                                  82157
H - Laboratory Billed by Outpatient Hospital   82157 - ANDROSTENEDIONE                   M            07/01/2006        $38.86
I - Laboratory Billed by Physician82157        82157 - ANDROSTENEDIONE                   M            07/01/2006        $38.86
5 - Independent Laboratory        82160        82160 - ANDROSTERONE                      M            07/01/2006        $33.19
                                  82160
H - Laboratory Billed by Outpatient Hospital   82160 - ANDROSTERONE                      M            07/01/2006        $33.19
I - Laboratory Billed by Physician82160        82160 - ANDROSTERONE                      M            07/01/2006        $33.19
5 - Independent Laboratory        82163        82163 - ANGIOTENSIN II                    M            07/01/2006        $27.25
                                  82163
H - Laboratory Billed by Outpatient Hospital   82163 - ANGIOTENSIN II                    M            07/01/2006        $27.25
I - Laboratory Billed by Physician82163        82163 - ANGIOTENSIN II                    M            07/01/2006        $27.25
5 - Independent Laboratory        82164                                                  M
                                               82164 - ANGIOTENSIN I - CONVERTING ENZYME (ACE)        07/01/2006        $19.37
                                  82164
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82164 - ANGIOTENSIN I - CONVERTING ENZYME (ACE)        07/01/2006        $19.37
I - Laboratory Billed by Physician82164                                                  M
                                               82164 - ANGIOTENSIN I - CONVERTING ENZYME (ACE)        07/01/2006        $19.37
5 - Independent Laboratory        82172        82172 - APOLIPOPROTEIN, EACH              M            07/01/2006        $20.57
                                  82172
H - Laboratory Billed by Outpatient Hospital   82172 - APOLIPOPROTEIN, EACH              M            07/01/2006        $20.57
I - Laboratory Billed by Physician82172        82172 - APOLIPOPROTEIN, EACH              M            07/01/2006        $20.57
5 - Independent Laboratory        82175        82175 - ARSENIC                           M            07/01/2006        $25.18
                                  82175
H - Laboratory Billed by Outpatient Hospital   82175 - ARSENIC                           M            07/01/2006        $25.18
I - Laboratory Billed by Physician82175        82175 - ARSENIC                           M            07/01/2006        $25.18
5 - Independent Laboratory        82180        82180 - ASCORBIC ACID (VITAMIN C), BLOOD M             07/01/2006        $13.12
                                  82180
H - Laboratory Billed by Outpatient Hospital   82180 - ASCORBIC ACID (VITAMIN C), BLOOD M             07/01/2006        $13.12
I - Laboratory Billed by Physician82180        82180 - ASCORBIC ACID (VITAMIN C), BLOOD M             07/01/2006        $13.12
5 - Independent Laboratory        82190                                                  M
                                               82190 - ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE   07/01/2006        $19.79
                                  82190
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82190 - ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE   07/01/2006        $19.79
I - Laboratory Billed by Physician82190                                                  M
                                               82190 - ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE   07/01/2006        $19.79
5 - Independent Laboratory        82205                                                  M
                                               82205 - BARBITURATES, NOT ELSEWHERE SPECIFIED          07/01/2006        $15.21
                                  82205
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82205 - BARBITURATES, NOT ELSEWHERE SPECIFIED          07/01/2006        $15.21
I - Laboratory Billed by Physician82205                                                  M
                                               82205 - BARBITURATES, NOT ELSEWHERE SPECIFIED          07/01/2006        $15.21
5 - Independent Laboratory        82232        82232 - BETA-2 MICROGLOBULIN              M            07/01/2006        $21.48
                                  82232
H - Laboratory Billed by Outpatient Hospital   82232 - BETA-2 MICROGLOBULIN              M            07/01/2006        $21.48
I - Laboratory Billed by Physician82232        82232 - BETA-2 MICROGLOBULIN              M            07/01/2006        $21.48


 4/22/2012                                                     58 of 489                ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing     Charge
5 - Independent Laboratory        82239        82239 - BILE ACIDS; TOTAL                M            07/01/2006          $22.74
                                  82239
H - Laboratory Billed by Outpatient Hospital   82239 - BILE ACIDS; TOTAL                M            07/01/2006          $22.74
I - Laboratory Billed by Physician82239        82239 - BILE ACIDS; TOTAL                M            07/01/2006          $22.74
5 - Independent Laboratory        82240        82240 - BILE ACIDS; CHOLYLGLYCINE        M            07/01/2006          $23.09
                                  82240
H - Laboratory Billed by Outpatient Hospital   82240 - BILE ACIDS; CHOLYLGLYCINE        M            07/01/2006          $23.09
I - Laboratory Billed by Physician82240        82240 - BILE ACIDS; CHOLYLGLYCINE        M            07/01/2006          $23.09
5 - Independent Laboratory        82247        82247 - BILIRUBIN; TOTAL                 M            07/01/2006           $6.67
                                  82247
H - Laboratory Billed by Outpatient Hospital   82247 - BILIRUBIN; TOTAL                 M            07/01/2006           $6.67
I - Laboratory Billed by Physician82247        82247 - BILIRUBIN; TOTAL                 M            07/01/2006           $6.67
5 - Independent Laboratory        82248        82248 - BILIRUBIN; DIRECT                M            07/01/2006           $6.67
                                  82248
H - Laboratory Billed by Outpatient Hospital   82248 - BILIRUBIN; DIRECT                M            07/01/2006           $6.67
I - Laboratory Billed by Physician82248        82248 - BILIRUBIN; DIRECT                M            07/01/2006           $6.67
5 - Independent Laboratory        82252        82252 - BILIRUBIN; FECES, QUALITATIVE    M            07/01/2006           $2.70
                                  82252
H - Laboratory Billed by Outpatient Hospital   82252 - BILIRUBIN; FECES, QUALITATIVE    M            07/01/2006           $2.70
I - Laboratory Billed by Physician82252        82252 - BILIRUBIN; FECES, QUALITATIVE    M            07/01/2006           $2.70
5 - Independent Laboratory        82261        82261 - BIOTINIDASE, EACH SPECIMEN       M            07/01/2006          $22.39
                                  82261
H - Laboratory Billed by Outpatient Hospital   82261 - BIOTINIDASE, EACH SPECIMEN       M            07/01/2006          $22.39
I - Laboratory Billed by Physician82261        82261 - BIOTINIDASE, EACH SPECIMEN       M            07/01/2006          $22.39
5 - Independent Laboratory        82270                                                 M            07/01/2006           $4.31
                                               82270 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIV
                                  82270
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $4.31
                                               82270 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIV
I - Laboratory Billed by Physician82270                                                 M            07/01/2006           $4.31
                                               82270 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIV
5 - Independent Laboratory        82271                                                 M            07/01/2006           $4.27
                                               82271 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES
                                  82271
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $4.27
                                               82271 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES
I - Laboratory Billed by Physician82271                                                 M            07/01/2006           $4.27
                                               82271 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES
5 - Independent Laboratory        82272                                                 M            07/01/2006           $4.27
                                               82272 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, SINGLE SPE
                                  82272
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $4.27
                                               82272 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, SINGLE SPE
I - Laboratory Billed by Physician82272                                                 M            07/01/2006           $4.27
                                               82272 - BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, SINGLE SPE
5 - Independent Laboratory        82274                                                 M            07/01/2006          $19.27
                                               82274 - BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE,
                                  82274
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $19.27
                                               82274 - BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE,
I - Laboratory Billed by Physician82274                                                 M            07/01/2006          $19.27
                                               82274 - BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE,
5 - Independent Laboratory        82286        82286 - BRADYKININ                       M            07/01/2006           $9.14
                                  82286
H - Laboratory Billed by Outpatient Hospital   82286 - BRADYKININ                       M            07/01/2006           $9.14
I - Laboratory Billed by Physician82286        82286 - BRADYKININ                       M            07/01/2006           $9.14
5 - Independent Laboratory        82300        82300 - CADMIUM                          M            07/01/2006          $30.71
                                  82300
H - Laboratory Billed by Outpatient Hospital   82300 - CADMIUM                          M            07/01/2006          $30.71
I - Laboratory Billed by Physician82300        82300 - CADMIUM                          M            07/01/2006          $30.71
5 - Independent Laboratory        82306        82306 - CALCIFEDIOL (25-OH VITAMIN D-3)  M            07/01/2006          $39.29
                                  82306
H - Laboratory Billed by Outpatient Hospital   82306 - CALCIFEDIOL (25-OH VITAMIN D-3)  M            07/01/2006          $39.29
I - Laboratory Billed by Physician82306        82306 - CALCIFEDIOL (25-OH VITAMIN D-3)  M            07/01/2006          $39.29
5 - Independent Laboratory        82307        82307 - CALCIFEROL (VITAMIN D)           M            07/01/2006          $42.77
                                  82307
H - Laboratory Billed by Outpatient Hospital   82307 - CALCIFEROL (VITAMIN D)           M            07/01/2006          $42.77
I - Laboratory Billed by Physician82307        82307 - CALCIFEROL (VITAMIN D)           M            07/01/2006          $42.77
5 - Independent Laboratory        82308        82308 - CALCITONIN                       M            07/01/2006          $35.54
                                  82308
H - Laboratory Billed by Outpatient Hospital   82308 - CALCITONIN                       M            07/01/2006          $35.54
I - Laboratory Billed by Physician82308        82308 - CALCITONIN                       M            07/01/2006          $35.54
5 - Independent Laboratory        82310        82310 - CALCIUM; TOTAL                   M            07/01/2006           $6.84
                                  82310
H - Laboratory Billed by Outpatient Hospital   82310 - CALCIUM; TOTAL                   M            07/01/2006           $6.84
I - Laboratory Billed by Physician82310        82310 - CALCIUM; TOTAL                   M            07/01/2006           $6.84
5 - Independent Laboratory        82330        82330 - CALCIUM; IONIZED                 M            07/01/2006          $15.45
                                  82330
H - Laboratory Billed by Outpatient Hospital   82330 - CALCIUM; IONIZED                 M            07/01/2006          $15.45
I - Laboratory Billed by Physician82330        82330 - CALCIUM; IONIZED                 M            07/01/2006          $15.45
5 - Independent Laboratory        82331        82331 - CALCIUM; AFTER CALCIUM INFUSION MTEST         07/01/2006           $6.87
                                  82331
H - Laboratory Billed by Outpatient Hospital   82331 - CALCIUM; AFTER CALCIUM INFUSION MTEST         07/01/2006           $6.87
I - Laboratory Billed by Physician82331        82331 - CALCIUM; AFTER CALCIUM INFUSION MTEST         07/01/2006           $6.87
5 - Independent Laboratory        82340                                                 M
                                               82340 - CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN 07/01/2006             $8.01
                                  82340
H - Laboratory Billed by Outpatient Hospital                                            M
                                               82340 - CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN 07/01/2006             $8.01
I - Laboratory Billed by Physician82340                                                 M
                                               82340 - CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN 07/01/2006             $8.01
5 - Independent Laboratory        82355        82355 - CALCULUS; QUALITATIVE ANALYSIS M              07/01/2006          $15.36
                                  82355
H - Laboratory Billed by Outpatient Hospital   82355 - CALCULUS; QUALITATIVE ANALYSIS M              07/01/2006          $15.36
I - Laboratory Billed by Physician82355        82355 - CALCULUS; QUALITATIVE ANALYSIS M              07/01/2006          $15.36
5 - Independent Laboratory        82360                                                 M
                                               82360 - CALCULUS; QUANTITATIVE ANALYSIS, CHEMICAL 07/01/2006              $17.09
                                  82360
H - Laboratory Billed by Outpatient Hospital                                            M
                                               82360 - CALCULUS; QUANTITATIVE ANALYSIS, CHEMICAL 07/01/2006              $17.09
I - Laboratory Billed by Physician82360                                                 M
                                               82360 - CALCULUS; QUANTITATIVE ANALYSIS, CHEMICAL 07/01/2006              $17.09
5 - Independent Laboratory        82365        82365 - CALCULUS; INFRARED SPECTROSCOPY  M            07/01/2006          $17.11
                                  82365
H - Laboratory Billed by Outpatient Hospital   82365 - CALCULUS; INFRARED SPECTROSCOPY  M            07/01/2006          $17.11
I - Laboratory Billed by Physician82365        82365 - CALCULUS; INFRARED SPECTROSCOPY  M            07/01/2006          $17.11


 4/22/2012                                                     59 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3    LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing      Charge
5 - Independent Laboratory        82370        82370 - CALCULUS; X-RAY DIFFRACTION     M            07/01/2006           $16.63
                                  82370
H - Laboratory Billed by Outpatient Hospital   82370 - CALCULUS; X-RAY DIFFRACTION     M            07/01/2006           $16.63
I - Laboratory Billed by Physician82370        82370 - CALCULUS; X-RAY DIFFRACTION     M            07/01/2006           $16.63
5 - Independent Laboratory        82373                                                M
                                               82373 - CARBOHYDRATE DEFICIENT TRANSFERRIN           07/01/2006           $23.97
                                  82373
H - Laboratory Billed by Outpatient Hospital                                           M
                                               82373 - CARBOHYDRATE DEFICIENT TRANSFERRIN           07/01/2006           $23.97
I - Laboratory Billed by Physician82373                                                M
                                               82373 - CARBOHYDRATE DEFICIENT TRANSFERRIN           07/01/2006           $23.97
5 - Independent Laboratory        82374        82374 - CARBON DIOXIDE (BICARBONATE)    M            07/01/2006             $6.49
                                  82374
H - Laboratory Billed by Outpatient Hospital   82374 - CARBON DIOXIDE (BICARBONATE)    M            07/01/2006             $6.49
I - Laboratory Billed by Physician82374        82374 - CARBON DIOXIDE (BICARBONATE)    M            07/01/2006             $6.49
5 - Independent Laboratory        82375                                                M            07/01/2006
                                               82375 - CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUANTITATIVE                $16.36
                                  82375
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               82375 - CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUANTITATIVE                $16.36
I - Laboratory Billed by Physician82375                                                M            07/01/2006
                                               82375 - CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUANTITATIVE                $16.36
5 - Independent Laboratory        82376                                                M            07/01/2006
                                               82376 - CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUALITATIVE                   $7.95
                                  82376
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               82376 - CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUALITATIVE                   $7.95
I - Laboratory Billed by Physician82376                                                M            07/01/2006
                                               82376 - CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUALITATIVE                   $7.95
5 - Independent Laboratory        82378        82378 - CARCINOEMBRYONIC ANTIGEN (CEA)M              07/01/2006           $25.18
                                  82378
H - Laboratory Billed by Outpatient Hospital   82378 - CARCINOEMBRYONIC ANTIGEN (CEA)M              07/01/2006           $25.18
I - Laboratory Billed by Physician82378        82378 - CARCINOEMBRYONIC ANTIGEN (CEA)M              07/01/2006           $25.18
5 - Independent Laboratory        82379                                                M            07/01/2006
                                               82379 - CARNITINE (TOTAL AND FREE), QUANTITATIVE, EACH SPECIMEN           $22.39
                                  82379
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               82379 - CARNITINE (TOTAL AND FREE), QUANTITATIVE, EACH SPECIMEN           $22.39
I - Laboratory Billed by Physician82379                                                M            07/01/2006
                                               82379 - CARNITINE (TOTAL AND FREE), QUANTITATIVE, EACH SPECIMEN           $22.39
5 - Independent Laboratory        82380        82380 - CAROTENE                        M            07/01/2006           $12.25
                                  82380
H - Laboratory Billed by Outpatient Hospital   82380 - CAROTENE                        M            07/01/2006           $12.25
I - Laboratory Billed by Physician82380        82380 - CAROTENE                        M            07/01/2006           $12.25
5 - Independent Laboratory        82382        82382 - CATECHOLAMINES; TOTAL URINE     M            07/01/2006           $22.82
                                  82382
H - Laboratory Billed by Outpatient Hospital   82382 - CATECHOLAMINES; TOTAL URINE     M            07/01/2006           $22.82
I - Laboratory Billed by Physician82382        82382 - CATECHOLAMINES; TOTAL URINE     M            07/01/2006           $22.82
5 - Independent Laboratory        82383        82383 - CATECHOLAMINES; BLOOD           M            07/01/2006           $33.26
                                  82383
H - Laboratory Billed by Outpatient Hospital   82383 - CATECHOLAMINES; BLOOD           M            07/01/2006           $33.26
I - Laboratory Billed by Physician82383        82383 - CATECHOLAMINES; BLOOD           M            07/01/2006           $33.26
5 - Independent Laboratory        82384        82384 - CATECHOLAMINES; FRACTIONATED M               07/01/2006           $33.52
                                  82384
H - Laboratory Billed by Outpatient Hospital   82384 - CATECHOLAMINES; FRACTIONATED M               07/01/2006           $33.52
I - Laboratory Billed by Physician82384        82384 - CATECHOLAMINES; FRACTIONATED M               07/01/2006           $33.52
5 - Independent Laboratory        82387        82387 - CATHEPSIN-D                     M            07/01/2006           $27.62
                                  82387
H - Laboratory Billed by Outpatient Hospital   82387 - CATHEPSIN-D                     M            07/01/2006           $27.62
I - Laboratory Billed by Physician82387        82387 - CATHEPSIN-D                     M            07/01/2006           $27.62
5 - Independent Laboratory        82390        82390 - CERULOPLASMIN                   M            07/01/2006           $14.26
                                  82390
H - Laboratory Billed by Outpatient Hospital   82390 - CERULOPLASMIN                   M            07/01/2006           $14.26
I - Laboratory Billed by Physician82390        82390 - CERULOPLASMIN                   M            07/01/2006           $14.26
5 - Independent Laboratory        82397        82397 - CHEMILUMINESCENT ASSAY          M            07/01/2006           $18.75
                                  82397
H - Laboratory Billed by Outpatient Hospital   82397 - CHEMILUMINESCENT ASSAY          M            07/01/2006           $18.75
I - Laboratory Billed by Physician82397        82397 - CHEMILUMINESCENT ASSAY          M            07/01/2006           $18.75
5 - Independent Laboratory        82415        82415 - CHLORAMPHENICOL                 M            07/01/2006           $16.82
                                  82415
H - Laboratory Billed by Outpatient Hospital   82415 - CHLORAMPHENICOL                 M            07/01/2006           $16.82
I - Laboratory Billed by Physician82415        82415 - CHLORAMPHENICOL                 M            07/01/2006           $16.82
5 - Independent Laboratory        82435        82435 - CHLORIDE; BLOOD                 M            07/01/2006             $6.10
                                  82435
H - Laboratory Billed by Outpatient Hospital   82435 - CHLORIDE; BLOOD                 M            07/01/2006             $6.10
I - Laboratory Billed by Physician82435        82435 - CHLORIDE; BLOOD                 M            07/01/2006             $6.10
5 - Independent Laboratory        82436        82436 - CHLORIDE; URINE                 M            07/01/2006             $6.67
                                  82436
H - Laboratory Billed by Outpatient Hospital   82436 - CHLORIDE; URINE                 M            07/01/2006             $6.67
I - Laboratory Billed by Physician82436        82436 - CHLORIDE; URINE                 M            07/01/2006             $6.67
5 - Independent Laboratory        82438        82438 - CHLORIDE; OTHER SOURCE          M            07/01/2006             $6.30
                                  82438
H - Laboratory Billed by Outpatient Hospital   82438 - CHLORIDE; OTHER SOURCE          M            07/01/2006             $6.30
I - Laboratory Billed by Physician82438        82438 - CHLORIDE; OTHER SOURCE          M            07/01/2006             $6.30
5 - Independent Laboratory        82441        82441 - CHLORINATED HYDROCARBONS, SCREENM            07/01/2006             $7.71
                                  82441
H - Laboratory Billed by Outpatient Hospital   82441 - CHLORINATED HYDROCARBONS, SCREENM            07/01/2006             $7.71
I - Laboratory Billed by Physician82441        82441 - CHLORINATED HYDROCARBONS, SCREENM            07/01/2006             $7.71
5 - Independent Laboratory        82465                                                M
                                               82465 - CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 07/01/2006                 $5.78
                                  82465
H - Laboratory Billed by Outpatient Hospital                                           M
                                               82465 - CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 07/01/2006                 $5.78
I - Laboratory Billed by Physician82465                                                M
                                               82465 - CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 07/01/2006                 $5.78
5 - Independent Laboratory        82480        82480 - CHOLINESTERASE; SERUM           M            07/01/2006           $10.46
                                  82480
H - Laboratory Billed by Outpatient Hospital   82480 - CHOLINESTERASE; SERUM           M            07/01/2006           $10.46
I - Laboratory Billed by Physician82480        82480 - CHOLINESTERASE; SERUM           M            07/01/2006           $10.46
5 - Independent Laboratory        82482        82482 - CHOLINESTERASE; RBC             M            07/01/2006           $10.20
                                  82482
H - Laboratory Billed by Outpatient Hospital   82482 - CHOLINESTERASE; RBC             M            07/01/2006           $10.20
I - Laboratory Billed by Physician82482        82482 - CHOLINESTERASE; RBC             M            07/01/2006           $10.20


 4/22/2012                                                     60 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH     Pricing    Charge
5 - Independent Laboratory        82485                                                  M
                                               82485 - CHONDROITIN B SULFATE, QUANTITATIVE            07/01/2006         $27.41
                                  82485
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82485 - CHONDROITIN B SULFATE, QUANTITATIVE            07/01/2006         $27.41
I - Laboratory Billed by Physician82485                                                  M
                                               82485 - CHONDROITIN B SULFATE, QUANTITATIVE            07/01/2006         $27.41
5 - Independent Laboratory        82486                                                  M            07/01/2006         $23.97
                                               82486 - CHROMATOGRAPHY, QUALITATIVE; COLUMN (EG, GAS LIQUID OR HPLC), ANALYTE NOT ELSEW
                                  82486
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $23.97
                                               82486 - CHROMATOGRAPHY, QUALITATIVE; COLUMN (EG, GAS LIQUID OR HPLC), ANALYTE NOT ELSEW
I - Laboratory Billed by Physician82486                                                  M            07/01/2006         $23.97
                                               82486 - CHROMATOGRAPHY, QUALITATIVE; COLUMN (EG, GAS LIQUID OR HPLC), ANALYTE NOT ELSEW
5 - Independent Laboratory        82487                                                  M            07/01/2006         $21.19
                                               82487 - CHROMATOGRAPHY, QUALITATIVE; PAPER, 1-DIMENSIONAL, ANALYTE NOT ELSEWHERE SPEC
                                  82487
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $21.19
                                               82487 - CHROMATOGRAPHY, QUALITATIVE; PAPER, 1-DIMENSIONAL, ANALYTE NOT ELSEWHERE SPEC
I - Laboratory Billed by Physician82487                                                  M            07/01/2006         $21.19
                                               82487 - CHROMATOGRAPHY, QUALITATIVE; PAPER, 1-DIMENSIONAL, ANALYTE NOT ELSEWHERE SPEC
5 - Independent Laboratory        82488                                                  M            07/01/2006         $28.36
                                               82488 - CHROMATOGRAPHY, QUALITATIVE; PAPER, 2-DIMENSIONAL, ANALYTE NOT ELSEWHERE SPEC
                                  82488
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $28.36
                                               82488 - CHROMATOGRAPHY, QUALITATIVE; PAPER, 2-DIMENSIONAL, ANALYTE NOT ELSEWHERE SPEC
I - Laboratory Billed by Physician82488                                                  M            07/01/2006         $28.36
                                               82488 - CHROMATOGRAPHY, QUALITATIVE; PAPER, 2-DIMENSIONAL, ANALYTE NOT ELSEWHERE SPEC
5 - Independent Laboratory        82489                                                  M            07/01/2006         $24.55
                                               82489 - CHROMATOGRAPHY, QUALITATIVE; THIN LAYER, ANALYTE NOT ELSEWHERE SPECIFIED
                                  82489
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $24.55
                                               82489 - CHROMATOGRAPHY, QUALITATIVE; THIN LAYER, ANALYTE NOT ELSEWHERE SPECIFIED
I - Laboratory Billed by Physician82489                                                  M            07/01/2006         $24.55
                                               82489 - CHROMATOGRAPHY, QUALITATIVE; THIN LAYER, ANALYTE NOT ELSEWHERE SPECIFIED
5 - Independent Laboratory        82491        82491 - CHROMATOGRAPHY, QUANTITATIVE, M                07/01/2006          SINGLE
                                                                                         COLUMN (EG, GAS LIQUID OR HPLC);$23.97 ANALYTE N
                                  82491
H - Laboratory Billed by Outpatient Hospital   82491 - CHROMATOGRAPHY, QUANTITATIVE, M                07/01/2006          SINGLE
                                                                                         COLUMN (EG, GAS LIQUID OR HPLC);$23.97 ANALYTE N
I - Laboratory Billed by Physician82491        82491 - CHROMATOGRAPHY, QUANTITATIVE, M                07/01/2006          SINGLE
                                                                                         COLUMN (EG, GAS LIQUID OR HPLC);$23.97 ANALYTE N
5 - Independent Laboratory        82492        82492 - CHROMATOGRAPHY, QUANTITATIVE, M                07/01/2006          MULTIPLE ANALYTE
                                                                                         COLUMN (EG, GAS LIQUID OR HPLC);$23.97
                                  82492
H - Laboratory Billed by Outpatient Hospital   82492 - CHROMATOGRAPHY, QUANTITATIVE, M                07/01/2006          MULTIPLE ANALYTE
                                                                                         COLUMN (EG, GAS LIQUID OR HPLC);$23.97
I - Laboratory Billed by Physician82492        82492 - CHROMATOGRAPHY, QUANTITATIVE, M                07/01/2006          MULTIPLE ANALYTE
                                                                                         COLUMN (EG, GAS LIQUID OR HPLC);$23.97
5 - Independent Laboratory        82495        82495 - CHROMIUM                          M            07/01/2006         $26.92
                                  82495
H - Laboratory Billed by Outpatient Hospital   82495 - CHROMIUM                          M            07/01/2006         $26.92
I - Laboratory Billed by Physician82495        82495 - CHROMIUM                          M            07/01/2006         $26.92
5 - Independent Laboratory        82507        82507 - CITRATE                           M            07/01/2006         $36.91
                                  82507
H - Laboratory Billed by Outpatient Hospital   82507 - CITRATE                           M            07/01/2006         $36.91
I - Laboratory Billed by Physician82507        82507 - CITRATE                           M            07/01/2006         $36.91
5 - Independent Laboratory        82520        82520 - COCAINE OR METABOLITE             M            07/01/2006         $20.11
                                  82520
H - Laboratory Billed by Outpatient Hospital   82520 - COCAINE OR METABOLITE             M            07/01/2006         $20.11
I - Laboratory Billed by Physician82520        82520 - COCAINE OR METABOLITE             M            07/01/2006         $20.11
5 - Independent Laboratory        82523        82523 - COLLAGEN CROSS LINKS, ANY METHOD  M            07/01/2006         $24.80
                                  82523
H - Laboratory Billed by Outpatient Hospital   82523 - COLLAGEN CROSS LINKS, ANY METHOD  M            07/01/2006         $24.80
I - Laboratory Billed by Physician82523        82523 - COLLAGEN CROSS LINKS, ANY METHOD  M            07/01/2006         $24.80
5 - Independent Laboratory        82525        82525 - COPPER                            M            07/01/2006         $16.47
                                  82525
H - Laboratory Billed by Outpatient Hospital   82525 - COPPER                            M            07/01/2006         $16.47
I - Laboratory Billed by Physician82525        82525 - COPPER                            M            07/01/2006         $16.47
5 - Independent Laboratory        82528        82528 - CORTICOSTERONE                    M            07/01/2006         $29.88
                                  82528
H - Laboratory Billed by Outpatient Hospital   82528 - CORTICOSTERONE                    M            07/01/2006         $29.88
I - Laboratory Billed by Physician82528        82528 - CORTICOSTERONE                    M            07/01/2006         $29.88
5 - Independent Laboratory        82530        82530 - CORTISOL; FREE                    M            07/01/2006         $22.18
                                  82530
H - Laboratory Billed by Outpatient Hospital   82530 - CORTISOL; FREE                    M            07/01/2006         $22.18
I - Laboratory Billed by Physician82530        82530 - CORTISOL; FREE                    M            07/01/2006         $22.18
5 - Independent Laboratory        82533        82533 - CORTISOL; TOTAL                   M            07/01/2006         $21.64
                                  82533
H - Laboratory Billed by Outpatient Hospital   82533 - CORTISOL; TOTAL                   M            07/01/2006         $21.64
I - Laboratory Billed by Physician82533        82533 - CORTISOL; TOTAL                   M            07/01/2006         $21.64
5 - Independent Laboratory        82540        82540 - CREATINE                          M            07/01/2006          $6.16
                                  82540
H - Laboratory Billed by Outpatient Hospital   82540 - CREATINE                          M            07/01/2006          $6.16
I - Laboratory Billed by Physician82540        82540 - CREATINE                          M            07/01/2006          $6.16
5 - Independent Laboratory        82541                                                  M            07/01/2006         $23.97
                                               82541 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
                                  82541
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $23.97
                                               82541 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
I - Laboratory Billed by Physician82541                                                  M            07/01/2006         $23.97
                                               82541 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
5 - Independent Laboratory        82542                                                  M            07/01/2006         $23.97
                                               82542 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
                                  82542
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $23.97
                                               82542 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
I - Laboratory Billed by Physician82542                                                  M            07/01/2006         $23.97
                                               82542 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
5 - Independent Laboratory        82543                                                  M            07/01/2006         $23.97
                                               82543 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
                                  82543
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $23.97
                                               82543 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
I - Laboratory Billed by Physician82543                                                  M            07/01/2006         $23.97
                                               82543 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
5 - Independent Laboratory        82544                                                  M            07/01/2006         $23.97
                                               82544 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
                                  82544
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         $23.97
                                               82544 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
I - Laboratory Billed by Physician82544                                                  M            07/01/2006         $23.97
                                               82544 - COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/ MS), ANALYTE NO
5 - Independent Laboratory        82550        82550 - CREATINE KINASE (CK), (CPK); TOTALM            07/01/2006          $8.65
                                  82550
H - Laboratory Billed by Outpatient Hospital   82550 - CREATINE KINASE (CK), (CPK); TOTALM            07/01/2006          $8.65
I - Laboratory Billed by Physician82550        82550 - CREATINE KINASE (CK), (CPK); TOTALM            07/01/2006          $8.65
5 - Independent Laboratory        82552                                                  M
                                               82552 - CREATINE KINASE (CK), (CPK); ISOENZYMES        07/01/2006         $17.77
                                  82552
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82552 - CREATINE KINASE (CK), (CPK); ISOENZYMES        07/01/2006         $17.77
I - Laboratory Billed by Physician82552                                                  M
                                               82552 - CREATINE KINASE (CK), (CPK); ISOENZYMES        07/01/2006         $17.77


 4/22/2012                                                     61 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        82553                                                  M
                                               82553 - CREATINE KINASE (CK), (CPK); MB FRACTION ONLY 07/01/2006         $15.32
                                  82553
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82553 - CREATINE KINASE (CK), (CPK); MB FRACTION ONLY 07/01/2006         $15.32
I - Laboratory Billed by Physician82553                                                  M
                                               82553 - CREATINE KINASE (CK), (CPK); MB FRACTION ONLY 07/01/2006         $15.32
5 - Independent Laboratory        82554                                                  M
                                               82554 - CREATINE KINASE (CK), (CPK); ISOFORMS          07/01/2006        $15.75
                                  82554
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82554 - CREATINE KINASE (CK), (CPK); ISOFORMS          07/01/2006        $15.75
I - Laboratory Billed by Physician82554                                                  M
                                               82554 - CREATINE KINASE (CK), (CPK); ISOFORMS          07/01/2006        $15.75
5 - Independent Laboratory        82565        82565 - CREATININE; BLOOD                 M            07/01/2006          $6.80
                                  82565
H - Laboratory Billed by Outpatient Hospital   82565 - CREATININE; BLOOD                 M            07/01/2006          $6.80
I - Laboratory Billed by Physician82565        82565 - CREATININE; BLOOD                 M            07/01/2006          $6.80
5 - Independent Laboratory        82570        82570 - CREATININE; OTHER SOURCE          M            07/01/2006          $6.87
                                  82570
H - Laboratory Billed by Outpatient Hospital   82570 - CREATININE; OTHER SOURCE          M            07/01/2006          $6.87
I - Laboratory Billed by Physician82570        82570 - CREATININE; OTHER SOURCE          M            07/01/2006          $6.87
5 - Independent Laboratory        82575        82575 - CREATININE; CLEARANCE             M            07/01/2006        $12.54
                                  82575
H - Laboratory Billed by Outpatient Hospital   82575 - CREATININE; CLEARANCE             M            07/01/2006        $12.54
I - Laboratory Billed by Physician82575        82575 - CREATININE; CLEARANCE             M            07/01/2006        $12.54
5 - Independent Laboratory        82585        82585 - CRYOFIBRINOGEN                    M            07/01/2006        $11.38
                                  82585
H - Laboratory Billed by Outpatient Hospital   82585 - CRYOFIBRINOGEN                    M            07/01/2006        $11.38
I - Laboratory Billed by Physician82585        82585 - CRYOFIBRINOGEN                    M            07/01/2006        $11.38
5 - Independent Laboratory        82595                                                  M            07/01/2006
                                               82595 - CRYOGLOBULIN, QUALITATIVE OR SEMI-QUANTITATIVE (EG, CRYOCRIT)      $8.59
                                  82595
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               82595 - CRYOGLOBULIN, QUALITATIVE OR SEMI-QUANTITATIVE (EG, CRYOCRIT)      $8.59
I - Laboratory Billed by Physician82595                                                  M            07/01/2006
                                               82595 - CRYOGLOBULIN, QUALITATIVE OR SEMI-QUANTITATIVE (EG, CRYOCRIT)      $8.59
5 - Independent Laboratory        82600        82600 - CYANIDE                           M            07/01/2006        $25.75
                                  82600
H - Laboratory Billed by Outpatient Hospital   82600 - CYANIDE                           M            07/01/2006        $25.75
I - Laboratory Billed by Physician82600        82600 - CYANIDE                           M            07/01/2006        $25.75
5 - Independent Laboratory        82607        82607 - CYANOCOBALAMIN (VITAMIN B-12); M               07/01/2006        $20.01
                                  82607
H - Laboratory Billed by Outpatient Hospital   82607 - CYANOCOBALAMIN (VITAMIN B-12); M               07/01/2006        $20.01
I - Laboratory Billed by Physician82607        82607 - CYANOCOBALAMIN (VITAMIN B-12); M               07/01/2006        $20.01
5 - Independent Laboratory        82608                                                  M            07/01/2006
                                               82608 - CYANOCOBALAMIN (VITAMIN B-12); UNSATURATED BINDING CAPACITY      $19.01
                                  82608
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               82608 - CYANOCOBALAMIN (VITAMIN B-12); UNSATURATED BINDING CAPACITY      $19.01
I - Laboratory Billed by Physician82608                                                  M            07/01/2006
                                               82608 - CYANOCOBALAMIN (VITAMIN B-12); UNSATURATED BINDING CAPACITY      $19.01
5 - Independent Laboratory        82615        82615 - CYSTINE AND HOMOCYSTINE, URINE, M QUALITATIVE 07/01/2006         $10.84
                                  82615
H - Laboratory Billed by Outpatient Hospital   82615 - CYSTINE AND HOMOCYSTINE, URINE, M QUALITATIVE 07/01/2006         $10.84
I - Laboratory Billed by Physician82615        82615 - CYSTINE AND HOMOCYSTINE, URINE, M QUALITATIVE 07/01/2006         $10.84
5 - Independent Laboratory        82626        82626 - DEHYDROEPIANDROSTERONE (DHEA)     M            07/01/2006        $33.54
                                  82626
H - Laboratory Billed by Outpatient Hospital   82626 - DEHYDROEPIANDROSTERONE (DHEA)     M            07/01/2006        $33.54
I - Laboratory Billed by Physician82626        82626 - DEHYDROEPIANDROSTERONE (DHEA)     M            07/01/2006        $33.54
5 - Independent Laboratory        82627                                                  M
                                               82627 - DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 07/01/2006               $29.52
                                  82627
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82627 - DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 07/01/2006               $29.52
I - Laboratory Billed by Physician82627                                                  M
                                               82627 - DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 07/01/2006               $29.52
5 - Independent Laboratory        82633        82633 - DESOXYCORTICOSTERONE, 11-         M            07/01/2006        $41.12
                                  82633
H - Laboratory Billed by Outpatient Hospital   82633 - DESOXYCORTICOSTERONE, 11-         M            07/01/2006        $41.12
I - Laboratory Billed by Physician82633        82633 - DESOXYCORTICOSTERONE, 11-         M            07/01/2006        $41.12
5 - Independent Laboratory        82634        82634 - DEOXYCORTISOL, 11-                M            07/01/2006        $38.86
                                  82634
H - Laboratory Billed by Outpatient Hospital   82634 - DEOXYCORTISOL, 11-                M            07/01/2006        $38.86
I - Laboratory Billed by Physician82634        82634 - DEOXYCORTISOL, 11-                M            07/01/2006        $38.86
5 - Independent Laboratory        82638        82638 - DIBUCAINE NUMBER                  M            07/01/2006        $16.25
                                  82638
H - Laboratory Billed by Outpatient Hospital   82638 - DIBUCAINE NUMBER                  M            07/01/2006        $16.25
I - Laboratory Billed by Physician82638        82638 - DIBUCAINE NUMBER                  M            07/01/2006        $16.25
5 - Independent Laboratory        82646        82646 - DIHYDROCODEINONE                  M            07/01/2006        $27.41
                                  82646
H - Laboratory Billed by Outpatient Hospital   82646 - DIHYDROCODEINONE                  M            07/01/2006        $27.41
I - Laboratory Billed by Physician82646        82646 - DIHYDROCODEINONE                  M            07/01/2006        $27.41
5 - Independent Laboratory        82649        82649 - DIHYDROMORPHINONE                 M            07/01/2006        $34.11
                                  82649
H - Laboratory Billed by Outpatient Hospital   82649 - DIHYDROMORPHINONE                 M            07/01/2006        $34.11
I - Laboratory Billed by Physician82649        82649 - DIHYDROMORPHINONE                 M            07/01/2006        $34.11
5 - Independent Laboratory        82651        82651 - DIHYDROTESTOSTERONE (DHT)         M            07/01/2006        $34.27
                                  82651
H - Laboratory Billed by Outpatient Hospital   82651 - DIHYDROTESTOSTERONE (DHT)         M            07/01/2006        $34.27
I - Laboratory Billed by Physician82651        82651 - DIHYDROTESTOSTERONE (DHT)         M            07/01/2006        $34.27
5 - Independent Laboratory        82652        82652 - DIHYDROXYVITAMIN D, 1,25-         M            07/01/2006        $51.09
                                  82652
H - Laboratory Billed by Outpatient Hospital   82652 - DIHYDROXYVITAMIN D, 1,25-         M            07/01/2006        $51.09
I - Laboratory Billed by Physician82652        82652 - DIHYDROXYVITAMIN D, 1,25-         M            07/01/2006        $51.09
5 - Independent Laboratory        82654        82654 - DIMETHADIONE                      M            07/01/2006        $18.37
                                  82654
H - Laboratory Billed by Outpatient Hospital   82654 - DIMETHADIONE                      M            07/01/2006        $18.37
I - Laboratory Billed by Physician82654        82654 - DIMETHADIONE                      M            07/01/2006        $18.37
5 - Independent Laboratory        82656                                                  M            07/01/2006        $15.31
                                               82656 - ELASTASE, PANCREATIC (EL-1), FECAL, QUALITATIVE OR SEMI-QUANTITATIVE
                                  82656
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $15.31
                                               82656 - ELASTASE, PANCREATIC (EL-1), FECAL, QUALITATIVE OR SEMI-QUANTITATIVE
I - Laboratory Billed by Physician82656                                                  M            07/01/2006        $15.31
                                               82656 - ELASTASE, PANCREATIC (EL-1), FECAL, QUALITATIVE OR SEMI-QUANTITATIVE


 4/22/2012                                                     62 of 489                ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        82657                                                  M           07/01/2006        $23.97
                                               82657 - ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIF
                                  82657
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $23.97
                                               82657 - ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIF
I - Laboratory Billed by Physician82657                                                  M           07/01/2006        $23.97
                                               82657 - ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIF
5 - Independent Laboratory        82658                                                  M           07/01/2006        $23.97
                                               82658 - ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIF
                                  82658
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $23.97
                                               82658 - ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIF
I - Laboratory Billed by Physician82658                                                  M           07/01/2006        $23.97
                                               82658 - ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIF
5 - Independent Laboratory        82664                                                  M           SPECIFIED
                                               82664 - ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE 07/01/2006             $45.60
                                  82664
H - Laboratory Billed by Outpatient Hospital                                             M           SPECIFIED
                                               82664 - ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE 07/01/2006             $45.60
I - Laboratory Billed by Physician82664                                                  M           SPECIFIED
                                               82664 - ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE 07/01/2006             $45.60
5 - Independent Laboratory        82666        82666 - EPIANDROSTERONE                   M           07/01/2006        $28.51
                                  82666
H - Laboratory Billed by Outpatient Hospital   82666 - EPIANDROSTERONE                   M           07/01/2006        $28.51
I - Laboratory Billed by Physician82666        82666 - EPIANDROSTERONE                   M           07/01/2006        $28.51
5 - Independent Laboratory        82668        82668 - ERYTHROPOIETIN                    M           07/01/2006        $24.95
                                  82668
H - Laboratory Billed by Outpatient Hospital   82668 - ERYTHROPOIETIN                    M           07/01/2006        $24.95
I - Laboratory Billed by Physician82668        82668 - ERYTHROPOIETIN                    M           07/01/2006        $24.95
5 - Independent Laboratory        82670        82670 - ESTRADIOL                         M           07/01/2006        $37.09
                                  82670
H - Laboratory Billed by Outpatient Hospital   82670 - ESTRADIOL                         M           07/01/2006        $37.09
I - Laboratory Billed by Physician82670        82670 - ESTRADIOL                         M           07/01/2006        $37.09
5 - Independent Laboratory        82671        82671 - ESTROGENS; FRACTIONATED           M           07/01/2006        $42.87
                                  82671
H - Laboratory Billed by Outpatient Hospital   82671 - ESTROGENS; FRACTIONATED           M           07/01/2006        $42.87
I - Laboratory Billed by Physician82671        82671 - ESTROGENS; FRACTIONATED           M           07/01/2006        $42.87
5 - Independent Laboratory        82672        82672 - ESTROGENS; TOTAL                  M           07/01/2006        $28.79
                                  82672
H - Laboratory Billed by Outpatient Hospital   82672 - ESTROGENS; TOTAL                  M           07/01/2006        $28.79
I - Laboratory Billed by Physician82672        82672 - ESTROGENS; TOTAL                  M           07/01/2006        $28.79
5 - Independent Laboratory        82677        82677 - ESTRIOL                           M           07/01/2006        $32.10
                                  82677
H - Laboratory Billed by Outpatient Hospital   82677 - ESTRIOL                           M           07/01/2006        $32.10
I - Laboratory Billed by Physician82677        82677 - ESTRIOL                           M           07/01/2006        $32.10
5 - Independent Laboratory        82679        82679 - ESTRONE                           M           07/01/2006        $33.14
                                  82679
H - Laboratory Billed by Outpatient Hospital   82679 - ESTRONE                           M           07/01/2006        $33.14
I - Laboratory Billed by Physician82679        82679 - ESTRONE                           M           07/01/2006        $33.14
5 - Independent Laboratory        82690        82690 - ETHCHLORVYNOL                     M           07/01/2006        $22.94
                                  82690
H - Laboratory Billed by Outpatient Hospital   82690 - ETHCHLORVYNOL                     M           07/01/2006        $22.94
I - Laboratory Billed by Physician82690        82690 - ETHCHLORVYNOL                     M           07/01/2006        $22.94
5 - Independent Laboratory        82693        82693 - ETHYLENE GLYCOL                   M           07/01/2006        $19.78
                                  82693
H - Laboratory Billed by Outpatient Hospital   82693 - ETHYLENE GLYCOL                   M           07/01/2006        $19.78
I - Laboratory Billed by Physician82693        82693 - ETHYLENE GLYCOL                   M           07/01/2006        $19.78
5 - Independent Laboratory        82696        82696 - ETIOCHOLANOLONE                   M           07/01/2006        $31.30
                                  82696
H - Laboratory Billed by Outpatient Hospital   82696 - ETIOCHOLANOLONE                   M           07/01/2006        $31.30
I - Laboratory Billed by Physician82696        82696 - ETIOCHOLANOLONE                   M           07/01/2006        $31.30
5 - Independent Laboratory        82705        82705 - FAT OR LIPIDS, FECES; QUALITATIVE M           07/01/2006          $6.75
                                  82705
H - Laboratory Billed by Outpatient Hospital   82705 - FAT OR LIPIDS, FECES; QUALITATIVE M           07/01/2006          $6.75
I - Laboratory Billed by Physician82705        82705 - FAT OR LIPIDS, FECES; QUALITATIVE M           07/01/2006          $6.75
5 - Independent Laboratory        82710        82710 - FAT OR LIPIDS, FECES; QUANTITATIVEM           07/01/2006        $22.30
                                  82710
H - Laboratory Billed by Outpatient Hospital   82710 - FAT OR LIPIDS, FECES; QUANTITATIVEM           07/01/2006        $22.30
I - Laboratory Billed by Physician82710        82710 - FAT OR LIPIDS, FECES; QUANTITATIVEM           07/01/2006        $22.30
5 - Independent Laboratory        82715                                                  M
                                               82715 - FAT DIFFERENTIAL, FECES, QUANTITATIVE         07/01/2006        $22.85
                                  82715
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82715 - FAT DIFFERENTIAL, FECES, QUANTITATIVE         07/01/2006        $22.85
I - Laboratory Billed by Physician82715                                                  M
                                               82715 - FAT DIFFERENTIAL, FECES, QUANTITATIVE         07/01/2006        $22.85
5 - Independent Laboratory        82725        82725 - FATTY ACIDS, NONESTERIFIED        M           07/01/2006        $17.67
                                  82725
H - Laboratory Billed by Outpatient Hospital   82725 - FATTY ACIDS, NONESTERIFIED        M           07/01/2006        $17.67
I - Laboratory Billed by Physician82725        82725 - FATTY ACIDS, NONESTERIFIED        M           07/01/2006        $17.67
5 - Independent Laboratory        82726        82726 - VERY LONG CHAIN FATTY ACIDS       M           07/01/2006        $23.97
                                  82726
H - Laboratory Billed by Outpatient Hospital   82726 - VERY LONG CHAIN FATTY ACIDS       M           07/01/2006        $23.97
I - Laboratory Billed by Physician82726        82726 - VERY LONG CHAIN FATTY ACIDS       M           07/01/2006        $23.97
5 - Independent Laboratory        82728        82728 - FERRITIN                          M           07/01/2006        $18.08
                                  82728
H - Laboratory Billed by Outpatient Hospital   82728 - FERRITIN                          M           07/01/2006        $18.08
I - Laboratory Billed by Physician82728        82728 - FERRITIN                          M           07/01/2006        $18.08
5 - Independent Laboratory        82731                                                  M           07/01/2006
                                               82731 - FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI-QUANTITATIVE $85.49
                                  82731
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               82731 - FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI-QUANTITATIVE $85.49
I - Laboratory Billed by Physician82731                                                  M           07/01/2006
                                               82731 - FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI-QUANTITATIVE $85.49
5 - Independent Laboratory        82735        82735 - FLUORIDE                          M           07/01/2006        $24.61
                                  82735
H - Laboratory Billed by Outpatient Hospital   82735 - FLUORIDE                          M           07/01/2006        $24.61
I - Laboratory Billed by Physician82735        82735 - FLUORIDE                          M           07/01/2006        $24.61
5 - Independent Laboratory        82742        82742 - FLURAZEPAM                        M           07/01/2006        $26.28
                                  82742
H - Laboratory Billed by Outpatient Hospital   82742 - FLURAZEPAM                        M           07/01/2006        $26.28
I - Laboratory Billed by Physician82742        82742 - FLURAZEPAM                        M           07/01/2006        $26.28


 4/22/2012                                                    63 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing    Charge
5 - Independent Laboratory        82746        82746 - FOLIC ACID; SERUM                 M           07/01/2006        $19.51
                                  82746
H - Laboratory Billed by Outpatient Hospital   82746 - FOLIC ACID; SERUM                 M           07/01/2006        $19.51
I - Laboratory Billed by Physician82746        82746 - FOLIC ACID; SERUM                 M           07/01/2006        $19.51
5 - Independent Laboratory        82747        82747 - FOLIC ACID; RBC                   M           07/01/2006        $22.99
                                  82747
H - Laboratory Billed by Outpatient Hospital   82747 - FOLIC ACID; RBC                   M           07/01/2006        $22.99
I - Laboratory Billed by Physician82747        82747 - FOLIC ACID; RBC                   M           07/01/2006        $22.99
5 - Independent Laboratory        82757        82757 - FRUCTOSE, SEMEN                   M           07/01/2006        $23.03
                                  82757
H - Laboratory Billed by Outpatient Hospital   82757 - FRUCTOSE, SEMEN                   M           07/01/2006        $23.03
I - Laboratory Billed by Physician82757        82757 - FRUCTOSE, SEMEN                   M           07/01/2006        $23.03
5 - Independent Laboratory        82759        82759 - GALACTOKINASE, RBC                M           07/01/2006        $28.51
                                  82759
H - Laboratory Billed by Outpatient Hospital   82759 - GALACTOKINASE, RBC                M           07/01/2006        $28.51
I - Laboratory Billed by Physician82759        82759 - GALACTOKINASE, RBC                M           07/01/2006        $28.51
5 - Independent Laboratory        82760        82760 - GALACTOSE                         M           07/01/2006        $14.86
                                  82760
H - Laboratory Billed by Outpatient Hospital   82760 - GALACTOSE                         M           07/01/2006        $14.86
I - Laboratory Billed by Physician82760        82760 - GALACTOSE                         M           07/01/2006        $14.86
5 - Independent Laboratory        82775                                                  M           QUANTITATIVE
                                               82775 - GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 07/01/2006            $27.96
                                  82775
H - Laboratory Billed by Outpatient Hospital                                             M           QUANTITATIVE
                                               82775 - GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 07/01/2006            $27.96
I - Laboratory Billed by Physician82775                                                  M           QUANTITATIVE
                                               82775 - GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 07/01/2006            $27.96
5 - Independent Laboratory        82776                                                  M           SCREEN
                                               82776 - GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 07/01/2006            $10.74
                                  82776
H - Laboratory Billed by Outpatient Hospital                                             M           SCREEN
                                               82776 - GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 07/01/2006            $10.74
I - Laboratory Billed by Physician82776                                                  M           SCREEN
                                               82776 - GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; 07/01/2006            $10.74
5 - Independent Laboratory        82784                                                  EACH
                                               82784 - GAMMAGLOBULIN; IGA, IGD, IGG, IGM,M           07/01/2006        $12.34
                                  82784
H - Laboratory Billed by Outpatient Hospital                                             EACH
                                               82784 - GAMMAGLOBULIN; IGA, IGD, IGG, IGM,M           07/01/2006        $12.34
I - Laboratory Billed by Physician82784                                                  EACH
                                               82784 - GAMMAGLOBULIN; IGA, IGD, IGG, IGM,M           07/01/2006        $12.34
5 - Independent Laboratory        82785        82785 - GAMMAGLOBULIN; IGE                M           07/01/2006        $21.86
                                  82785
H - Laboratory Billed by Outpatient Hospital   82785 - GAMMAGLOBULIN; IGE                M           07/01/2006        $21.86
I - Laboratory Billed by Physician82785        82785 - GAMMAGLOBULIN; IGE                M           07/01/2006        $21.86
5 - Independent Laboratory        82787                                                  M           07/01/2006        $10.64
                                               82787 - GAMMAGLOBULIN; IMMUNOGLOBULIN SUBCLASSES, (IGG1, 2, 3, OR 4), EACH
                                  82787
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $10.64
                                               82787 - GAMMAGLOBULIN; IMMUNOGLOBULIN SUBCLASSES, (IGG1, 2, 3, OR 4), EACH
I - Laboratory Billed by Physician82787                                                  M           07/01/2006        $10.64
                                               82787 - GAMMAGLOBULIN; IMMUNOGLOBULIN SUBCLASSES, (IGG1, 2, 3, OR 4), EACH
5 - Independent Laboratory        82800        82800 - GASES, BLOOD, PH ONLY             M           07/01/2006        $11.24
                                  82800
H - Laboratory Billed by Outpatient Hospital   82800 - GASES, BLOOD, PH ONLY             M           07/01/2006        $11.24
I - Laboratory Billed by Physician82800        82800 - GASES, BLOOD, PH ONLY             M           07/01/2006        $11.24
5 - Independent Laboratory        82803                                                  M           07/01/2006        $25.69
                                               82803 - GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O
                                  82803
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $25.69
                                               82803 - GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O
I - Laboratory Billed by Physician82803                                                  M           07/01/2006        $25.69
                                               82803 - GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O
5 - Independent Laboratory        82805                                                  M           07/01/2006        $37.67
                                               82805 - GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O
                                  82805
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $37.67
                                               82805 - GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O
I - Laboratory Billed by Physician82805                                                  M           07/01/2006        $37.67
                                               82805 - GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O
5 - Independent Laboratory        82810                                                  M           07/01/2006        $11.59
                                               82810 - GASES, BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETR
                                  82810
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $11.59
                                               82810 - GASES, BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETR
I - Laboratory Billed by Physician82810                                                  M           07/01/2006        $11.59
                                               82810 - GASES, BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETR
5 - Independent Laboratory        82820                                                  M           07/01/2006        $13.26
                                               82820 - HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN SATURATION WITH OXYGEN)
                                  82820
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $13.26
                                               82820 - HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN SATURATION WITH OXYGEN)
I - Laboratory Billed by Physician82820                                                  M           07/01/2006        $13.26
                                               82820 - HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN SATURATION WITH OXYGEN)
5 - Independent Laboratory        82926                                                  M
                                               82926 - GASTRIC ACID, FREE AND TOTAL, EACH SPECIMEN 07/01/2006            $7.23
                                  82926
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82926 - GASTRIC ACID, FREE AND TOTAL, EACH SPECIMEN 07/01/2006            $7.23
I - Laboratory Billed by Physician82926                                                  M
                                               82926 - GASTRIC ACID, FREE AND TOTAL, EACH SPECIMEN 07/01/2006            $7.23
5 - Independent Laboratory        82928                                                  M
                                               82928 - GASTRIC ACID, FREE OR TOTAL, EACH SPECIMEN 07/01/2006             $8.69
                                  82928
H - Laboratory Billed by Outpatient Hospital                                             M
                                               82928 - GASTRIC ACID, FREE OR TOTAL, EACH SPECIMEN 07/01/2006             $8.69
I - Laboratory Billed by Physician82928                                                  M
                                               82928 - GASTRIC ACID, FREE OR TOTAL, EACH SPECIMEN 07/01/2006             $8.69
5 - Independent Laboratory        82938        82938 - GASTRIN AFTER SECRETIN STIMULATIONM           07/01/2006        $23.48
                                  82938
H - Laboratory Billed by Outpatient Hospital   82938 - GASTRIN AFTER SECRETIN STIMULATIONM           07/01/2006        $23.48
I - Laboratory Billed by Physician82938        82938 - GASTRIN AFTER SECRETIN STIMULATIONM           07/01/2006        $23.48
5 - Independent Laboratory        82941        82941 - GASTRIN                           M           07/01/2006        $23.41
                                  82941
H - Laboratory Billed by Outpatient Hospital   82941 - GASTRIN                           M           07/01/2006        $23.41
I - Laboratory Billed by Physician82941        82941 - GASTRIN                           M           07/01/2006        $23.41
5 - Independent Laboratory        82943        82943 - GLUCAGON                          M           07/01/2006        $18.97
                                  82943
H - Laboratory Billed by Outpatient Hospital   82943 - GLUCAGON                          M           07/01/2006        $18.97
I - Laboratory Billed by Physician82943        82943 - GLUCAGON                          M           07/01/2006        $18.97
5 - Independent Laboratory        82945        82945 - GLUCOSE, BODY FLUID, OTHER THANM  BLOOD       07/01/2006          $5.21
                                  82945
H - Laboratory Billed by Outpatient Hospital   82945 - GLUCOSE, BODY FLUID, OTHER THANM  BLOOD       07/01/2006          $5.21
I - Laboratory Billed by Physician82945        82945 - GLUCOSE, BODY FLUID, OTHER THANM  BLOOD       07/01/2006          $5.21
5 - Independent Laboratory        82946        82946 - GLUCAGON TOLERANCE TEST           M           07/01/2006        $20.01
                                  82946
H - Laboratory Billed by Outpatient Hospital   82946 - GLUCAGON TOLERANCE TEST           M           07/01/2006        $20.01
I - Laboratory Billed by Physician82946        82946 - GLUCAGON TOLERANCE TEST           M           07/01/2006        $20.01


 4/22/2012                                                     64 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                             Medicaid/BH     Pricing    Charge
5 - Independent Laboratory        82947                                                M           07/01/2006
                                               82947 - GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)             $5.21
                                  82947
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006
                                               82947 - GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)             $5.21
I - Laboratory Billed by Physician82947                                                M           07/01/2006
                                               82947 - GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)             $5.21
5 - Independent Laboratory        82948        82948 - GLUCOSE; BLOOD, REAGENT STRIP M             07/01/2006          $4.21
                                  82948
H - Laboratory Billed by Outpatient Hospital   82948 - GLUCOSE; BLOOD, REAGENT STRIP M             07/01/2006          $4.21
I - Laboratory Billed by Physician82948        82948 - GLUCOSE; BLOOD, REAGENT STRIP M             07/01/2006          $4.21
5 - Independent Laboratory        82950                                                M           07/01/2006
                                               82950 - GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE)                   $6.31
                                  82950
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006
                                               82950 - GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE)                   $6.31
I - Laboratory Billed by Physician82950                                                M           07/01/2006
                                               82950 - GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE)                   $6.31
5 - Independent Laboratory        82951                                                M           07/01/2006         $17.09
                                               82951 - GLUCOSE; TOLERANCE TEST (GTT), THREE SPECIMENS (INCLUDES GLUCOSE)
                                  82951
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $17.09
                                               82951 - GLUCOSE; TOLERANCE TEST (GTT), THREE SPECIMENS (INCLUDES GLUCOSE)
I - Laboratory Billed by Physician82951                                                M           07/01/2006         $17.09
                                               82951 - GLUCOSE; TOLERANCE TEST (GTT), THREE SPECIMENS (INCLUDES GLUCOSE)
5 - Independent Laboratory        82952                                                M           07/01/2006
                                               82952 - GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND THREE SPECIMENS $5.21
                                  82952
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006
                                               82952 - GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND THREE SPECIMENS $5.21
I - Laboratory Billed by Physician82952                                                M           07/01/2006
                                               82952 - GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND THREE SPECIMENS $5.21
5 - Independent Laboratory        82953                                                M
                                               82953 - GLUCOSE; TOLBUTAMIDE TOLERANCE TEST         07/01/2006         $20.10
                                  82953
H - Laboratory Billed by Outpatient Hospital                                           M
                                               82953 - GLUCOSE; TOLBUTAMIDE TOLERANCE TEST         07/01/2006         $20.10
I - Laboratory Billed by Physician82953                                                M
                                               82953 - GLUCOSE; TOLBUTAMIDE TOLERANCE TEST         07/01/2006         $20.10
5 - Independent Laboratory        82955                                                M            QUANTITATIVE
                                               82955 - GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD);07/01/2006            $12.87
                                  82955
H - Laboratory Billed by Outpatient Hospital                                           M            QUANTITATIVE
                                               82955 - GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD);07/01/2006            $12.87
I - Laboratory Billed by Physician82955                                                M            QUANTITATIVE
                                               82955 - GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD);07/01/2006            $12.87
5 - Independent Laboratory        82960                                                M            SCREEN
                                               82960 - GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD);07/01/2006             $8.05
                                  82960
H - Laboratory Billed by Outpatient Hospital                                           M            SCREEN
                                               82960 - GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD);07/01/2006             $8.05
I - Laboratory Billed by Physician82960                                                M            SCREEN
                                               82960 - GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD);07/01/2006             $8.05
5 - Independent Laboratory        82962                                                M           07/01/2006          FDA SPECIFICALLY
                                               82962 - GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE $3.11
                                  82962
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006          FDA SPECIFICALLY
                                               82962 - GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE $3.11
I - Laboratory Billed by Physician82962                                                M           07/01/2006          FDA SPECIFICALLY
                                               82962 - GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE $3.11
5 - Independent Laboratory        82963        82963 - GLUCOSIDASE, BETA               M           07/01/2006         $28.51
                                  82963
H - Laboratory Billed by Outpatient Hospital   82963 - GLUCOSIDASE, BETA               M           07/01/2006         $28.51
I - Laboratory Billed by Physician82963        82963 - GLUCOSIDASE, BETA               M           07/01/2006         $28.51
5 - Independent Laboratory        82965        82965 - GLUTAMATE DEHYDROGENASE         M           07/01/2006         $10.26
                                  82965
H - Laboratory Billed by Outpatient Hospital   82965 - GLUTAMATE DEHYDROGENASE         M           07/01/2006         $10.26
I - Laboratory Billed by Physician82965        82965 - GLUTAMATE DEHYDROGENASE         M           07/01/2006         $10.26
5 - Independent Laboratory        82975        82975 - GLUTAMINE (GLUTAMIC ACID AMIDE) M           07/01/2006         $21.02
                                  82975
H - Laboratory Billed by Outpatient Hospital   82975 - GLUTAMINE (GLUTAMIC ACID AMIDE) M           07/01/2006         $21.02
I - Laboratory Billed by Physician82975        82975 - GLUTAMINE (GLUTAMIC ACID AMIDE) M           07/01/2006         $21.02
5 - Independent Laboratory        82977        82977 - GLUTAMYLTRANSFERASE, GAMMA (GGT)M           07/01/2006          $9.28
                                  82977
H - Laboratory Billed by Outpatient Hospital   82977 - GLUTAMYLTRANSFERASE, GAMMA (GGT)M           07/01/2006          $9.28
I - Laboratory Billed by Physician82977        82977 - GLUTAMYLTRANSFERASE, GAMMA (GGT)M           07/01/2006          $9.28
5 - Independent Laboratory        82978        82978 - GLUTATHIONE                     M           07/01/2006         $18.91
                                  82978
H - Laboratory Billed by Outpatient Hospital   82978 - GLUTATHIONE                     M           07/01/2006         $18.91
I - Laboratory Billed by Physician82978        82978 - GLUTATHIONE                     M           07/01/2006         $18.91
5 - Independent Laboratory        82979        82979 - GLUTATHIONE REDUCTASE, RBC      M           07/01/2006          $9.14
                                  82979
H - Laboratory Billed by Outpatient Hospital   82979 - GLUTATHIONE REDUCTASE, RBC      M           07/01/2006          $9.14
I - Laboratory Billed by Physician82979        82979 - GLUTATHIONE REDUCTASE, RBC      M           07/01/2006          $9.14
5 - Independent Laboratory        82980        82980 - GLUTETHIMIDE                    M           07/01/2006         $24.32
                                  82980
H - Laboratory Billed by Outpatient Hospital   82980 - GLUTETHIMIDE                    M           07/01/2006         $24.32
I - Laboratory Billed by Physician82980        82980 - GLUTETHIMIDE                    M           07/01/2006         $24.32
5 - Independent Laboratory        82985        82985 - GLYCATED PROTEIN                M           07/01/2006         $20.01
                                  82985
H - Laboratory Billed by Outpatient Hospital   82985 - GLYCATED PROTEIN                M           07/01/2006         $20.01
I - Laboratory Billed by Physician82985        82985 - GLYCATED PROTEIN                M           07/01/2006         $20.01
5 - Independent Laboratory        83001                                                M           07/01/2006
                                               83001 - GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH)               $24.67
                                  83001
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006
                                               83001 - GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH)               $24.67
I - Laboratory Billed by Physician83001                                                M           07/01/2006
                                               83001 - GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH)               $24.67
5 - Independent Laboratory        83002                                                M
                                               83002 - GONADOTROPIN; LUTEINIZING HORMONE (LH)      07/01/2006         $24.59
                                  83002
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83002 - GONADOTROPIN; LUTEINIZING HORMONE (LH)      07/01/2006         $24.59
I - Laboratory Billed by Physician83002                                                M
                                               83002 - GONADOTROPIN; LUTEINIZING HORMONE (LH)      07/01/2006         $24.59
5 - Independent Laboratory        83003                                                M
                                               83003 - GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN)  07/01/2006         $22.13
                                  83003
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83003 - GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN)  07/01/2006         $22.13
I - Laboratory Billed by Physician83003                                                M
                                               83003 - GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN)  07/01/2006         $22.13
5 - Independent Laboratory        83008                                                M
                                               83008 - GUANOSINE MONOPHOSPHATE (GMP), CYCLIC       07/01/2006         $22.28
                                  83008
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83008 - GUANOSINE MONOPHOSPHATE (GMP), CYCLIC       07/01/2006         $22.28
I - Laboratory Billed by Physician83008                                                M
                                               83008 - GUANOSINE MONOPHOSPHATE (GMP), CYCLIC       07/01/2006         $22.28
5 - Independent Laboratory        83009                                                M           07/01/2006         $89.40
                                               83009 - HELICOBACTER PYLORI, BLOOD TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE IS
                                  83009
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $89.40
                                               83009 - HELICOBACTER PYLORI, BLOOD TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE IS
I - Laboratory Billed by Physician83009                                                M           07/01/2006         $89.40
                                               83009 - HELICOBACTER PYLORI, BLOOD TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE IS


 4/22/2012                                                     65 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        83010        83010 - HAPTOGLOBIN; QUANTITATIVE        M            07/01/2006        $16.70
                                  83010
H - Laboratory Billed by Outpatient Hospital   83010 - HAPTOGLOBIN; QUANTITATIVE        M            07/01/2006        $16.70
I - Laboratory Billed by Physician83010        83010 - HAPTOGLOBIN; QUANTITATIVE        M            07/01/2006        $16.70
5 - Independent Laboratory        83012        83012 - HAPTOGLOBIN; PHENOTYPES          M            07/01/2006        $22.82
                                  83012
H - Laboratory Billed by Outpatient Hospital   83012 - HAPTOGLOBIN; PHENOTYPES          M            07/01/2006        $22.82
I - Laboratory Billed by Physician83012        83012 - HAPTOGLOBIN; PHENOTYPES          M            07/01/2006        $22.82
5 - Independent Laboratory        83013                                                 M            07/01/2006        $89.40
                                               83013 - HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE
                                  83013
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006        $89.40
                                               83013 - HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE
I - Laboratory Billed by Physician83013                                                 M            07/01/2006        $89.40
                                               83013 - HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE
5 - Independent Laboratory        83014                                                 M
                                               83014 - HELICOBACTER PYLORI; DRUG ADMINISTRATION      07/01/2006        $10.43
                                  83014
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83014 - HELICOBACTER PYLORI; DRUG ADMINISTRATION      07/01/2006        $10.43
I - Laboratory Billed by Physician83014                                                 M
                                               83014 - HELICOBACTER PYLORI; DRUG ADMINISTRATION      07/01/2006        $10.43
5 - Independent Laboratory        83015                                                 M            07/01/2006        $24.99
                                               83015 - HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); SCREEN
                                  83015
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006        $24.99
                                               83015 - HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); SCREEN
I - Laboratory Billed by Physician83015                                                 M            07/01/2006        $24.99
                                               83015 - HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); SCREEN
5 - Independent Laboratory        83018                                                 M            07/01/2006        $29.15
                                               83018 - HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); QUANTIT
                                  83018
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006        $29.15
                                               83018 - HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); QUANTIT
I - Laboratory Billed by Physician83018                                                 M            07/01/2006        $29.15
                                               83018 - HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); QUANTIT
5 - Independent Laboratory        83020                                                 M             ELECTROPHORESIS (EG, A2, S, C, AND/OR
                                               83020 - HEMOGLOBIN FRACTIONATION AND QUANTITATION;07/01/2006            $17.09
                                  83020
H - Laboratory Billed by Outpatient Hospital                                            M             ELECTROPHORESIS (EG, A2, S, C, AND/OR
                                               83020 - HEMOGLOBIN FRACTIONATION AND QUANTITATION;07/01/2006            $17.09
I - Laboratory Billed by Physician83020                                                 M             ELECTROPHORESIS (EG, A2, S, C, AND/OR
                                               83020 - HEMOGLOBIN FRACTIONATION AND QUANTITATION;07/01/2006            $17.09
5 - Independent Laboratory        83021                                                 M             CHROMATOGRAPHY (EG, A2, S, C, AND/O
                                               83021 - HEMOGLOBIN FRACTIONATION AND QUANTITATION;07/01/2006            $23.97
                                  83021
H - Laboratory Billed by Outpatient Hospital                                            M             CHROMATOGRAPHY (EG, A2, S, C, AND/O
                                               83021 - HEMOGLOBIN FRACTIONATION AND QUANTITATION;07/01/2006            $23.97
I - Laboratory Billed by Physician83021                                                 M             CHROMATOGRAPHY (EG, A2, S, C, AND/O
                                               83021 - HEMOGLOBIN FRACTIONATION AND QUANTITATION;07/01/2006            $23.97
5 - Independent Laboratory        83026                                                 M            07/01/2006
                                               83026 - HEMOGLOBIN; BY COPPER SULFATE METHOD, NON-AUTOMATED               $3.14
                                  83026
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               83026 - HEMOGLOBIN; BY COPPER SULFATE METHOD, NON-AUTOMATED               $3.14
I - Laboratory Billed by Physician83026                                                 M            07/01/2006
                                               83026 - HEMOGLOBIN; BY COPPER SULFATE METHOD, NON-AUTOMATED               $3.14
5 - Independent Laboratory        83030        83030 - HEMOGLOBIN; F (FETAL), CHEMICAL M             07/01/2006        $10.98
                                  83030
H - Laboratory Billed by Outpatient Hospital   83030 - HEMOGLOBIN; F (FETAL), CHEMICAL M             07/01/2006        $10.98
I - Laboratory Billed by Physician83030        83030 - HEMOGLOBIN; F (FETAL), CHEMICAL M             07/01/2006        $10.98
5 - Independent Laboratory        83033                                                 M
                                               83033 - HEMOGLOBIN; F (FETAL), QUALITATIVE            07/01/2006          $7.91
                                  83033
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83033 - HEMOGLOBIN; F (FETAL), QUALITATIVE            07/01/2006          $7.91
I - Laboratory Billed by Physician83033                                                 M
                                               83033 - HEMOGLOBIN; F (FETAL), QUALITATIVE            07/01/2006          $7.91
5 - Independent Laboratory        83036        83036 - HEMOGLOBIN; GLYCOSYLATED (A1C) M              07/01/2006        $12.88
                                  83036
H - Laboratory Billed by Outpatient Hospital   83036 - HEMOGLOBIN; GLYCOSYLATED (A1C) M              07/01/2006        $12.88
I - Laboratory Billed by Physician83036        83036 - HEMOGLOBIN; GLYCOSYLATED (A1C) M              07/01/2006        $12.88
5 - Independent Laboratory        83037                                                 BY           07/01/2006        $14.50
                                               83037 - HEMOGLOBIN; GLYCOSYLATED (A1C) M DEVICE CLEARED BY FDA FOR HOME USE
                                  83037
H - Laboratory Billed by Outpatient Hospital                                            BY           07/01/2006        $14.50
                                               83037 - HEMOGLOBIN; GLYCOSYLATED (A1C) M DEVICE CLEARED BY FDA FOR HOME USE
I - Laboratory Billed by Physician83037                                                 BY           07/01/2006        $14.50
                                               83037 - HEMOGLOBIN; GLYCOSYLATED (A1C) M DEVICE CLEARED BY FDA FOR HOME USE
5 - Independent Laboratory        83045                                                 M
                                               83045 - HEMOGLOBIN; METHEMOGLOBIN, QUALITATIVE        07/01/2006          $6.58
                                  83045
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83045 - HEMOGLOBIN; METHEMOGLOBIN, QUALITATIVE        07/01/2006          $6.58
I - Laboratory Billed by Physician83045                                                 M
                                               83045 - HEMOGLOBIN; METHEMOGLOBIN, QUALITATIVE        07/01/2006          $6.58
5 - Independent Laboratory        83050                                                 M
                                               83050 - HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE       07/01/2006          $7.34
                                  83050
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83050 - HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE       07/01/2006          $7.34
I - Laboratory Billed by Physician83050                                                 M
                                               83050 - HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE       07/01/2006          $7.34
5 - Independent Laboratory        83051        83051 - HEMOGLOBIN; PLASMA               M            07/01/2006          $9.70
                                  83051
H - Laboratory Billed by Outpatient Hospital   83051 - HEMOGLOBIN; PLASMA               M            07/01/2006          $9.70
I - Laboratory Billed by Physician83051        83051 - HEMOGLOBIN; PLASMA               M            07/01/2006          $9.70
5 - Independent Laboratory        83055                                                 M
                                               83055 - HEMOGLOBIN; SULFHEMOGLOBIN, QUALITATIVE       07/01/2006          $6.53
                                  83055
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83055 - HEMOGLOBIN; SULFHEMOGLOBIN, QUALITATIVE       07/01/2006          $6.53
I - Laboratory Billed by Physician83055                                                 M
                                               83055 - HEMOGLOBIN; SULFHEMOGLOBIN, QUALITATIVE       07/01/2006          $6.53
5 - Independent Laboratory        83060                                                 M
                                               83060 - HEMOGLOBIN; SULFHEMOGLOBIN, QUANTITATIVE 07/01/2006             $10.98
                                  83060
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83060 - HEMOGLOBIN; SULFHEMOGLOBIN, QUANTITATIVE 07/01/2006             $10.98
I - Laboratory Billed by Physician83060                                                 M
                                               83060 - HEMOGLOBIN; SULFHEMOGLOBIN, QUANTITATIVE 07/01/2006             $10.98
5 - Independent Laboratory        83065        83065 - HEMOGLOBIN; THERMOLABILE         M            07/01/2006          $9.14
                                  83065
H - Laboratory Billed by Outpatient Hospital   83065 - HEMOGLOBIN; THERMOLABILE         M            07/01/2006          $9.14
I - Laboratory Billed by Physician83065        83065 - HEMOGLOBIN; THERMOLABILE         M            07/01/2006          $9.14
5 - Independent Laboratory        83068        83068 - HEMOGLOBIN; UNSTABLE, SCREEN M                07/01/2006        $11.24
                                  83068
H - Laboratory Billed by Outpatient Hospital   83068 - HEMOGLOBIN; UNSTABLE, SCREEN M                07/01/2006        $11.24
I - Laboratory Billed by Physician83068        83068 - HEMOGLOBIN; UNSTABLE, SCREEN M                07/01/2006        $11.24
5 - Independent Laboratory        83069        83069 - HEMOGLOBIN; URINE                M            07/01/2006          $5.23
                                  83069
H - Laboratory Billed by Outpatient Hospital   83069 - HEMOGLOBIN; URINE                M            07/01/2006          $5.23
I - Laboratory Billed by Physician83069        83069 - HEMOGLOBIN; URINE                M            07/01/2006          $5.23
5 - Independent Laboratory        83070        83070 - HEMOSIDERIN; QUALITATIVE         M            07/01/2006          $6.31
                                  83070
H - Laboratory Billed by Outpatient Hospital   83070 - HEMOSIDERIN; QUALITATIVE         M            07/01/2006          $6.31
I - Laboratory Billed by Physician83070        83070 - HEMOSIDERIN; QUALITATIVE         M            07/01/2006          $6.31


 4/22/2012                                                     66 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        83071        83071 - HEMOSIDERIN; QUANTITATIVE       M             07/01/2006          $8.27
                                  83071
H - Laboratory Billed by Outpatient Hospital   83071 - HEMOSIDERIN; QUANTITATIVE       M             07/01/2006          $8.27
I - Laboratory Billed by Physician83071        83071 - HEMOSIDERIN; QUANTITATIVE       M             07/01/2006          $8.27
5 - Independent Laboratory        83080        83080 - B-HEXOSAMINIDASE, EACH ASSAY M                07/01/2006        $22.39
                                  83080
H - Laboratory Billed by Outpatient Hospital   83080 - B-HEXOSAMINIDASE, EACH ASSAY M                07/01/2006        $22.39
I - Laboratory Billed by Physician83080        83080 - B-HEXOSAMINIDASE, EACH ASSAY M                07/01/2006        $22.39
5 - Independent Laboratory        83088        83088 - HISTAMINE                       M             07/01/2006        $39.20
                                  83088
H - Laboratory Billed by Outpatient Hospital   83088 - HISTAMINE                       M             07/01/2006        $39.20
I - Laboratory Billed by Physician83088        83088 - HISTAMINE                       M             07/01/2006        $39.20
5 - Independent Laboratory        83090        83090 - HOMOCYSTEINE                    M             07/01/2006        $22.39
                                  83090
H - Laboratory Billed by Outpatient Hospital   83090 - HOMOCYSTEINE                    M             07/01/2006        $22.39
I - Laboratory Billed by Physician83090        83090 - HOMOCYSTEINE                    M             07/01/2006        $22.39
5 - Independent Laboratory        83150        83150 - HOMOVANILLIC ACID (HVA)         M             07/01/2006        $25.69
                                  83150
H - Laboratory Billed by Outpatient Hospital   83150 - HOMOVANILLIC ACID (HVA)         M             07/01/2006        $25.69
I - Laboratory Billed by Physician83150        83150 - HOMOVANILLIC ACID (HVA)         M             07/01/2006        $25.69
5 - Independent Laboratory        83491                                                M
                                               83491 - HYDROXYCORTICOSTEROIDS, 17- (17-OHCS)         07/01/2006        $23.25
                                  83491
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83491 - HYDROXYCORTICOSTEROIDS, 17- (17-OHCS)         07/01/2006        $23.25
I - Laboratory Billed by Physician83491                                                M
                                               83491 - HYDROXYCORTICOSTEROIDS, 17- (17-OHCS)         07/01/2006        $23.25
5 - Independent Laboratory        83497                                                M
                                               83497 - HYDROXYINDOLACETIC ACID, 5-(HIAA)             07/01/2006        $14.34
                                  83497
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83497 - HYDROXYINDOLACETIC ACID, 5-(HIAA)             07/01/2006        $14.34
I - Laboratory Billed by Physician83497                                                M
                                               83497 - HYDROXYINDOLACETIC ACID, 5-(HIAA)             07/01/2006        $14.34
5 - Independent Laboratory        83498        83498 - HYDROXYPROGESTERONE, 17-D       M             07/01/2006        $36.05
                                  83498
H - Laboratory Billed by Outpatient Hospital   83498 - HYDROXYPROGESTERONE, 17-D       M             07/01/2006        $36.05
I - Laboratory Billed by Physician83498        83498 - HYDROXYPROGESTERONE, 17-D       M             07/01/2006        $36.05
5 - Independent Laboratory        83499        83499 - HYDROXYPROGESTERONE, 20-        M             07/01/2006        $33.46
                                  83499
H - Laboratory Billed by Outpatient Hospital   83499 - HYDROXYPROGESTERONE, 20-        M             07/01/2006        $33.46
I - Laboratory Billed by Physician83499        83499 - HYDROXYPROGESTERONE, 20-        M             07/01/2006        $33.46
5 - Independent Laboratory        83500        83500 - HYDROXYPROLINE; FREE            M             07/01/2006        $30.07
                                  83500
H - Laboratory Billed by Outpatient Hospital   83500 - HYDROXYPROLINE; FREE            M             07/01/2006        $30.07
I - Laboratory Billed by Physician83500        83500 - HYDROXYPROLINE; FREE            M             07/01/2006        $30.07
5 - Independent Laboratory        83505        83505 - HYDROXYPROLINE; TOTAL           M             07/01/2006        $32.26
                                  83505
H - Laboratory Billed by Outpatient Hospital   83505 - HYDROXYPROLINE; TOTAL           M             07/01/2006        $32.26
I - Laboratory Billed by Physician83505        83505 - HYDROXYPROLINE; TOTAL           M             07/01/2006        $32.26
5 - Independent Laboratory        83516        83516 - IMMUNOASSAY FOR ANALYTE OTHERM                07/01/2006        $15.31
                                                                                        THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AG
                                  83516
H - Laboratory Billed by Outpatient Hospital   83516 - IMMUNOASSAY FOR ANALYTE OTHERM                07/01/2006        $15.31
                                                                                        THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AG
I - Laboratory Billed by Physician83516        83516 - IMMUNOASSAY FOR ANALYTE OTHERM                07/01/2006        $15.31
                                                                                        THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AG
5 - Independent Laboratory        83518        83518 - IMMUNOASSAY FOR ANALYTE OTHERM                07/01/2006        $11.26
                                                                                        THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AG
                                  83518
H - Laboratory Billed by Outpatient Hospital   83518 - IMMUNOASSAY FOR ANALYTE OTHERM                07/01/2006        $11.26
                                                                                        THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AG
I - Laboratory Billed by Physician83518        83518 - IMMUNOASSAY FOR ANALYTE OTHERM                07/01/2006        $11.26
                                                                                        THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AG
5 - Independent Laboratory        83519                                                M             07/01/2006        $15.64
                                               83519 - IMMUNOASSAY, ANALYTE, QUANTITATIVE; BY RADIOPHARMACEUTICAL TECHNIQUE (EG, RIA)
                                  83519
H - Laboratory Billed by Outpatient Hospital                                           M             07/01/2006        $15.64
                                               83519 - IMMUNOASSAY, ANALYTE, QUANTITATIVE; BY RADIOPHARMACEUTICAL TECHNIQUE (EG, RIA)
I - Laboratory Billed by Physician83519                                                M             07/01/2006        $15.64
                                               83519 - IMMUNOASSAY, ANALYTE, QUANTITATIVE; BY RADIOPHARMACEUTICAL TECHNIQUE (EG, RIA)
5 - Independent Laboratory        83520                                                M             07/01/2006
                                               83520 - IMMUNOASSAY, ANALYTE, QUANTITATIVE; NOT OTHERWISE SPECIFIED $17.19
                                  83520
H - Laboratory Billed by Outpatient Hospital                                           M             07/01/2006
                                               83520 - IMMUNOASSAY, ANALYTE, QUANTITATIVE; NOT OTHERWISE SPECIFIED $17.19
I - Laboratory Billed by Physician83520                                                M             07/01/2006
                                               83520 - IMMUNOASSAY, ANALYTE, QUANTITATIVE; NOT OTHERWISE SPECIFIED $17.19
5 - Independent Laboratory        83525        83525 - INSULIN; TOTAL                  M             07/01/2006        $15.18
                                  83525
H - Laboratory Billed by Outpatient Hospital   83525 - INSULIN; TOTAL                  M             07/01/2006        $15.18
I - Laboratory Billed by Physician83525        83525 - INSULIN; TOTAL                  M             07/01/2006        $15.18
5 - Independent Laboratory        83527        83527 - INSULIN; FREE                   M             07/01/2006        $17.19
                                  83527
H - Laboratory Billed by Outpatient Hospital   83527 - INSULIN; FREE                   M             07/01/2006        $17.19
I - Laboratory Billed by Physician83527        83527 - INSULIN; FREE                   M             07/01/2006        $17.19
5 - Independent Laboratory        83528        83528 - INTRINSIC FACTOR                M             07/01/2006        $21.11
                                  83528
H - Laboratory Billed by Outpatient Hospital   83528 - INTRINSIC FACTOR                M             07/01/2006        $21.11
I - Laboratory Billed by Physician83528        83528 - INTRINSIC FACTOR                M             07/01/2006        $21.11
5 - Independent Laboratory        83540        83540 - IRON                            M             07/01/2006          $8.60
                                  83540
H - Laboratory Billed by Outpatient Hospital   83540 - IRON                            M             07/01/2006          $8.60
I - Laboratory Billed by Physician83540        83540 - IRON                            M             07/01/2006          $8.60
5 - Independent Laboratory        83550        83550 - IRON BINDING CAPACITY           M             07/01/2006        $11.60
                                  83550
H - Laboratory Billed by Outpatient Hospital   83550 - IRON BINDING CAPACITY           M             07/01/2006        $11.60
I - Laboratory Billed by Physician83550        83550 - IRON BINDING CAPACITY           M             07/01/2006        $11.60
5 - Independent Laboratory        83570        83570 - ISOCITRIC DEHYDROGENASE (IDH) M               07/01/2006        $11.74
                                  83570
H - Laboratory Billed by Outpatient Hospital   83570 - ISOCITRIC DEHYDROGENASE (IDH) M               07/01/2006        $11.74
I - Laboratory Billed by Physician83570        83570 - ISOCITRIC DEHYDROGENASE (IDH) M               07/01/2006        $11.74
5 - Independent Laboratory        83582                                                M
                                               83582 - KETOGENIC STEROIDS, FRACTIONATION             07/01/2006        $18.81
                                  83582
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83582 - KETOGENIC STEROIDS, FRACTIONATION             07/01/2006        $18.81
I - Laboratory Billed by Physician83582                                                M
                                               83582 - KETOGENIC STEROIDS, FRACTIONATION             07/01/2006        $18.81


 4/22/2012                                                    67 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        83586        83586 - KETOSTEROIDS, 17- (17-KS); TOTAL M            07/01/2006        $17.00
                                  83586
H - Laboratory Billed by Outpatient Hospital   83586 - KETOSTEROIDS, 17- (17-KS); TOTAL M            07/01/2006        $17.00
I - Laboratory Billed by Physician83586        83586 - KETOSTEROIDS, 17- (17-KS); TOTAL M            07/01/2006        $17.00
5 - Independent Laboratory        83593                                                  M
                                               83593 - KETOSTEROIDS, 17- (17-KS); FRACTIONATION      07/01/2006        $34.91
                                  83593
H - Laboratory Billed by Outpatient Hospital                                             M
                                               83593 - KETOSTEROIDS, 17- (17-KS); FRACTIONATION      07/01/2006        $34.91
I - Laboratory Billed by Physician83593                                                  M
                                               83593 - KETOSTEROIDS, 17- (17-KS); FRACTIONATION      07/01/2006        $34.91
5 - Independent Laboratory        83605        83605 - LACTATE (LACTIC ACID)             M           07/01/2006        $14.17
                                  83605
H - Laboratory Billed by Outpatient Hospital   83605 - LACTATE (LACTIC ACID)             M           07/01/2006        $14.17
I - Laboratory Billed by Physician83605        83605 - LACTATE (LACTIC ACID)             M           07/01/2006        $14.17
5 - Independent Laboratory        83615        83615 - LACTATE DEHYDROGENASE (LD), (LDH);M           07/01/2006          $8.02
                                  83615
H - Laboratory Billed by Outpatient Hospital   83615 - LACTATE DEHYDROGENASE (LD), (LDH);M           07/01/2006          $8.02
I - Laboratory Billed by Physician83615        83615 - LACTATE DEHYDROGENASE (LD), (LDH);M           07/01/2006          $8.02
5 - Independent Laboratory        83625                                                  M           07/01/2006        $16.99
                                               83625 - LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION
                                  83625
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $16.99
                                               83625 - LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION
I - Laboratory Billed by Physician83625                                                  M           07/01/2006        $16.99
                                               83625 - LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION
5 - Independent Laboratory        83630        83630 - LACTOFERRIN, FECAL; QUALITATIVE M             07/01/2006        $26.05
                                  83630
H - Laboratory Billed by Outpatient Hospital   83630 - LACTOFERRIN, FECAL; QUALITATIVE M             07/01/2006        $26.05
I - Laboratory Billed by Physician83630        83630 - LACTOFERRIN, FECAL; QUALITATIVE M             07/01/2006        $26.05
5 - Independent Laboratory        83631        83631 - LACTOFERRIN, FECAL; QUANTITATIVE  M           07/01/2006        $25.77
                                  83631
H - Laboratory Billed by Outpatient Hospital   83631 - LACTOFERRIN, FECAL; QUANTITATIVE  M           07/01/2006        $25.77
I - Laboratory Billed by Physician83631        83631 - LACTOFERRIN, FECAL; QUANTITATIVE  M           07/01/2006        $25.77
5 - Independent Laboratory        83632                                                  M           07/01/2006        $26.83
                                               83632 - LACTOGEN, HUMAN PLACENTAL (HPL) HUMAN CHORIONIC SOMATOMAMMOTROPIN
                                  83632
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $26.83
                                               83632 - LACTOGEN, HUMAN PLACENTAL (HPL) HUMAN CHORIONIC SOMATOMAMMOTROPIN
I - Laboratory Billed by Physician83632                                                  M           07/01/2006        $26.83
                                               83632 - LACTOGEN, HUMAN PLACENTAL (HPL) HUMAN CHORIONIC SOMATOMAMMOTROPIN
5 - Independent Laboratory        83633        83633 - LACTOSE, URINE; QUALITATIVE       M           07/01/2006          $7.31
                                  83633
H - Laboratory Billed by Outpatient Hospital   83633 - LACTOSE, URINE; QUALITATIVE       M           07/01/2006          $7.31
I - Laboratory Billed by Physician83633        83633 - LACTOSE, URINE; QUALITATIVE       M           07/01/2006          $7.31
5 - Independent Laboratory        83634        83634 - LACTOSE, URINE; QUANTITATIVE      M           07/01/2006        $15.30
                                  83634
H - Laboratory Billed by Outpatient Hospital   83634 - LACTOSE, URINE; QUANTITATIVE      M           07/01/2006        $15.30
I - Laboratory Billed by Physician83634        83634 - LACTOSE, URINE; QUANTITATIVE      M           07/01/2006        $15.30
5 - Independent Laboratory        83655        83655 - LEAD                              M           07/01/2006        $16.06
                                  83655
H - Laboratory Billed by Outpatient Hospital   83655 - LEAD                              M           07/01/2006        $16.06
I - Laboratory Billed by Physician83655        83655 - LEAD                              M           07/01/2006        $16.06
5 - Independent Laboratory        83661                                                  M           07/01/2006        $29.17
                                               83661 - FETAL LUNG MATURITY ASSESSMENT; LECITHIN SPHINGOMYELIN (L/S) RATIO
                                  83661
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $29.17
                                               83661 - FETAL LUNG MATURITY ASSESSMENT; LECITHIN SPHINGOMYELIN (L/S) RATIO
I - Laboratory Billed by Physician83661                                                  M           07/01/2006        $29.17
                                               83661 - FETAL LUNG MATURITY ASSESSMENT; LECITHIN SPHINGOMYELIN (L/S) RATIO
5 - Independent Laboratory        83662                                                  M           07/01/2006
                                               83662 - FETAL LUNG MATURITY ASSESSMENT; FOAM STABILITY TEST             $25.11
                                  83662
H - Laboratory Billed by Outpatient Hospital                                             M           05/01/2005
                                               83662 - FETAL LUNG MATURITY ASSESSMENT; FOAM STABILITY TEST             $25.11
I - Laboratory Billed by Physician83662                                                  M           07/01/2006
                                               83662 - FETAL LUNG MATURITY ASSESSMENT; FOAM STABILITY TEST             $25.11
5 - Independent Laboratory        83663                                                  M           07/01/2006
                                               83663 - FETAL LUNG MATURITY ASSESSMENT; FLUORESCENCE POLARIZATION $25.11
                                  83663
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               83663 - FETAL LUNG MATURITY ASSESSMENT; FLUORESCENCE POLARIZATION $25.11
I - Laboratory Billed by Physician83663                                                  M           07/01/2006
                                               83663 - FETAL LUNG MATURITY ASSESSMENT; FLUORESCENCE POLARIZATION $25.11
5 - Independent Laboratory        83664                                                  M           07/01/2006
                                               83664 - FETAL LUNG MATURITY ASSESSMENT; LAMELLAR BODY DENSITY           $25.11
                                  83664
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               83664 - FETAL LUNG MATURITY ASSESSMENT; LAMELLAR BODY DENSITY           $25.11
I - Laboratory Billed by Physician83664                                                  M           07/01/2006
                                               83664 - FETAL LUNG MATURITY ASSESSMENT; LAMELLAR BODY DENSITY           $25.11
5 - Independent Laboratory        83670        83670 - LEUCINE AMINOPEPTIDASE (LAP)      M           07/01/2006        $12.16
                                  83670
H - Laboratory Billed by Outpatient Hospital   83670 - LEUCINE AMINOPEPTIDASE (LAP)      M           07/01/2006        $12.16
I - Laboratory Billed by Physician83670        83670 - LEUCINE AMINOPEPTIDASE (LAP)      M           07/01/2006        $12.16
5 - Independent Laboratory        83690        83690 - LIPASE                            M           07/01/2006          $9.14
                                  83690
H - Laboratory Billed by Outpatient Hospital   83690 - LIPASE                            M           07/01/2006          $9.14
I - Laboratory Billed by Physician83690        83690 - LIPASE                            M           07/01/2006          $9.14
5 - Independent Laboratory        83695        83695 - LIPOPROTEIN (A)                   M           07/01/2006        $17.00
                                  83695
H - Laboratory Billed by Outpatient Hospital   83695 - LIPOPROTEIN (A)                   M           07/01/2006        $17.00
I - Laboratory Billed by Physician83695        83695 - LIPOPROTEIN (A)                   M           07/01/2006        $17.00
5 - Independent Laboratory        83698                                                  M           01/01/2007
                                               83698 - LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2, (LP-PLA2)              $45.05
                                  83698
H - Laboratory Billed by Outpatient Hospital                                             M           01/01/2007
                                               83698 - LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2, (LP-PLA2)              $45.05
I - Laboratory Billed by Physician83698                                                  M           01/01/2007
                                               83698 - LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2, (LP-PLA2)              $45.05
5 - Independent Laboratory        83700                                                  M           07/01/2006
                                               83700 - LIPOPROTEIN, BLOOD; ELECTROPHORETIC SEPARATION AND QUANTITATION $14.79
                                  83700
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               83700 - LIPOPROTEIN, BLOOD; ELECTROPHORETIC SEPARATION AND QUANTITATION $14.79
I - Laboratory Billed by Physician83700                                                  M           07/01/2006
                                               83700 - LIPOPROTEIN, BLOOD; ELECTROPHORETIC SEPARATION AND QUANTITATION $14.79
5 - Independent Laboratory        83701                                                  M           07/01/2006        $32.60
                                               83701 - LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND QUANTITATION OF LIPOPROT
                                  83701
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $32.60
                                               83701 - LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND QUANTITATION OF LIPOPROT
I - Laboratory Billed by Physician83701                                                  M           07/01/2006        $32.60
                                               83701 - LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND QUANTITATION OF LIPOPROT
5 - Independent Laboratory        83704                                                  M           07/01/2006        $41.44
                                               83704 - LIPOPROTEIN, BLOOD; QUANTITATION OF LIPOPROTEIN PARTICLE NUMBERS AND LIPOPROTE
                                  83704
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $41.44
                                               83704 - LIPOPROTEIN, BLOOD; QUANTITATION OF LIPOPROTEIN PARTICLE NUMBERS AND LIPOPROTE
I - Laboratory Billed by Physician83704                                                  M           07/01/2006        $41.44
                                               83704 - LIPOPROTEIN, BLOOD; QUANTITATION OF LIPOPROTEIN PARTICLE NUMBERS AND LIPOPROTE


 4/22/2012                                                    68 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        83718                                                M            07/01/2006        $10.87
                                               83718 - LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)
                                  83718
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006        $10.87
                                               83718 - LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)
I - Laboratory Billed by Physician83718                                                M            07/01/2006        $10.87
                                               83718 - LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)
5 - Independent Laboratory        83719                                                M            07/01/2006
                                               83719 - LIPOPROTEIN, DIRECT MEASUREMENT; VLDL CHOLESTEROL              $15.45
                                  83719
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               83719 - LIPOPROTEIN, DIRECT MEASUREMENT; VLDL CHOLESTEROL              $15.45
I - Laboratory Billed by Physician83719                                                M            07/01/2006
                                               83719 - LIPOPROTEIN, DIRECT MEASUREMENT; VLDL CHOLESTEROL              $15.45
5 - Independent Laboratory        83721                                                M            07/01/2006
                                               83721 - LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL               $12.66
                                  83721
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               83721 - LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL               $12.66
I - Laboratory Billed by Physician83721                                                M            07/01/2006
                                               83721 - LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL               $12.66
5 - Independent Laboratory        83727                                                M
                                               83727 - LUTEINIZING RELEASING FACTOR (LRH)           07/01/2006        $22.82
                                  83727
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83727 - LUTEINIZING RELEASING FACTOR (LRH)           07/01/2006        $22.82
I - Laboratory Billed by Physician83727                                                M
                                               83727 - LUTEINIZING RELEASING FACTOR (LRH)           07/01/2006        $22.82
5 - Independent Laboratory        83735        83735 - MAGNESIUM                       M            07/01/2006          $8.89
                                  83735
H - Laboratory Billed by Outpatient Hospital   83735 - MAGNESIUM                       M            07/01/2006          $8.89
I - Laboratory Billed by Physician83735        83735 - MAGNESIUM                       M            07/01/2006          $8.89
5 - Independent Laboratory        83775        83775 - MALATE DEHYDROGENASE            M            07/01/2006          $9.79
                                  83775
H - Laboratory Billed by Outpatient Hospital   83775 - MALATE DEHYDROGENASE            M            07/01/2006          $9.79
I - Laboratory Billed by Physician83775        83775 - MALATE DEHYDROGENASE            M            07/01/2006          $9.79
5 - Independent Laboratory        83785        83785 - MANGANESE                       M            07/01/2006        $32.64
                                  83785
H - Laboratory Billed by Outpatient Hospital   83785 - MANGANESE                       M            07/01/2006        $32.64
I - Laboratory Billed by Physician83785        83785 - MANGANESE                       M            07/01/2006        $32.64
5 - Independent Laboratory        83788        83788 - MASS SPECTROMETRY AND TANDEM M               07/01/2006          ANALYTE NOT ELS
                                                                                       MASS SPECTROMETRY (MS, MS/MS),$23.97
                                  83788
H - Laboratory Billed by Outpatient Hospital   83788 - MASS SPECTROMETRY AND TANDEM M               07/01/2006          ANALYTE NOT ELS
                                                                                       MASS SPECTROMETRY (MS, MS/MS),$23.97
I - Laboratory Billed by Physician83788        83788 - MASS SPECTROMETRY AND TANDEM M               07/01/2006          ANALYTE NOT ELS
                                                                                       MASS SPECTROMETRY (MS, MS/MS),$23.97
5 - Independent Laboratory        83789        83789 - MASS SPECTROMETRY AND TANDEM M               07/01/2006          ANALYTE NOT ELS
                                                                                       MASS SPECTROMETRY (MS, MS/MS),$23.97
                                  83789
H - Laboratory Billed by Outpatient Hospital   83789 - MASS SPECTROMETRY AND TANDEM M               07/01/2006          ANALYTE NOT ELS
                                                                                       MASS SPECTROMETRY (MS, MS/MS),$23.97
I - Laboratory Billed by Physician83789        83789 - MASS SPECTROMETRY AND TANDEM M               07/01/2006          ANALYTE NOT ELS
                                                                                       MASS SPECTROMETRY (MS, MS/MS),$23.97
5 - Independent Laboratory        83805        83805 - MEPROBAMATE                     M            07/01/2006        $23.40
                                  83805
H - Laboratory Billed by Outpatient Hospital   83805 - MEPROBAMATE                     M            07/01/2006        $23.40
I - Laboratory Billed by Physician83805        83805 - MEPROBAMATE                     M            07/01/2006        $23.40
5 - Independent Laboratory        83825        83825 - MERCURY, QUANTITATIVE           M            07/01/2006        $21.58
                                  83825
H - Laboratory Billed by Outpatient Hospital   83825 - MERCURY, QUANTITATIVE           M            07/01/2006        $21.58
I - Laboratory Billed by Physician83825        83825 - MERCURY, QUANTITATIVE           M            07/01/2006        $21.58
5 - Independent Laboratory        83835        83835 - METANEPHRINES                   M            07/01/2006        $22.49
                                  83835
H - Laboratory Billed by Outpatient Hospital   83835 - METANEPHRINES                   M            07/01/2006        $22.49
I - Laboratory Billed by Physician83835        83835 - METANEPHRINES                   M            07/01/2006        $22.49
5 - Independent Laboratory        83840        83840 - METHADONE                       M            07/01/2006        $21.67
                                  83840
H - Laboratory Billed by Outpatient Hospital   83840 - METHADONE                       M            07/01/2006        $21.67
I - Laboratory Billed by Physician83840        83840 - METHADONE                       M            07/01/2006        $21.67
5 - Independent Laboratory        83857        83857 - METHEMALBUMIN                   M            07/01/2006        $14.26
                                  83857
H - Laboratory Billed by Outpatient Hospital   83857 - METHEMALBUMIN                   M            07/01/2006        $14.26
I - Laboratory Billed by Physician83857        83857 - METHEMALBUMIN                   M            07/01/2006        $14.26
5 - Independent Laboratory        83858        83858 - METHSUXIMIDE                    M            07/01/2006        $19.67
                                  83858
H - Laboratory Billed by Outpatient Hospital   83858 - METHSUXIMIDE                    M            07/01/2006        $19.67
I - Laboratory Billed by Physician83858        83858 - METHSUXIMIDE                    M            07/01/2006        $19.67
5 - Independent Laboratory        83864                                                M
                                               83864 - MUCOPOLYSACCHARIDES, ACID; QUANTITATIVE      07/01/2006        $26.43
                                  83864
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83864 - MUCOPOLYSACCHARIDES, ACID; QUANTITATIVE      07/01/2006        $26.43
I - Laboratory Billed by Physician83864                                                M
                                               83864 - MUCOPOLYSACCHARIDES, ACID; QUANTITATIVE      07/01/2006        $26.43
5 - Independent Laboratory        83866                                                M
                                               83866 - MUCOPOLYSACCHARIDES, ACID; SCREEN            07/01/2006        $13.07
                                  83866
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83866 - MUCOPOLYSACCHARIDES, ACID; SCREEN            07/01/2006        $13.07
I - Laboratory Billed by Physician83866                                                M
                                               83866 - MUCOPOLYSACCHARIDES, ACID; SCREEN            07/01/2006        $13.07
5 - Independent Laboratory        83872                                                M
                                               83872 - MUCIN, SYNOVIAL FLUID (ROPES TEST)           07/01/2006          $7.78
                                  83872
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83872 - MUCIN, SYNOVIAL FLUID (ROPES TEST)           07/01/2006          $7.78
I - Laboratory Billed by Physician83872                                                M
                                               83872 - MUCIN, SYNOVIAL FLUID (ROPES TEST)           07/01/2006          $7.78
5 - Independent Laboratory        83873                                                M
                                               83873 - MYELIN BASIC PROTEIN, CEREBROSPINAL FLUID    07/01/2006        $22.84
                                  83873
H - Laboratory Billed by Outpatient Hospital                                           M
                                               83873 - MYELIN BASIC PROTEIN, CEREBROSPINAL FLUID    07/01/2006        $22.84
I - Laboratory Billed by Physician83873                                                M
                                               83873 - MYELIN BASIC PROTEIN, CEREBROSPINAL FLUID    07/01/2006        $22.84
5 - Independent Laboratory        83874        83874 - MYOGLOBIN                       M            07/01/2006        $17.14
                                  83874
H - Laboratory Billed by Outpatient Hospital   83874 - MYOGLOBIN                       M            07/01/2006        $17.14
I - Laboratory Billed by Physician83874        83874 - MYOGLOBIN                       M            07/01/2006        $17.14
5 - Independent Laboratory        83880        83880 - NATRIURETIC PEPTIDE             M            07/01/2006        $45.06
                                  83880
H - Laboratory Billed by Outpatient Hospital   83880 - NATRIURETIC PEPTIDE             M            07/01/2006        $45.06
I - Laboratory Billed by Physician83880        83880 - NATRIURETIC PEPTIDE             M            07/01/2006        $45.06
5 - Independent Laboratory        83883                                                M            SPECIFIED
                                               83883 - NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE 07/01/2006            $18.05
                                  83883
H - Laboratory Billed by Outpatient Hospital                                           M            SPECIFIED
                                               83883 - NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE 07/01/2006            $18.05
I - Laboratory Billed by Physician83883                                                M            SPECIFIED
                                               83883 - NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE 07/01/2006            $18.05


 4/22/2012                                                     69 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                Level 3      Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                            Medicaid/BH     Pricing     Charge
5 - Independent Laboratory        83885        83885 - NICKEL                         M           07/01/2006          $32.52
                                  83885
H - Laboratory Billed by Outpatient Hospital   83885 - NICKEL                         M           07/01/2006          $32.52
I - Laboratory Billed by Physician83885        83885 - NICKEL                         M           07/01/2006          $32.52
5 - Independent Laboratory        83887        83887 - NICOTINE                       M           07/01/2006          $31.44
                                  83887
H - Laboratory Billed by Outpatient Hospital   83887 - NICOTINE                       M           07/01/2006          $31.44
I - Laboratory Billed by Physician83887        83887 - NICOTINE                       M           07/01/2006          $31.44
5 - Independent Laboratory        83890                                               M           07/01/2006
                                               83890 - MOLECULAR DIAGNOSTICS; MOLECULAR ISOLATION OR EXTRACTION        $5.32
                                  83890
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006
                                               83890 - MOLECULAR DIAGNOSTICS; MOLECULAR ISOLATION OR EXTRACTION        $5.32
I - Laboratory Billed by Physician83890                                               M           07/01/2006
                                               83890 - MOLECULAR DIAGNOSTICS; MOLECULAR ISOLATION OR EXTRACTION        $5.32
5 - Independent Laboratory        83891                                               M           07/01/2006           $5.32
                                               83891 - MOLECULAR DIAGNOSTICS; ISOLATION OR EXTRACTION OF HIGHLY PURIFIED NUCLEIC ACID
                                  83891
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006           $5.32
                                               83891 - MOLECULAR DIAGNOSTICS; ISOLATION OR EXTRACTION OF HIGHLY PURIFIED NUCLEIC ACID
I - Laboratory Billed by Physician83891                                               M           07/01/2006           $5.32
                                               83891 - MOLECULAR DIAGNOSTICS; ISOLATION OR EXTRACTION OF HIGHLY PURIFIED NUCLEIC ACID
5 - Independent Laboratory        83892                                               M
                                               83892 - MOLECULAR DIAGNOSTICS; ENZYMATIC DIGESTION 07/01/2006           $5.32
                                  83892
H - Laboratory Billed by Outpatient Hospital                                          M
                                               83892 - MOLECULAR DIAGNOSTICS; ENZYMATIC DIGESTION 07/01/2006           $5.32
I - Laboratory Billed by Physician83892                                               M
                                               83892 - MOLECULAR DIAGNOSTICS; ENZYMATIC DIGESTION 07/01/2006           $5.32
5 - Independent Laboratory        83893                                               M           07/01/2006
                                               83893 - MOLECULAR DIAGNOSTICS; DOT/SLOT BLOT PRODUCTION                 $5.32
                                  83893
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006
                                               83893 - MOLECULAR DIAGNOSTICS; DOT/SLOT BLOT PRODUCTION                 $5.32
I - Laboratory Billed by Physician83893                                               M           07/01/2006
                                               83893 - MOLECULAR DIAGNOSTICS; DOT/SLOT BLOT PRODUCTION                 $5.32
5 - Independent Laboratory        83894                                               M           07/01/2006            AGAROSE, POLYAC
                                               83894 - MOLECULAR DIAGNOSTICS; SEPARATION BY GEL ELECTROPHORESIS (EG, $5.32
                                  83894
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006            AGAROSE, POLYAC
                                               83894 - MOLECULAR DIAGNOSTICS; SEPARATION BY GEL ELECTROPHORESIS (EG, $5.32
I - Laboratory Billed by Physician83894                                               M           07/01/2006            AGAROSE, POLYAC
                                               83894 - MOLECULAR DIAGNOSTICS; SEPARATION BY GEL ELECTROPHORESIS (EG, $5.32
5 - Independent Laboratory        83896        83896 - MOLECULAR DIAGNOSTICS; NUCLEICM            07/01/2006
                                                                                      ACID PROBE, EACH                 $5.32
                                  83896
H - Laboratory Billed by Outpatient Hospital   83896 - MOLECULAR DIAGNOSTICS; NUCLEICM            07/01/2006
                                                                                      ACID PROBE, EACH                 $5.32
I - Laboratory Billed by Physician83896        83896 - MOLECULAR DIAGNOSTICS; NUCLEICM            07/01/2006
                                                                                      ACID PROBE, EACH                 $5.32
5 - Independent Laboratory        83897        83897 - MOLECULAR DIAGNOSTICS; NUCLEICM            07/01/2006           $5.32
                                                                                      ACID TRANSFER (EG, SOUTHERN, NORTHERN)
                                  83897
H - Laboratory Billed by Outpatient Hospital   83897 - MOLECULAR DIAGNOSTICS; NUCLEICM            07/01/2006           $5.32
                                                                                      ACID TRANSFER (EG, SOUTHERN, NORTHERN)
I - Laboratory Billed by Physician83897        83897 - MOLECULAR DIAGNOSTICS; NUCLEICM            07/01/2006           $5.32
                                                                                      ACID TRANSFER (EG, SOUTHERN, NORTHERN)
5 - Independent Laboratory        83898                                               M           07/01/2006          $22.25
                                               83898 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, EACH NUCLEIC ACID
                                  83898
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          $22.25
                                               83898 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, EACH NUCLEIC ACID
I - Laboratory Billed by Physician83898                                               M           07/01/2006          $22.25
                                               83898 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, EACH NUCLEIC ACID
5 - Independent Laboratory        83900                                               M           07/01/2006          $44.03
                                               83900 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, MULTIPLEX, FIRST T
                                  83900
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          $44.03
                                               83900 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, MULTIPLEX, FIRST T
I - Laboratory Billed by Physician83900                                               M           07/01/2006          $44.03
                                               83900 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, MULTIPLEX, FIRST T
5 - Independent Laboratory        83901                                               M           07/01/2006          $22.25
                                               83901 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, MULTIPLEX, EACH AD
                                  83901
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          $22.25
                                               83901 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, MULTIPLEX, EACH AD
I - Laboratory Billed by Physician83901                                               M           07/01/2006          $22.25
                                               83901 - MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC ACID, MULTIPLEX, EACH AD
5 - Independent Laboratory        83902                                               M           07/01/2006
                                               83902 - MOLECULAR DIAGNOSTICS; REVERSE TRANSCRIPTION                   $18.84
                                  83902
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006
                                               83902 - MOLECULAR DIAGNOSTICS; REVERSE TRANSCRIPTION                   $18.84
I - Laboratory Billed by Physician83902                                               M           07/01/2006
                                               83902 - MOLECULAR DIAGNOSTICS; REVERSE TRANSCRIPTION                   $18.84
5 - Independent Laboratory        83903                                               M           07/01/2006          $22.25
                                               83903 - MOLECULAR DIAGNOSTICS; MUTATION SCANNING, BY PHYSICAL PROPERTIES (EG, SINGLE ST
                                  83903
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          $22.25
                                               83903 - MOLECULAR DIAGNOSTICS; MUTATION SCANNING, BY PHYSICAL PROPERTIES (EG, SINGLE ST
I - Laboratory Billed by Physician83903                                               M           07/01/2006          $22.25
                                               83903 - MOLECULAR DIAGNOSTICS; MUTATION SCANNING, BY PHYSICAL PROPERTIES (EG, SINGLE ST
5 - Independent Laboratory        83904                                               M           07/01/2006          SINGLE
                                               83904 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY SEQUENCING, $22.25 SEGMENT,
                                  83904
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          SINGLE
                                               83904 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY SEQUENCING, $22.25 SEGMENT,
I - Laboratory Billed by Physician83904                                               M           07/01/2006          SINGLE
                                               83904 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY SEQUENCING, $22.25 SEGMENT,
5 - Independent Laboratory        83905                                               M           07/01/2006          $22.25
                                               83905 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE SPECIFIC TRANSCRIPTION
                                  83905
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          $22.25
                                               83905 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE SPECIFIC TRANSCRIPTION
I - Laboratory Billed by Physician83905                                               M           07/01/2006          $22.25
                                               83905 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE SPECIFIC TRANSCRIPTION
5 - Independent Laboratory        83906                                               M           07/01/2006          $22.25
                                               83906 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE SPECIFIC TRANSLATION,
                                  83906
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          $22.25
                                               83906 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE SPECIFIC TRANSLATION,
I - Laboratory Billed by Physician83906                                               M           07/01/2006          $22.25
                                               83906 - MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE SPECIFIC TRANSLATION,
5 - Independent Laboratory        83907                                               CELLS PRIOR 07/01/2006 ACID EXTRACTION (EG, STOO
                                               83907 - MOLECULAR DIAGNOSTICS; LYSIS OFM           TO NUCLEIC          $17.54
                                  83907
H - Laboratory Billed by Outpatient Hospital                                          CELLS PRIOR 07/01/2006 ACID EXTRACTION (EG, STOO
                                               83907 - MOLECULAR DIAGNOSTICS; LYSIS OFM           TO NUCLEIC          $17.54
I - Laboratory Billed by Physician83907                                               CELLS PRIOR 07/01/2006 ACID EXTRACTION (EG, STOO
                                               83907 - MOLECULAR DIAGNOSTICS; LYSIS OFM           TO NUCLEIC          $17.54
5 - Independent Laboratory        83908                                               M            OF PATIENT          ACID,
                                               83908 - MOLECULAR DIAGNOSTICS; SIGNAL AMPLIFICATION07/01/2006 NUCLEIC$22.01 EACH NUCLE
                                  83908
H - Laboratory Billed by Outpatient Hospital                                          M            OF PATIENT          ACID,
                                               83908 - MOLECULAR DIAGNOSTICS; SIGNAL AMPLIFICATION07/01/2006 NUCLEIC$22.01 EACH NUCLE
I - Laboratory Billed by Physician83908                                               M            OF PATIENT          ACID,
                                               83908 - MOLECULAR DIAGNOSTICS; SIGNAL AMPLIFICATION07/01/2006 NUCLEIC$22.01 EACH NUCLE
5 - Independent Laboratory        83909                                               M           07/01/2006          $22.01
                                               83909 - MOLECULAR DIAGNOSTICS; SEPARATION AND IDENTIFICATION BY HIGH RESOLUTION TECHNI
                                  83909
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006          $22.01
                                               83909 - MOLECULAR DIAGNOSTICS; SEPARATION AND IDENTIFICATION BY HIGH RESOLUTION TECHNI
I - Laboratory Billed by Physician83909                                               M           07/01/2006          $22.01
                                               83909 - MOLECULAR DIAGNOSTICS; SEPARATION AND IDENTIFICATION BY HIGH RESOLUTION TECHNI
5 - Independent Laboratory        83912                                               M           07/01/2006
                                               83912 - MOLECULAR DIAGNOSTICS; INTERPRETATION AND REPORT                $5.32
                                  83912
H - Laboratory Billed by Outpatient Hospital                                          M           07/01/2006
                                               83912 - MOLECULAR DIAGNOSTICS; INTERPRETATION AND REPORT                $5.32
I - Laboratory Billed by Physician83912                                               M           07/01/2006
                                               83912 - MOLECULAR DIAGNOSTICS; INTERPRETATION AND REPORT                $5.32
5 - Independent Laboratory        83913                                               M
                                               83913 - MOLECULAR DIAGNOSTICS; RNA STABILIZATION   01/01/2007          $17.72
                                  83913
H - Laboratory Billed by Outpatient Hospital                                          M
                                               83913 - MOLECULAR DIAGNOSTICS; RNA STABILIZATION   01/01/2007          $17.72
I - Laboratory Billed by Physician83913                                               M
                                               83913 - MOLECULAR DIAGNOSTICS; RNA STABILIZATION   01/01/2007          $17.72


 4/22/2012                                                    70 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3      Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        83914                                                 M           07/01/2006        $22.01
                                               83914 - MUTATION IDENTIFICATION BY ENZYMATIC LIGATION OR PRIMER EXTENSION, SINGLE SEGME
                                  83914
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006        $22.01
                                               83914 - MUTATION IDENTIFICATION BY ENZYMATIC LIGATION OR PRIMER EXTENSION, SINGLE SEGME
I - Laboratory Billed by Physician83914                                                 M           07/01/2006        $22.01
                                               83914 - MUTATION IDENTIFICATION BY ENZYMATIC LIGATION OR PRIMER EXTENSION, SINGLE SEGME
5 - Independent Laboratory        83915        83915 - NUCLEOTIDASE 5'-                 M           07/01/2006        $14.80
                                  83915
H - Laboratory Billed by Outpatient Hospital   83915 - NUCLEOTIDASE 5'-                 M           07/01/2006        $14.80
I - Laboratory Billed by Physician83915        83915 - NUCLEOTIDASE 5'-                 M           07/01/2006        $14.80
5 - Independent Laboratory        83916                                                 M
                                               83916 - OLIGOCLONAL IMMUNE (OLIGOCLONAL BANDS)       07/01/2006        $26.69
                                  83916
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83916 - OLIGOCLONAL IMMUNE (OLIGOCLONAL BANDS)       07/01/2006        $26.69
I - Laboratory Billed by Physician83916                                                 M
                                               83916 - OLIGOCLONAL IMMUNE (OLIGOCLONAL BANDS)       07/01/2006        $26.69
5 - Independent Laboratory        83918                                                 M           07/01/2006
                                               83918 - ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN              $21.85
                                  83918
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               83918 - ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN              $21.85
I - Laboratory Billed by Physician83918                                                 M           07/01/2006
                                               83918 - ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN              $21.85
5 - Independent Laboratory        83919        83919 - ORGANIC ACIDS; QUALITATIVE, EACHMSPECIMEN    07/01/2006        $21.85
                                  83919
H - Laboratory Billed by Outpatient Hospital   83919 - ORGANIC ACIDS; QUALITATIVE, EACHMSPECIMEN    07/01/2006        $21.85
I - Laboratory Billed by Physician83919        83919 - ORGANIC ACIDS; QUALITATIVE, EACHMSPECIMEN    07/01/2006        $21.85
5 - Independent Laboratory        83921                                                 M
                                               83921 - ORGANIC ACID, SINGLE, QUANTITATIVE           07/01/2006        $21.85
                                  83921
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83921 - ORGANIC ACID, SINGLE, QUANTITATIVE           07/01/2006        $21.85
I - Laboratory Billed by Physician83921                                                 M
                                               83921 - ORGANIC ACID, SINGLE, QUANTITATIVE           07/01/2006        $21.85
5 - Independent Laboratory        83925                                                 M
                                               83925 - OPIATES, (EG, MORPHINE, MEPERIDINE)          07/01/2006        $25.83
                                  83925
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83925 - OPIATES, (EG, MORPHINE, MEPERIDINE)          07/01/2006        $25.83
I - Laboratory Billed by Physician83925                                                 M
                                               83925 - OPIATES, (EG, MORPHINE, MEPERIDINE)          07/01/2006        $25.83
5 - Independent Laboratory        83930        83930 - OSMOLALITY; BLOOD                M           07/01/2006          $8.78
                                  83930
H - Laboratory Billed by Outpatient Hospital   83930 - OSMOLALITY; BLOOD                M           07/01/2006          $8.78
I - Laboratory Billed by Physician83930        83930 - OSMOLALITY; BLOOD                M           07/01/2006          $8.78
5 - Independent Laboratory        83935        83935 - OSMOLALITY; URINE                M           07/01/2006          $9.04
                                  83935
H - Laboratory Billed by Outpatient Hospital   83935 - OSMOLALITY; URINE                M           07/01/2006          $9.04
I - Laboratory Billed by Physician83935        83935 - OSMOLALITY; URINE                M           07/01/2006          $9.04
5 - Independent Laboratory        83937        83937 - OSTEOCALCIN (BONE G1A PROTEIN) M             07/01/2006        $39.62
                                  83937
H - Laboratory Billed by Outpatient Hospital   83937 - OSTEOCALCIN (BONE G1A PROTEIN) M             07/01/2006        $39.62
I - Laboratory Billed by Physician83937        83937 - OSTEOCALCIN (BONE G1A PROTEIN) M             07/01/2006        $39.62
5 - Independent Laboratory        83945        83945 - OXALATE                          M           07/01/2006        $17.09
                                  83945
H - Laboratory Billed by Outpatient Hospital   83945 - OXALATE                          M           07/01/2006        $17.09
I - Laboratory Billed by Physician83945        83945 - OXALATE                          M           07/01/2006        $17.09
5 - Independent Laboratory        83950        83950 - ONCOPROTEIN, HER-2/NEU           M           07/01/2006        $85.49
                                  83950
H - Laboratory Billed by Outpatient Hospital   83950 - ONCOPROTEIN, HER-2/NEU           M           07/01/2006        $85.49
I - Laboratory Billed by Physician83950        83950 - ONCOPROTEIN, HER-2/NEU           M           07/01/2006        $85.49
5 - Independent Laboratory        83970                                                 M
                                               83970 - PARATHORMONE (PARATHYROID HORMONE)           07/01/2006        $54.79
                                  83970
H - Laboratory Billed by Outpatient Hospital                                            M
                                               83970 - PARATHORMONE (PARATHYROID HORMONE)           07/01/2006        $54.79
I - Laboratory Billed by Physician83970                                                 M
                                               83970 - PARATHORMONE (PARATHYROID HORMONE)           07/01/2006        $54.79
5 - Independent Laboratory        83986        83986 - PH, BODY FLUID, EXCEPT BLOOD     M           07/01/2006          $4.75
                                  83986
H - Laboratory Billed by Outpatient Hospital   83986 - PH, BODY FLUID, EXCEPT BLOOD     M           07/01/2006          $4.75
I - Laboratory Billed by Physician83986        83986 - PH, BODY FLUID, EXCEPT BLOOD     M           07/01/2006          $4.75
5 - Independent Laboratory        83992        83992 - PHENCYCLIDINE (PCP)              M           07/01/2006        $19.51
                                  83992
H - Laboratory Billed by Outpatient Hospital   83992 - PHENCYCLIDINE (PCP)              M           07/01/2006        $19.51
I - Laboratory Billed by Physician83992        83992 - PHENCYCLIDINE (PCP)              M           07/01/2006        $19.51
5 - Independent Laboratory        84022        84022 - PHENOTHIAZINE                    M           07/01/2006        $20.67
                                  84022
H - Laboratory Billed by Outpatient Hospital   84022 - PHENOTHIAZINE                    M           07/01/2006        $20.67
I - Laboratory Billed by Physician84022        84022 - PHENOTHIAZINE                    M           07/01/2006        $20.67
5 - Independent Laboratory        84030        84030 - PHENYLALANINE (PKU), BLOOD       M           07/01/2006          $7.31
                                  84030
H - Laboratory Billed by Outpatient Hospital   84030 - PHENYLALANINE (PKU), BLOOD       M           07/01/2006          $7.31
I - Laboratory Billed by Physician84030        84030 - PHENYLALANINE (PKU), BLOOD       M           07/01/2006          $7.31
5 - Independent Laboratory        84035        84035 - PHENYLKETONES, QUALITATIVE       M           07/01/2006          $4.85
                                  84035
H - Laboratory Billed by Outpatient Hospital   84035 - PHENYLKETONES, QUALITATIVE       M           07/01/2006          $4.85
I - Laboratory Billed by Physician84035        84035 - PHENYLKETONES, QUALITATIVE       M           07/01/2006          $4.85
5 - Independent Laboratory        84060        84060 - PHOSPHATASE, ACID; TOTAL         M           07/01/2006          $9.80
                                  84060
H - Laboratory Billed by Outpatient Hospital   84060 - PHOSPHATASE, ACID; TOTAL         M           07/01/2006          $9.80
I - Laboratory Billed by Physician84060        84060 - PHOSPHATASE, ACID; TOTAL         M           07/01/2006          $9.80
5 - Independent Laboratory        84061                                                 M
                                               84061 - PHOSPHATASE, ACID; FORENSIC EXAMINATION      07/01/2006        $10.51


 4/22/2012                                                    71 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                             Medicaid/BH     Pricing   Charge
                                  84061
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84061 - PHOSPHATASE, ACID; FORENSIC EXAMINATION     07/01/2006        $10.51
I - Laboratory Billed by Physician84061                                                M
                                               84061 - PHOSPHATASE, ACID; FORENSIC EXAMINATION     07/01/2006        $10.51
5 - Independent Laboratory        84066        84066 - PHOSPHATASE, ACID; PROSTATIC    M           07/01/2006        $12.83
                                  84066
H - Laboratory Billed by Outpatient Hospital   84066 - PHOSPHATASE, ACID; PROSTATIC    M           07/01/2006        $12.83
I - Laboratory Billed by Physician84066        84066 - PHOSPHATASE, ACID; PROSTATIC    M           07/01/2006        $12.83
5 - Independent Laboratory        84075        84075 - PHOSPHATASE, ALKALINE;          M           07/01/2006          $6.87
                                  84075
H - Laboratory Billed by Outpatient Hospital   84075 - PHOSPHATASE, ALKALINE;          M           07/01/2006          $6.87
I - Laboratory Billed by Physician84075        84075 - PHOSPHATASE, ALKALINE;          M           07/01/2006          $6.87
5 - Independent Laboratory        84078                                                M           07/01/2006
                                               84078 - PHOSPHATASE, ALKALINE; HEAT STABLE (TOTAL NOT INCLUDED)         $9.69
                                  84078
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006
                                               84078 - PHOSPHATASE, ALKALINE; HEAT STABLE (TOTAL NOT INCLUDED)         $9.69
I - Laboratory Billed by Physician84078                                                M           07/01/2006
                                               84078 - PHOSPHATASE, ALKALINE; HEAT STABLE (TOTAL NOT INCLUDED)         $9.69
5 - Independent Laboratory        84080                                                M
                                               84080 - PHOSPHATASE, ALKALINE; ISOENZYMES           07/01/2006        $19.63
                                  84080
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84080 - PHOSPHATASE, ALKALINE; ISOENZYMES           07/01/2006        $19.63
I - Laboratory Billed by Physician84080                                                M
                                               84080 - PHOSPHATASE, ALKALINE; ISOENZYMES           07/01/2006        $19.63
5 - Independent Laboratory        84081        84081 - PHOSPHATIDYLGLYCEROL            M           07/01/2006        $21.94
                                  84081
H - Laboratory Billed by Outpatient Hospital   84081 - PHOSPHATIDYLGLYCEROL            M           07/01/2006        $21.94
I - Laboratory Billed by Physician84081        84081 - PHOSPHATIDYLGLYCEROL            M           07/01/2006        $21.94
5 - Independent Laboratory        84085                                                M
                                               84085 - PHOSPHOGLUCONATE, 6-, DEHYDROGENASE, RBC 07/01/2006             $8.95
                                  84085
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84085 - PHOSPHOGLUCONATE, 6-, DEHYDROGENASE, RBC 07/01/2006             $8.95
I - Laboratory Billed by Physician84085                                                M
                                               84085 - PHOSPHOGLUCONATE, 6-, DEHYDROGENASE, RBC 07/01/2006             $8.95
5 - Independent Laboratory        84087        84087 - PHOSPHOHEXOSE ISOMERASE         M           07/01/2006        $13.70
                                  84087
H - Laboratory Billed by Outpatient Hospital   84087 - PHOSPHOHEXOSE ISOMERASE         M           07/01/2006        $13.70
I - Laboratory Billed by Physician84087        84087 - PHOSPHOHEXOSE ISOMERASE         M           07/01/2006        $13.70
5 - Independent Laboratory        84100                                                M
                                               84100 - PHOSPHORUS INORGANIC (PHOSPHATE);           07/01/2006          $6.30
                                  84100
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84100 - PHOSPHORUS INORGANIC (PHOSPHATE);           07/01/2006          $6.30
I - Laboratory Billed by Physician84100                                                M
                                               84100 - PHOSPHORUS INORGANIC (PHOSPHATE);           07/01/2006          $6.30
5 - Independent Laboratory        84105                                                M
                                               84105 - PHOSPHORUS INORGANIC (PHOSPHATE); URINE     07/01/2006          $6.87
                                  84105
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84105 - PHOSPHORUS INORGANIC (PHOSPHATE); URINE     07/01/2006          $6.87
I - Laboratory Billed by Physician84105                                                M
                                               84105 - PHOSPHORUS INORGANIC (PHOSPHATE); URINE     07/01/2006          $6.87
5 - Independent Laboratory        84106                                                M
                                               84106 - PORPHOBILINOGEN, URINE; QUALITATIVE         07/01/2006          $5.69
                                  84106
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84106 - PORPHOBILINOGEN, URINE; QUALITATIVE         07/01/2006          $5.69
I - Laboratory Billed by Physician84106                                                M
                                               84106 - PORPHOBILINOGEN, URINE; QUALITATIVE         07/01/2006          $5.69
5 - Independent Laboratory        84110                                                M
                                               84110 - PORPHOBILINOGEN, URINE; QUANTITATIVE        07/01/2006        $11.21
                                  84110
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84110 - PORPHOBILINOGEN, URINE; QUANTITATIVE        07/01/2006        $11.21
I - Laboratory Billed by Physician84110                                                M
                                               84110 - PORPHOBILINOGEN, URINE; QUANTITATIVE        07/01/2006        $11.21
5 - Independent Laboratory        84119        84119 - PORPHYRINS, URINE; QUALITATIVE M            07/01/2006          $9.13
                                  84119
H - Laboratory Billed by Outpatient Hospital   84119 - PORPHYRINS, URINE; QUALITATIVE M            07/01/2006          $9.13
I - Laboratory Billed by Physician84119        84119 - PORPHYRINS, URINE; QUALITATIVE M            07/01/2006          $9.13
5 - Independent Laboratory        84120                                                AND FRACTIONATION
                                               84120 - PORPHYRINS, URINE; QUANTITATION M           07/01/2006        $19.52
                                  84120
H - Laboratory Billed by Outpatient Hospital                                           AND FRACTIONATION
                                               84120 - PORPHYRINS, URINE; QUANTITATION M           07/01/2006        $19.52
I - Laboratory Billed by Physician84120                                                AND FRACTIONATION
                                               84120 - PORPHYRINS, URINE; QUANTITATION M           07/01/2006        $19.52
5 - Independent Laboratory        84126        84126 - PORPHYRINS, FECES; QUANTITATIVE M           07/01/2006        $33.81
                                  84126
H - Laboratory Billed by Outpatient Hospital   84126 - PORPHYRINS, FECES; QUANTITATIVE M           07/01/2006        $33.81
I - Laboratory Billed by Physician84126        84126 - PORPHYRINS, FECES; QUANTITATIVE M           07/01/2006        $33.81
5 - Independent Laboratory        84127        84127 - PORPHYRINS, FECES; QUALITATIVE M            07/01/2006        $15.47
                                  84127
H - Laboratory Billed by Outpatient Hospital   84127 - PORPHYRINS, FECES; QUALITATIVE M            07/01/2006        $15.47
I - Laboratory Billed by Physician84127        84127 - PORPHYRINS, FECES; QUALITATIVE M            07/01/2006        $15.47
5 - Independent Laboratory        84132        84132 - POTASSIUM; SERUM                M           07/01/2006          $6.10
                                  84132
H - Laboratory Billed by Outpatient Hospital   84132 - POTASSIUM; SERUM                M           07/01/2006          $6.10
I - Laboratory Billed by Physician84132        84132 - POTASSIUM; SERUM                M           07/01/2006          $6.10
5 - Independent Laboratory        84133        84133 - POTASSIUM; URINE                M           07/01/2006          $5.71
                                  84133
H - Laboratory Billed by Outpatient Hospital   84133 - POTASSIUM; URINE                M           07/01/2006          $5.71
I - Laboratory Billed by Physician84133        84133 - POTASSIUM; URINE                M           07/01/2006          $5.71
5 - Independent Laboratory        84134        84134 - PREALBUMIN                      M           07/01/2006        $19.36
                                  84134
H - Laboratory Billed by Outpatient Hospital   84134 - PREALBUMIN                      M           07/01/2006        $19.36
I - Laboratory Billed by Physician84134        84134 - PREALBUMIN                      M           07/01/2006        $19.36


 4/22/2012                                                     72 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing     Charge
5 - Independent Laboratory        84135        84135 - PREGNANEDIOL                     M           07/01/2006         $25.39
                                  84135
H - Laboratory Billed by Outpatient Hospital   84135 - PREGNANEDIOL                     M           07/01/2006         $25.39
I - Laboratory Billed by Physician84135        84135 - PREGNANEDIOL                     M           07/01/2006         $25.39
5 - Independent Laboratory        84138        84138 - PREGNANETRIOL                    M           07/01/2006         $25.14
                                  84138
H - Laboratory Billed by Outpatient Hospital   84138 - PREGNANETRIOL                    M           07/01/2006         $25.14
I - Laboratory Billed by Physician84138        84138 - PREGNANETRIOL                    M           07/01/2006         $25.14
5 - Independent Laboratory        84140        84140 - PREGNENOLONE                     M           07/01/2006         $27.45
                                  84140
H - Laboratory Billed by Outpatient Hospital   84140 - PREGNENOLONE                     M           07/01/2006         $27.45
I - Laboratory Billed by Physician84140        84140 - PREGNENOLONE                     M           07/01/2006         $27.45
5 - Independent Laboratory        84143        84143 - 17-HYDROXYPREGNENOLONE           M           07/01/2006         $30.30
                                  84143
H - Laboratory Billed by Outpatient Hospital   84143 - 17-HYDROXYPREGNENOLONE           M           07/01/2006         $30.30
I - Laboratory Billed by Physician84143        84143 - 17-HYDROXYPREGNENOLONE           M           07/01/2006         $30.30
5 - Independent Laboratory        84144        84144 - PROGESTERONE                     M           07/01/2006         $27.69
                                  84144
H - Laboratory Billed by Outpatient Hospital   84144 - PROGESTERONE                     M           07/01/2006         $27.69
I - Laboratory Billed by Physician84144        84144 - PROGESTERONE                     M           07/01/2006         $27.69
5 - Independent Laboratory        84146        84146 - PROLACTIN                        M           07/01/2006         $25.73
                                  84146
H - Laboratory Billed by Outpatient Hospital   84146 - PROLACTIN                        M           07/01/2006         $25.73
I - Laboratory Billed by Physician84146        84146 - PROLACTIN                        M           07/01/2006         $25.73
5 - Independent Laboratory        84150        84150 - PROSTAGLANDIN, EACH              M           07/01/2006         $33.14
                                  84150
H - Laboratory Billed by Outpatient Hospital   84150 - PROSTAGLANDIN, EACH              M           07/01/2006         $33.14
I - Laboratory Billed by Physician84150        84150 - PROSTAGLANDIN, EACH              M           07/01/2006         $33.14
5 - Independent Laboratory        84152                                                 COMPLEXED (DIRECT MEASUREMENT)
                                               84152 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
                                  84152
H - Laboratory Billed by Outpatient Hospital                                            COMPLEXED (DIRECT MEASUREMENT)
                                               84152 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
I - Laboratory Billed by Physician84152                                                 COMPLEXED (DIRECT MEASUREMENT)
                                               84152 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
5 - Independent Laboratory        84153                                                 TOTAL
                                               84153 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
                                  84153
H - Laboratory Billed by Outpatient Hospital                                            TOTAL
                                               84153 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
I - Laboratory Billed by Physician84153                                                 TOTAL
                                               84153 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
5 - Independent Laboratory        84154                                                 FREE
                                               84154 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
                                  84154
H - Laboratory Billed by Outpatient Hospital                                            FREE
                                               84154 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
I - Laboratory Billed by Physician84154                                                 FREE
                                               84154 - PROSTATE SPECIFIC ANTIGEN (PSA); M           07/01/2006         $24.42
5 - Independent Laboratory        84155                                                 M           07/01/2006
                                               84155 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM                   $4.86
                                  84155
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               84155 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM                   $4.86
I - Laboratory Billed by Physician84155                                                 M           07/01/2006
                                               84155 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM                   $4.86
5 - Independent Laboratory        84156                                                 M           07/01/2006
                                               84156 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE                   $4.86
                                  84156
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               84156 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE                   $4.86
I - Laboratory Billed by Physician84156                                                 M           07/01/2006
                                               84156 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE                   $4.86
5 - Independent Laboratory        84157                                                 M           07/01/2006          $4.86
                                               84157 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CERE
                                  84157
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006          $4.86
                                               84157 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CERE
I - Laboratory Billed by Physician84157                                                 M           07/01/2006          $4.86
                                               84157 - PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CERE
5 - Independent Laboratory        84160                                                 M
                                               84160 - PROTEIN, TOTAL, BY REFRACTOMETRY, ANY SOURCE 07/01/2006          $6.87
                                  84160
H - Laboratory Billed by Outpatient Hospital                                            M
                                               84160 - PROTEIN, TOTAL, BY REFRACTOMETRY, ANY SOURCE 07/01/2006          $6.87
I - Laboratory Billed by Physician84160                                                 M
                                               84160 - PROTEIN, TOTAL, BY REFRACTOMETRY, ANY SOURCE 07/01/2006          $6.87
5 - Independent Laboratory        84163                                                 M           07/01/2006
                                               84163 - PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A)                  $15.48
                                  84163
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               84163 - PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A)                  $15.48
I - Laboratory Billed by Physician84163                                                 M           07/01/2006
                                               84163 - PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A)                  $15.48
5 - Independent Laboratory        84165                                                 M            QUANTITATION, SERUM
                                               84165 - PROTEIN; ELECTROPHORETIC FRACTIONATION AND07/01/2006            $14.26
                                  84165
H - Laboratory Billed by Outpatient Hospital                                            M            QUANTITATION, SERUM
                                               84165 - PROTEIN; ELECTROPHORETIC FRACTIONATION AND07/01/2006            $14.26
I - Laboratory Billed by Physician84165                                                 M            QUANTITATION, SERUM
                                               84165 - PROTEIN; ELECTROPHORETIC FRACTIONATION AND07/01/2006            $14.26
5 - Independent Laboratory        84166                                                 M            QUANTITATION, OTHER FLUIDS WITH CO
                                               84166 - PROTEIN; ELECTROPHORETIC FRACTIONATION AND07/01/2006            $23.67
                                  84166
H - Laboratory Billed by Outpatient Hospital                                            M            QUANTITATION, OTHER FLUIDS WITH CO
                                               84166 - PROTEIN; ELECTROPHORETIC FRACTIONATION AND07/01/2006            $23.67
I - Laboratory Billed by Physician84166                                                 M            QUANTITATION, OTHER FLUIDS WITH CO
                                               84166 - PROTEIN; ELECTROPHORETIC FRACTIONATION AND07/01/2006            $23.67
5 - Independent Laboratory        84181                                                 M           07/01/2006         $22.61
                                               84181 - PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FL
                                  84181
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006         $22.61
                                               84181 - PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FL
I - Laboratory Billed by Physician84181                                                 M           07/01/2006         $22.61
                                               84181 - PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FL
5 - Independent Laboratory        84182                                                 M           07/01/2006         $23.89
                                               84182 - PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FL
                                  84182
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006         $23.89
                                               84182 - PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FL


 4/22/2012                                                     73 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3 LVL3 Allowed
                                                      Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing   Charge
I - Laboratory Billed by Physician84182                                                M            07/01/2006        $23.89
                                               84182 - PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FL
5 - Independent Laboratory        84202                                                M
                                               84202 - PROTOPORPHYRIN, RBC; QUANTITATIVE            07/01/2006        $19.05
                                  84202
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84202 - PROTOPORPHYRIN, RBC; QUANTITATIVE            07/01/2006        $19.05
I - Laboratory Billed by Physician84202                                                M
                                               84202 - PROTOPORPHYRIN, RBC; QUANTITATIVE            07/01/2006        $19.05
5 - Independent Laboratory        84203        84203 - PROTOPORPHYRIN, RBC; SCREEN     M            07/01/2006        $11.43
                                  84203
H - Laboratory Billed by Outpatient Hospital   84203 - PROTOPORPHYRIN, RBC; SCREEN     M            07/01/2006        $11.43
I - Laboratory Billed by Physician84203        84203 - PROTOPORPHYRIN, RBC; SCREEN     M            07/01/2006        $11.43
5 - Independent Laboratory        84206        84206 - PROINSULIN                      M            07/01/2006        $22.35
                                  84206
H - Laboratory Billed by Outpatient Hospital   84206 - PROINSULIN                      M            07/01/2006        $22.35
I - Laboratory Billed by Physician84206        84206 - PROINSULIN                      M            07/01/2006        $22.35
5 - Independent Laboratory        84207                                                M
                                               84207 - PYRIDOXAL PHOSPHATE (VITAMIN B-6)            07/01/2006        $32.60
                                  84207
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84207 - PYRIDOXAL PHOSPHATE (VITAMIN B-6)            07/01/2006        $32.60
I - Laboratory Billed by Physician84207                                                M
                                               84207 - PYRIDOXAL PHOSPHATE (VITAMIN B-6)            07/01/2006        $32.60
5 - Independent Laboratory        84210        84210 - PYRUVATE                        M            07/01/2006        $14.41
                                  84210
H - Laboratory Billed by Outpatient Hospital   84210 - PYRUVATE                        M            07/01/2006        $14.41
I - Laboratory Billed by Physician84210        84210 - PYRUVATE                        M            07/01/2006        $14.41
5 - Independent Laboratory        84220        84220 - PYRUVATE KINASE                 M            07/01/2006        $12.52
                                  84220
H - Laboratory Billed by Outpatient Hospital   84220 - PYRUVATE KINASE                 M            07/01/2006        $12.52
I - Laboratory Billed by Physician84220        84220 - PYRUVATE KINASE                 M            07/01/2006        $12.52
5 - Independent Laboratory        84228        84228 - QUININE                         M            07/01/2006        $11.61
                                  84228
H - Laboratory Billed by Outpatient Hospital   84228 - QUININE                         M            07/01/2006        $11.61
I - Laboratory Billed by Physician84228        84228 - QUININE                         M            07/01/2006        $11.61
5 - Independent Laboratory        84233        84233 - RECEPTOR ASSAY; ESTROGEN        M            07/01/2006        $85.49
                                  84233
H - Laboratory Billed by Outpatient Hospital   84233 - RECEPTOR ASSAY; ESTROGEN        M            07/01/2006        $85.49
I - Laboratory Billed by Physician84233        84233 - RECEPTOR ASSAY; ESTROGEN        M            07/01/2006        $85.49
5 - Independent Laboratory        84234        84234 - RECEPTOR ASSAY; PROGESTERONE M               07/01/2006        $86.11
                                  84234
H - Laboratory Billed by Outpatient Hospital   84234 - RECEPTOR ASSAY; PROGESTERONE M               07/01/2006        $86.11
I - Laboratory Billed by Physician84234        84234 - RECEPTOR ASSAY; PROGESTERONE M               07/01/2006        $86.11
5 - Independent Laboratory        84235                                                M            07/01/2006        $69.46
                                               84235 - RECEPTOR ASSAY; ENDOCRINE, OTHER THAN ESTROGEN OR PROGESTERONE (SPECIFY HOR
                                  84235
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006        $69.46
                                               84235 - RECEPTOR ASSAY; ENDOCRINE, OTHER THAN ESTROGEN OR PROGESTERONE (SPECIFY HOR
I - Laboratory Billed by Physician84235                                                M            07/01/2006        $69.46
                                               84235 - RECEPTOR ASSAY; ENDOCRINE, OTHER THAN ESTROGEN OR PROGESTERONE (SPECIFY HOR
5 - Independent Laboratory        84238        84238 - RECEPTOR ASSAY; NON-ENDOCRINE M              07/01/2006
                                                                                       (SPECIFY RECEPTOR)             $48.54
                                  84238
H - Laboratory Billed by Outpatient Hospital   84238 - RECEPTOR ASSAY; NON-ENDOCRINE M              07/01/2006
                                                                                       (SPECIFY RECEPTOR)             $48.54
I - Laboratory Billed by Physician84238        84238 - RECEPTOR ASSAY; NON-ENDOCRINE M              07/01/2006
                                                                                       (SPECIFY RECEPTOR)             $48.54
5 - Independent Laboratory        84244        84244 - RENIN                           M            07/01/2006        $29.19
                                  84244
H - Laboratory Billed by Outpatient Hospital   84244 - RENIN                           M            07/01/2006        $29.19
I - Laboratory Billed by Physician84244        84244 - RENIN                           M            07/01/2006        $29.19
5 - Independent Laboratory        84252        84252 - RIBOFLAVIN (VITAMIN B-2)        M            07/01/2006        $15.45
                                  84252
H - Laboratory Billed by Outpatient Hospital   84252 - RIBOFLAVIN (VITAMIN B-2)        M            07/01/2006        $15.45
I - Laboratory Billed by Physician84252        84252 - RIBOFLAVIN (VITAMIN B-2)        M            07/01/2006        $15.45
5 - Independent Laboratory        84255        84255 - SELENIUM                        M            07/01/2006        $33.89
                                  84255
H - Laboratory Billed by Outpatient Hospital   84255 - SELENIUM                        M            07/01/2006        $33.89
I - Laboratory Billed by Physician84255        84255 - SELENIUM                        M            07/01/2006        $33.89
5 - Independent Laboratory        84260        84260 - SEROTONIN                       M            07/01/2006        $23.09
                                  84260
H - Laboratory Billed by Outpatient Hospital   84260 - SEROTONIN                       M            07/01/2006        $23.09
I - Laboratory Billed by Physician84260        84260 - SEROTONIN                       M            07/01/2006        $23.09
5 - Independent Laboratory        84270                                                M
                                               84270 - SEX HORMONE BINDING GLOBULIN (SHBG)          07/01/2006        $28.84
                                  84270
H - Laboratory Billed by Outpatient Hospital                                           M
                                               84270 - SEX HORMONE BINDING GLOBULIN (SHBG)          07/01/2006        $28.84
I - Laboratory Billed by Physician84270                                                M
                                               84270 - SEX HORMONE BINDING GLOBULIN (SHBG)          07/01/2006        $28.84
5 - Independent Laboratory        84275        84275 - SIALIC ACID                     M            07/01/2006        $17.83
                                  84275
H - Laboratory Billed by Outpatient Hospital   84275 - SIALIC ACID                     M            07/01/2006        $17.83
I - Laboratory Billed by Physician84275        84275 - SIALIC ACID                     M            07/01/2006        $17.83
5 - Independent Laboratory        84285        84285 - SILICA                          M            07/01/2006        $31.26
                                  84285
H - Laboratory Billed by Outpatient Hospital   84285 - SILICA                          M            07/01/2006        $31.26
I - Laboratory Billed by Physician84285        84285 - SILICA                          M            07/01/2006        $31.26
5 - Independent Laboratory        84295        84295 - SODIUM; SERUM                   M            07/01/2006          $6.38


 4/22/2012                                                    74 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing    Charge
                                  84295
H - Laboratory Billed by Outpatient Hospital   84295 - SODIUM; SERUM                   M            07/01/2006          $6.38
I - Laboratory Billed by Physician84295        84295 - SODIUM; SERUM                   M            07/01/2006          $6.38
5 - Independent Laboratory        84300        84300 - SODIUM; URINE                   M            07/01/2006          $6.45
                                  84300
H - Laboratory Billed by Outpatient Hospital   84300 - SODIUM; URINE                   M            07/01/2006          $6.45
I - Laboratory Billed by Physician84300        84300 - SODIUM; URINE                   M            07/01/2006          $6.45
5 - Independent Laboratory        84302        84302 - SODIUM; OTHER SOURCE            M            07/01/2006          $6.45
                                  84302
H - Laboratory Billed by Outpatient Hospital   84302 - SODIUM; OTHER SOURCE            M            07/01/2006          $6.45
I - Laboratory Billed by Physician84302        84302 - SODIUM; OTHER SOURCE            M            07/01/2006          $6.45
5 - Independent Laboratory        84305        84305 - SOMATOMEDIN                     M            07/01/2006         $28.22
                                  84305
H - Laboratory Billed by Outpatient Hospital   84305 - SOMATOMEDIN                     M            07/01/2006         $28.22
I - Laboratory Billed by Physician84305        84305 - SOMATOMEDIN                     M            07/01/2006         $28.22
5 - Independent Laboratory        84307        84307 - SOMATOSTATIN                    M            07/01/2006         $24.26
                                  84307
H - Laboratory Billed by Outpatient Hospital   84307 - SOMATOSTATIN                    M            07/01/2006         $24.26
I - Laboratory Billed by Physician84307        84307 - SOMATOSTATIN                    M            07/01/2006         $24.26
5 - Independent Laboratory        84311                                                M            07/01/2006
                                               84311 - SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED               $9.28
                                  84311
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               84311 - SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED               $9.28
I - Laboratory Billed by Physician84311                                                M            07/01/2006
                                               84311 - SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED               $9.28
5 - Independent Laboratory        84315        84315 - SPECIFIC GRAVITY (EXCEPT URINE) M            07/01/2006          $3.33
                                  84315
H - Laboratory Billed by Outpatient Hospital   84315 - SPECIFIC GRAVITY (EXCEPT URINE) M            07/01/2006          $3.33
I - Laboratory Billed by Physician84315        84315 - SPECIFIC GRAVITY (EXCEPT URINE) M            07/01/2006          $3.33
5 - Independent Laboratory        84375                                                M            07/01/2006
                                               84375 - SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY            $26.02
                                  84375
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               84375 - SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY            $26.02
I - Laboratory Billed by Physician84375                                                M            07/01/2006
                                               84375 - SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY            $26.02
5 - Independent Laboratory        84376                                                M            07/01/2006          $7.31
                                               84376 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUALITATIVE, EACH SPECIMEN
                                  84376
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006          $7.31
                                               84376 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUALITATIVE, EACH SPECIMEN
I - Laboratory Billed by Physician84376                                                M            07/01/2006          $7.31
                                               84376 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUALITATIVE, EACH SPECIMEN
5 - Independent Laboratory        84377                                                M            07/01/2006          $7.31
                                               84377 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE QUALITATIVE, EACH SPECIMEN
                                  84377
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006          $7.31
                                               84377 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE QUALITATIVE, EACH SPECIMEN
I - Laboratory Billed by Physician84377                                                M            07/01/2006          $7.31
                                               84377 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE QUALITATIVE, EACH SPECIMEN
5 - Independent Laboratory        84378                                                M            07/01/2006         $15.30
                                               84378 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUANTITATIVE, EACH SPECIMEN
                                  84378
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $15.30
                                               84378 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUANTITATIVE, EACH SPECIMEN
I - Laboratory Billed by Physician84378                                                M            07/01/2006         $15.30
                                               84378 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUANTITATIVE, EACH SPECIMEN
5 - Independent Laboratory        84379                                                M            07/01/2006         $15.30
                                               84379 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE QUANTITATIVE, EACH SPECIMEN
                                  84379
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $15.30
                                               84379 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE QUANTITATIVE, EACH SPECIMEN
I - Laboratory Billed by Physician84379                                                M            07/01/2006         $15.30
                                               84379 - SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE QUANTITATIVE, EACH SPECIMEN
5 - Independent Laboratory        84392        84392 - SULFATE, URINE                  M            07/01/2006          $6.31
                                  84392
H - Laboratory Billed by Outpatient Hospital   84392 - SULFATE, URINE                  M            07/01/2006          $6.31
I - Laboratory Billed by Physician84392        84392 - SULFATE, URINE                  M            07/01/2006          $6.31
5 - Independent Laboratory        84402        84402 - TESTOSTERONE; FREE              M            07/01/2006         $33.79
                                  84402
H - Laboratory Billed by Outpatient Hospital   84402 - TESTOSTERONE; FREE              M            07/01/2006         $33.79
I - Laboratory Billed by Physician84402        84402 - TESTOSTERONE; FREE              M            07/01/2006         $33.79
5 - Independent Laboratory        84403        84403 - TESTOSTERONE; TOTAL             M            07/01/2006         $34.28
                                  84403
H - Laboratory Billed by Outpatient Hospital   84403 - TESTOSTERONE; TOTAL             M            07/01/2006         $34.28
I - Laboratory Billed by Physician84403        84403 - TESTOSTERONE; TOTAL             M            07/01/2006         $34.28
5 - Independent Laboratory        84425        84425 - THIAMINE (VITAMIN B-1)          M            07/01/2006         $28.19
                                  84425
H - Laboratory Billed by Outpatient Hospital   84425 - THIAMINE (VITAMIN B-1)          M            07/01/2006         $28.19
I - Laboratory Billed by Physician84425        84425 - THIAMINE (VITAMIN B-1)          M            07/01/2006         $28.19
5 - Independent Laboratory        84430        84430 - THIOCYANATE                     M            07/01/2006         $15.45
                                  84430
H - Laboratory Billed by Outpatient Hospital   84430 - THIOCYANATE                     M            07/01/2006         $15.45
I - Laboratory Billed by Physician84430        84430 - THIOCYANATE                     M            07/01/2006         $15.45
5 - Independent Laboratory        84432        84432 - THYROGLOBULIN                   M            07/01/2006         $21.32
                                  84432
H - Laboratory Billed by Outpatient Hospital   84432 - THYROGLOBULIN                   M            07/01/2006         $21.32
I - Laboratory Billed by Physician84432        84432 - THYROGLOBULIN                   M            07/01/2006         $21.32
5 - Independent Laboratory        84436        84436 - THYROXINE; TOTAL                M            07/01/2006          $9.13
                                  84436
H - Laboratory Billed by Outpatient Hospital   84436 - THYROXINE; TOTAL                M            07/01/2006          $9.13
I - Laboratory Billed by Physician84436        84436 - THYROXINE; TOTAL                M            07/01/2006          $9.13


 4/22/2012                                                     75 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3      Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        84437                                                  M
                                               84437 - THYROXINE; REQUIRING ELUTION (EG, NEONATAL) 07/01/2006            $8.59
                                  84437
H - Laboratory Billed by Outpatient Hospital                                             M
                                               84437 - THYROXINE; REQUIRING ELUTION (EG, NEONATAL) 07/01/2006            $8.59
I - Laboratory Billed by Physician84437                                                  M
                                               84437 - THYROXINE; REQUIRING ELUTION (EG, NEONATAL) 07/01/2006            $8.59
5 - Independent Laboratory        84439        84439 - THYROXINE; FREE                   M           07/01/2006        $11.97
                                  84439
H - Laboratory Billed by Outpatient Hospital   84439 - THYROXINE; FREE                   M           07/01/2006        $11.97
I - Laboratory Billed by Physician84439        84439 - THYROXINE; FREE                   M           07/01/2006        $11.97
5 - Independent Laboratory        84442        84442 - THYROXINE BINDING GLOBULIN (TBG)M             07/01/2006        $19.63
                                  84442
H - Laboratory Billed by Outpatient Hospital   84442 - THYROXINE BINDING GLOBULIN (TBG)M             07/01/2006        $19.63
I - Laboratory Billed by Physician84442        84442 - THYROXINE BINDING GLOBULIN (TBG)M             07/01/2006        $19.63
5 - Independent Laboratory        84443        84443 - THYROID STIMULATING HORMONE (TSH) M           07/01/2006        $22.30
                                  84443
H - Laboratory Billed by Outpatient Hospital   84443 - THYROID STIMULATING HORMONE (TSH) M           07/01/2006        $22.30
I - Laboratory Billed by Physician84443        84443 - THYROID STIMULATING HORMONE (TSH) M           07/01/2006        $22.30
5 - Independent Laboratory        84445                                                  M
                                               84445 - THYROID STIMULATING IMMUNE GLOBULINS (TSI) 07/01/2006           $67.50
                                  84445
H - Laboratory Billed by Outpatient Hospital                                             M
                                               84445 - THYROID STIMULATING IMMUNE GLOBULINS (TSI) 07/01/2006           $67.50
I - Laboratory Billed by Physician84445                                                  M
                                               84445 - THYROID STIMULATING IMMUNE GLOBULINS (TSI) 07/01/2006           $67.50
5 - Independent Laboratory        84446        84446 - TOCOPHEROL ALPHA (VITAMIN E)      M           07/01/2006        $18.82
                                  84446
H - Laboratory Billed by Outpatient Hospital   84446 - TOCOPHEROL ALPHA (VITAMIN E)      M           07/01/2006        $18.82
I - Laboratory Billed by Physician84446        84446 - TOCOPHEROL ALPHA (VITAMIN E)      M           07/01/2006        $18.82
5 - Independent Laboratory        84449                                                  M
                                               84449 - TRANSCORTIN (CORTISOL BINDING GLOBULIN)       07/01/2006        $23.89
                                  84449
H - Laboratory Billed by Outpatient Hospital                                             M
                                               84449 - TRANSCORTIN (CORTISOL BINDING GLOBULIN)       07/01/2006        $23.89
I - Laboratory Billed by Physician84449                                                  M
                                               84449 - TRANSCORTIN (CORTISOL BINDING GLOBULIN)       07/01/2006        $23.89
5 - Independent Laboratory        84450                                                  M
                                               84450 - TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 07/01/2006              $6.86
                                  84450
H - Laboratory Billed by Outpatient Hospital                                             M
                                               84450 - TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 07/01/2006              $6.86
I - Laboratory Billed by Physician84450                                                  M
                                               84450 - TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 07/01/2006              $6.86
5 - Independent Laboratory        84460        84460 - TRANSFERASE; ALANINE AMINO (ALT)M  (SGPT)     07/01/2006          $7.03
                                  84460
H - Laboratory Billed by Outpatient Hospital   84460 - TRANSFERASE; ALANINE AMINO (ALT)M  (SGPT)     07/01/2006          $7.03
I - Laboratory Billed by Physician84460        84460 - TRANSFERASE; ALANINE AMINO (ALT)M  (SGPT)     07/01/2006          $7.03
5 - Independent Laboratory        84466        84466 - TRANSFERRIN                       M           07/01/2006        $16.95
                                  84466
H - Laboratory Billed by Outpatient Hospital   84466 - TRANSFERRIN                       M           07/01/2006        $16.95
I - Laboratory Billed by Physician84466        84466 - TRANSFERRIN                       M           07/01/2006        $16.95
5 - Independent Laboratory        84478        84478 - TRIGLYCERIDES                     M           07/01/2006          $7.64
                                  84478
H - Laboratory Billed by Outpatient Hospital   84478 - TRIGLYCERIDES                     M           07/01/2006          $7.64
I - Laboratory Billed by Physician84478        84478 - TRIGLYCERIDES                     M           07/01/2006          $7.64
5 - Independent Laboratory        84479                                                  M           07/01/2006          $8.59
                                               84479 - THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR)
                                  84479
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006          $8.59
                                               84479 - THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR)
I - Laboratory Billed by Physician84479                                                  M           07/01/2006          $8.59
                                               84479 - THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR)
5 - Independent Laboratory        84480        84480 - TRIIODOTHYRONINE T3; TOTAL (TT-3) M           07/01/2006        $18.82
                                  84480
H - Laboratory Billed by Outpatient Hospital   84480 - TRIIODOTHYRONINE T3; TOTAL (TT-3) M           07/01/2006        $18.82
I - Laboratory Billed by Physician84480        84480 - TRIIODOTHYRONINE T3; TOTAL (TT-3) M           07/01/2006        $18.82
5 - Independent Laboratory        84481        84481 - TRIIODOTHYRONINE T3; FREE         M           07/01/2006        $22.49
                                  84481
H - Laboratory Billed by Outpatient Hospital   84481 - TRIIODOTHYRONINE T3; FREE         M           07/01/2006        $22.49
I - Laboratory Billed by Physician84481        84481 - TRIIODOTHYRONINE T3; FREE         M           07/01/2006        $22.49
5 - Independent Laboratory        84482        84482 - TRIIODOTHYRONINE T3; REVERSE      M           07/01/2006        $20.92
                                  84482
H - Laboratory Billed by Outpatient Hospital   84482 - TRIIODOTHYRONINE T3; REVERSE      M           07/01/2006        $20.92
I - Laboratory Billed by Physician84482        84482 - TRIIODOTHYRONINE T3; REVERSE      M           07/01/2006        $20.92
5 - Independent Laboratory        84484        84484 - TROPONIN, QUANTITATIVE            M           07/01/2006        $13.06
                                  84484
H - Laboratory Billed by Outpatient Hospital   84484 - TROPONIN, QUANTITATIVE            M           07/01/2006        $13.06
I - Laboratory Billed by Physician84484        84484 - TROPONIN, QUANTITATIVE            M           07/01/2006        $13.06
5 - Independent Laboratory        84485        84485 - TRYPSIN; DUODENAL FLUID           M           07/01/2006          $9.97
                                  84485
H - Laboratory Billed by Outpatient Hospital   84485 - TRYPSIN; DUODENAL FLUID           M           07/01/2006          $9.97
I - Laboratory Billed by Physician84485        84485 - TRYPSIN; DUODENAL FLUID           M           07/01/2006          $9.97
5 - Independent Laboratory        84488        84488 - TRYPSIN; FECES, QUALITATIVE       M           07/01/2006          $5.20
                                  84488
H - Laboratory Billed by Outpatient Hospital   84488 - TRYPSIN; FECES, QUALITATIVE       M           07/01/2006          $5.20
I - Laboratory Billed by Physician84488        84488 - TRYPSIN; FECES, QUALITATIVE       M           07/01/2006          $5.20
5 - Independent Laboratory        84490                                                  M           07/01/2006
                                               84490 - TRYPSIN; FECES, QUANTITATIVE, 24-HOUR COLLECTION                $10.10
                                  84490
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               84490 - TRYPSIN; FECES, QUANTITATIVE, 24-HOUR COLLECTION                $10.10


 4/22/2012                                                    76 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
I - Laboratory Billed by Physician84490                                                  M           07/01/2006
                                               84490 - TRYPSIN; FECES, QUANTITATIVE, 24-HOUR COLLECTION                $10.10
5 - Independent Laboratory        84510        84510 - TYROSINE                          M           07/01/2006        $13.80
                                  84510
H - Laboratory Billed by Outpatient Hospital   84510 - TYROSINE                          M           07/01/2006        $13.80
I - Laboratory Billed by Physician84510        84510 - TYROSINE                          M           07/01/2006        $13.80
5 - Independent Laboratory        84512        84512 - TROPONIN, QUALITATIVE             M           07/01/2006        $10.22
                                  84512
H - Laboratory Billed by Outpatient Hospital   84512 - TROPONIN, QUALITATIVE             M           07/01/2006        $10.22
I - Laboratory Billed by Physician84512        84512 - TROPONIN, QUALITATIVE             M           07/01/2006        $10.22
5 - Independent Laboratory        84520        84520 - UREA NITROGEN; QUANTITATIVE       M           07/01/2006          $5.23
                                  84520
H - Laboratory Billed by Outpatient Hospital   84520 - UREA NITROGEN; QUANTITATIVE       M           07/01/2006          $5.23
I - Laboratory Billed by Physician84520        84520 - UREA NITROGEN; QUANTITATIVE       M           07/01/2006          $5.23
5 - Independent Laboratory        84525                                                  M           07/01/2006
                                               84525 - UREA NITROGEN; SEMIQUANTITATIVE (EG, REAGENT STRIP TEST)          $4.99
                                  84525
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               84525 - UREA NITROGEN; SEMIQUANTITATIVE (EG, REAGENT STRIP TEST)          $4.99
I - Laboratory Billed by Physician84525                                                  M           07/01/2006
                                               84525 - UREA NITROGEN; SEMIQUANTITATIVE (EG, REAGENT STRIP TEST)          $4.99
5 - Independent Laboratory        84540        84540 - UREA NITROGEN, URINE              M           07/01/2006          $6.31
                                  84540
H - Laboratory Billed by Outpatient Hospital   84540 - UREA NITROGEN, URINE              M           07/01/2006          $6.31
I - Laboratory Billed by Physician84540        84540 - UREA NITROGEN, URINE              M           07/01/2006          $6.31
5 - Independent Laboratory        84545        84545 - UREA NITROGEN, CLEARANCE          M           07/01/2006          $7.54
                                  84545
H - Laboratory Billed by Outpatient Hospital   84545 - UREA NITROGEN, CLEARANCE          M           07/01/2006          $7.54
I - Laboratory Billed by Physician84545        84545 - UREA NITROGEN, CLEARANCE          M           07/01/2006          $7.54
5 - Independent Laboratory        84550        84550 - URIC ACID; BLOOD                  M           07/01/2006          $5.99
                                  84550
H - Laboratory Billed by Outpatient Hospital   84550 - URIC ACID; BLOOD                  M           07/01/2006          $5.99
I - Laboratory Billed by Physician84550        84550 - URIC ACID; BLOOD                  M           07/01/2006          $5.99
5 - Independent Laboratory        84560        84560 - URIC ACID; OTHER SOURCE           M           07/01/2006          $6.31
                                  84560
H - Laboratory Billed by Outpatient Hospital   84560 - URIC ACID; OTHER SOURCE           M           07/01/2006          $6.31
I - Laboratory Billed by Physician84560        84560 - URIC ACID; OTHER SOURCE           M           07/01/2006          $6.31
5 - Independent Laboratory        84577        84577 - UROBILINOGEN, FECES, QUANTITATIVE M           07/01/2006          $4.64
                                  84577
H - Laboratory Billed by Outpatient Hospital   84577 - UROBILINOGEN, FECES, QUANTITATIVE M           07/01/2006          $4.64
I - Laboratory Billed by Physician84577        84577 - UROBILINOGEN, FECES, QUANTITATIVE M           07/01/2006          $4.64
5 - Independent Laboratory        84578        84578 - UROBILINOGEN, URINE; QUALITATIVEM             07/01/2006          $4.31
                                  84578
H - Laboratory Billed by Outpatient Hospital   84578 - UROBILINOGEN, URINE; QUALITATIVEM             07/01/2006          $4.31
I - Laboratory Billed by Physician84578        84578 - UROBILINOGEN, URINE; QUALITATIVEM             07/01/2006          $4.31
5 - Independent Laboratory        84580                                                  M           07/01/2006
                                               84580 - UROBILINOGEN, URINE; QUANTITATIVE, TIMED SPECIMEN                 $9.42
                                  84580
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               84580 - UROBILINOGEN, URINE; QUANTITATIVE, TIMED SPECIMEN                 $9.42
I - Laboratory Billed by Physician84580                                                  M           07/01/2006
                                               84580 - UROBILINOGEN, URINE; QUANTITATIVE, TIMED SPECIMEN                 $9.42
5 - Independent Laboratory        84583                                                  M
                                               84583 - UROBILINOGEN, URINE; SEMIQUANTITATIVE         07/01/2006          $6.67
                                  84583
H - Laboratory Billed by Outpatient Hospital                                             M
                                               84583 - UROBILINOGEN, URINE; SEMIQUANTITATIVE         07/01/2006          $6.67
I - Laboratory Billed by Physician84583                                                  M
                                               84583 - UROBILINOGEN, URINE; SEMIQUANTITATIVE         07/01/2006          $6.67
5 - Independent Laboratory        84585        84585 - VANILLYLMANDELIC ACID (VMA), URINEM           07/01/2006        $20.58
                                  84585
H - Laboratory Billed by Outpatient Hospital   84585 - VANILLYLMANDELIC ACID (VMA), URINEM           07/01/2006        $20.58
I - Laboratory Billed by Physician84585        84585 - VANILLYLMANDELIC ACID (VMA), URINEM           07/01/2006        $20.58
5 - Independent Laboratory        84586                                                  M
                                               84586 - VASOACTIVE INTESTINAL PEPTIDE (VIP)           07/01/2006        $46.90
                                  84586
H - Laboratory Billed by Outpatient Hospital                                             M
                                               84586 - VASOACTIVE INTESTINAL PEPTIDE (VIP)           07/01/2006        $46.90
I - Laboratory Billed by Physician84586                                                  M
                                               84586 - VASOACTIVE INTESTINAL PEPTIDE (VIP)           07/01/2006        $46.90
5 - Independent Laboratory        84588                                                  M
                                               84588 - VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)       07/01/2006        $45.06
                                  84588
H - Laboratory Billed by Outpatient Hospital                                             M
                                               84588 - VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)       07/01/2006        $45.06
I - Laboratory Billed by Physician84588                                                  M
                                               84588 - VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)       07/01/2006        $45.06
5 - Independent Laboratory        84590        84590 - VITAMIN A                         M           07/01/2006        $14.28
                                  84590
H - Laboratory Billed by Outpatient Hospital   84590 - VITAMIN A                         M           07/01/2006        $14.28
I - Laboratory Billed by Physician84590        84590 - VITAMIN A                         M           07/01/2006        $14.28
5 - Independent Laboratory        84591        84591 - VITAMIN, NOT OTHERWISE SPECIFIED  M           07/01/2006        $14.28
                                  84591
H - Laboratory Billed by Outpatient Hospital   84591 - VITAMIN, NOT OTHERWISE SPECIFIED  M           07/01/2006        $14.28
I - Laboratory Billed by Physician84591        84591 - VITAMIN, NOT OTHERWISE SPECIFIED  M           07/01/2006        $14.28
5 - Independent Laboratory        84597        84597 - VITAMIN K                         M           07/01/2006        $12.35
                                  84597
H - Laboratory Billed by Outpatient Hospital   84597 - VITAMIN K                         M           07/01/2006        $12.35
I - Laboratory Billed by Physician84597        84597 - VITAMIN K                         M           07/01/2006        $12.35
5 - Independent Laboratory        84600        84600 - VOLATILES (EG, ACETIC ANHYDRIDE, M            07/01/2006        $21.33
                                                                                         CARBON TETRACHLORIDE, DICHLOROETHANE, DICHLOR


 4/22/2012                                                    77 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing   Charge
                                  84600
H - Laboratory Billed by Outpatient Hospital                                            CARBON TETRACHLORIDE, DICHLOROETHANE, DICHLOR
                                               84600 - VOLATILES (EG, ACETIC ANHYDRIDE, M           07/01/2006        $21.33
I - Laboratory Billed by Physician84600                                                 CARBON TETRACHLORIDE, DICHLOROETHANE, DICHLOR
                                               84600 - VOLATILES (EG, ACETIC ANHYDRIDE, M           07/01/2006        $21.33
5 - Independent Laboratory        84620                                                 M
                                               84620 - XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE 07/01/2006          $15.72
                                  84620
H - Laboratory Billed by Outpatient Hospital                                            M
                                               84620 - XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE 07/01/2006          $15.72
I - Laboratory Billed by Physician84620                                                 M
                                               84620 - XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE 07/01/2006          $15.72
5 - Independent Laboratory        84630        84630 - ZINC                             M           07/01/2006        $15.11
                                  84630
H - Laboratory Billed by Outpatient Hospital   84630 - ZINC                             M           07/01/2006        $15.11
I - Laboratory Billed by Physician84630        84630 - ZINC                             M           07/01/2006        $15.11
5 - Independent Laboratory        84681        84681 - C-PEPTIDE                        M           07/01/2006        $27.62
                                  84681
H - Laboratory Billed by Outpatient Hospital   84681 - C-PEPTIDE                        M           07/01/2006        $27.62
I - Laboratory Billed by Physician84681        84681 - C-PEPTIDE                        M           07/01/2006        $27.62
5 - Independent Laboratory        84702                                                 M
                                               84702 - GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE 07/01/2006         $15.48
                                  84702
H - Laboratory Billed by Outpatient Hospital                                            M
                                               84702 - GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE 07/01/2006         $15.48
I - Laboratory Billed by Physician84702                                                 M
                                               84702 - GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE 07/01/2006         $15.48
5 - Independent Laboratory        84703                                                 M
                                               84703 - GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE 07/01/2006            $9.97
                                  84703
H - Laboratory Billed by Outpatient Hospital                                            M
                                               84703 - GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE 07/01/2006            $9.97
I - Laboratory Billed by Physician84703                                                 M
                                               84703 - GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE 07/01/2006            $9.97
5 - Independent Laboratory        84830                                                 M           07/01/2006        $13.32
                                               84830 - OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR HUMAN LUTEINIZING HOR
                                  84830
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006        $13.32
                                               84830 - OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR HUMAN LUTEINIZING HOR
I - Laboratory Billed by Physician84830                                                 M           07/01/2006        $13.32
                                               84830 - OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR HUMAN LUTEINIZING HOR
5 - Independent Laboratory        85002        85002 - BLEEDING TIME                    M           07/01/2006          $5.98
                                  85002
H - Laboratory Billed by Outpatient Hospital   85002 - BLEEDING TIME                    M           07/01/2006          $5.98
I - Laboratory Billed by Physician85002        85002 - BLEEDING TIME                    M           07/01/2006          $5.98
5 - Independent Laboratory        85004                                                 M
                                               85004 - BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT07/01/2006          $8.59
                                  85004
H - Laboratory Billed by Outpatient Hospital                                            M
                                               85004 - BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT07/01/2006          $8.59
I - Laboratory Billed by Physician85004                                                 M
                                               85004 - BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT07/01/2006          $8.59
5 - Independent Laboratory        85007                                                 M           07/01/2006          $4.57
                                               85007 - BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL W
                                  85007
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006          $4.57
                                               85007 - BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL W
I - Laboratory Billed by Physician85007                                                 M           07/01/2006          $4.57
                                               85007 - BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL W
5 - Independent Laboratory        85008                                                 M           07/01/2006          $4.19
                                               85008 - BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITHOUT MANUAL DIFFERENTIA
                                  85008
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006          $4.19
                                               85008 - BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITHOUT MANUAL DIFFERENTIA
I - Laboratory Billed by Physician85008                                                 M           07/01/2006          $4.19
                                               85008 - BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITHOUT MANUAL DIFFERENTIA
5 - Independent Laboratory        85009                                                 M           07/01/2006
                                               85009 - BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT           $4.64
                                  85009
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85009 - BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT           $4.64
I - Laboratory Billed by Physician85009                                                 M           07/01/2006
                                               85009 - BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT           $4.64
5 - Independent Laboratory        85013        85013 - BLOOD COUNT; SPUN MICROHEMATOCRITM           07/01/2006          $3.14
                                  85013
H - Laboratory Billed by Outpatient Hospital   85013 - BLOOD COUNT; SPUN MICROHEMATOCRITM           07/01/2006          $3.14
I - Laboratory Billed by Physician85013        85013 - BLOOD COUNT; SPUN MICROHEMATOCRITM           07/01/2006          $3.14
5 - Independent Laboratory        85014        85014 - BLOOD COUNT; HEMATOCRIT (HCT) M              07/01/2006          $3.14
                                  85014
H - Laboratory Billed by Outpatient Hospital   85014 - BLOOD COUNT; HEMATOCRIT (HCT) M              07/01/2006          $3.14
I - Laboratory Billed by Physician85014        85014 - BLOOD COUNT; HEMATOCRIT (HCT) M              07/01/2006          $3.14
5 - Independent Laboratory        85018        85018 - BLOOD COUNT; HEMOGLOBIN (HGB) M              07/01/2006          $3.14
                                  85018
H - Laboratory Billed by Outpatient Hospital   85018 - BLOOD COUNT; HEMOGLOBIN (HGB) M              07/01/2006          $3.14
I - Laboratory Billed by Physician85018        85018 - BLOOD COUNT; HEMOGLOBIN (HGB) M              07/01/2006          $3.14
5 - Independent Laboratory        85025                                                 M           07/01/2006        $10.32
                                               85025 - BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)
                                  85025
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006        $10.32
                                               85025 - BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)
I - Laboratory Billed by Physician85025                                                 M           07/01/2006        $10.32
                                               85025 - BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)
5 - Independent Laboratory        85027                                                 M           07/01/2006          PLATELET COUNT)
                                               85027 - BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND $8.59
                                  85027
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006          PLATELET COUNT)
                                               85027 - BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND $8.59
I - Laboratory Billed by Physician85027                                                 M           07/01/2006          PLATELET COUNT)
                                               85027 - BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND $8.59
5 - Independent Laboratory        85032                                                 M           07/01/2006          $5.71
                                               85032 - BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, OR PLATELET) EACH
                                  85032
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006          $5.71
                                               85032 - BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, OR PLATELET) EACH
I - Laboratory Billed by Physician85032                                                 M           07/01/2006          $5.71
                                               85032 - BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, OR PLATELET) EACH
5 - Independent Laboratory        85041                                                 M
                                               85041 - BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED 07/01/2006          $3.82
                                  85041
H - Laboratory Billed by Outpatient Hospital                                            M
                                               85041 - BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED 07/01/2006          $3.82
I - Laboratory Billed by Physician85041                                                 M
                                               85041 - BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED 07/01/2006          $3.82


 4/22/2012                                                    78 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                    Level 3      Level 3 LVL3 Allowed
                                                      Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH     Pricing    Charge
5 - Independent Laboratory        85044        85044 - BLOOD COUNT; RETICULOCYTE, MANUAL M            07/01/2006          $5.71
                                  85044
H - Laboratory Billed by Outpatient Hospital   85044 - BLOOD COUNT; RETICULOCYTE, MANUAL M            07/01/2006          $5.71
I - Laboratory Billed by Physician85044        85044 - BLOOD COUNT; RETICULOCYTE, MANUAL M            07/01/2006          $5.71
5 - Independent Laboratory        85045                                                  M
                                               85045 - BLOOD COUNT; RETICULOCYTE, AUTOMATED           07/01/2006          $5.31
                                  85045
H - Laboratory Billed by Outpatient Hospital                                             M
                                               85045 - BLOOD COUNT; RETICULOCYTE, AUTOMATED           07/01/2006          $5.31
I - Laboratory Billed by Physician85045                                                  M
                                               85045 - BLOOD COUNT; RETICULOCYTE, AUTOMATED           07/01/2006          $5.31
5 - Independent Laboratory        85046                                                  M            07/01/2006          $7.41
                                               85046 - BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING ONE OR MORE CELLULAR PARAM
                                  85046
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006          $7.41
                                               85046 - BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING ONE OR MORE CELLULAR PARAM
I - Laboratory Billed by Physician85046                                                  M            07/01/2006          $7.41
                                               85046 - BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING ONE OR MORE CELLULAR PARAM
5 - Independent Laboratory        85048                                                  M
                                               85048 - BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 07/01/2006                 $3.37
                                  85048
H - Laboratory Billed by Outpatient Hospital                                             M
                                               85048 - BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 07/01/2006                 $3.37
I - Laboratory Billed by Physician85048                                                  M
                                               85048 - BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 07/01/2006                 $3.37
5 - Independent Laboratory        85049        85049 - BLOOD COUNT; PLATELET, AUTOMATED  M            07/01/2006          $5.20
                                  85049
H - Laboratory Billed by Outpatient Hospital   85049 - BLOOD COUNT; PLATELET, AUTOMATED  M            07/01/2006          $5.20
I - Laboratory Billed by Physician85049        85049 - BLOOD COUNT; PLATELET, AUTOMATED  M            07/01/2006          $5.20
5 - Independent Laboratory        85055        85055 - RETICULATED PLATELET ASSAY        M            07/01/2006        $35.54
                                  85055
H - Laboratory Billed by Outpatient Hospital   85055 - RETICULATED PLATELET ASSAY        M            07/01/2006        $35.54
I - Laboratory Billed by Physician85055        85055 - RETICULATED PLATELET ASSAY        M            07/01/2006        $35.54
5 - Independent Laboratory        85060                                                  M            07/01/2006        $10.59
                                               85060 - BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT
                                  85060
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $10.59
                                               85060 - BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT
5 - Independent Laboratory        85097        85097 - BONE MARROW, SMEAR INTERPRETATION M            07/01/2006        $49.21
                                  85097
H - Laboratory Billed by Outpatient Hospital   85097 - BONE MARROW, SMEAR INTERPRETATION M            07/01/2006        $49.21
5 - Independent Laboratory        85130        85130 - CHROMOGENIC SUBSTRATE ASSAY M                  07/01/2006          $5.76
                                  85130
H - Laboratory Billed by Outpatient Hospital   85130 - CHROMOGENIC SUBSTRATE ASSAY M                  07/01/2006          $5.76
I - Laboratory Billed by Physician85130        85130 - CHROMOGENIC SUBSTRATE ASSAY M                  07/01/2006          $5.76
5 - Independent Laboratory        85170        85170 - CLOT RETRACTION                   M            07/01/2006          $4.80
                                  85170
H - Laboratory Billed by Outpatient Hospital   85170 - CLOT RETRACTION                   M            07/01/2006          $4.80
I - Laboratory Billed by Physician85170        85170 - CLOT RETRACTION                   M            07/01/2006          $4.80
5 - Independent Laboratory        85175                                                  M
                                               85175 - CLOT LYSIS TIME, WHOLE BLOOD DILUTION          07/01/2006          $5.20
                                  85175
H - Laboratory Billed by Outpatient Hospital                                             M
                                               85175 - CLOT LYSIS TIME, WHOLE BLOOD DILUTION          07/01/2006          $5.20
I - Laboratory Billed by Physician85175                                                  M
                                               85175 - CLOT LYSIS TIME, WHOLE BLOOD DILUTION          07/01/2006          $5.20
5 - Independent Laboratory        85210                                                  M
                                               85210 - CLOTTING; FACTOR II, PROTHROMBIN, SPECIFIC     07/01/2006        $17.23
                                  85210
H - Laboratory Billed by Outpatient Hospital                                             M
                                               85210 - CLOTTING; FACTOR II, PROTHROMBIN, SPECIFIC     07/01/2006        $17.23
I - Laboratory Billed by Physician85210                                                  M
                                               85210 - CLOTTING; FACTOR II, PROTHROMBIN, SPECIFIC     07/01/2006        $17.23
5 - Independent Laboratory        85220                                                  M            07/01/2006
                                               85220 - CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR          $23.43
                                  85220
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               85220 - CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR          $23.43
I - Laboratory Billed by Physician85220                                                  M            07/01/2006
                                               85220 - CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR          $23.43
5 - Independent Laboratory        85230                                                  M            07/01/2006
                                               85230 - CLOTTING; FACTOR VII (PROCONVERTIN, STABLE FACTOR)               $23.77
                                  85230
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               85230 - CLOTTING; FACTOR VII (PROCONVERTIN, STABLE FACTOR)               $23.77
I - Laboratory Billed by Physician85230                                                  M            07/01/2006
                                               85230 - CLOTTING; FACTOR VII (PROCONVERTIN, STABLE FACTOR)               $23.77
5 - Independent Laboratory        85240                                                  M
                                               85240 - CLOTTING; FACTOR VIII (AHG), ONE STAGE         07/01/2006        $23.77
                                  85240
H - Laboratory Billed by Outpatient Hospital                                             M
                                               85240 - CLOTTING; FACTOR VIII (AHG), ONE STAGE         07/01/2006        $23.77
I - Laboratory Billed by Physician85240                                                  M
                                               85240 - CLOTTING; FACTOR VIII (AHG), ONE STAGE         07/01/2006        $23.77
5 - Independent Laboratory        85244                                                  M
                                               85244 - CLOTTING; FACTOR VIII RELATED ANTIGEN          07/01/2006        $27.10
                                  85244
H - Laboratory Billed by Outpatient Hospital                                             M
                                               85244 - CLOTTING; FACTOR VIII RELATED ANTIGEN          07/01/2006        $27.10
I - Laboratory Billed by Physician85244                                                  M
                                               85244 - CLOTTING; FACTOR VIII RELATED ANTIGEN          07/01/2006        $27.10
5 - Independent Laboratory        85245        85245 - CLOTTING; FACTOR VIII, VW FACTOR, M            07/01/2006
                                                                                          RISTOCETIN COFACTOR           $30.46
                                  85245
H - Laboratory Billed by Outpatient Hospital   85245 - CLOTTING; FACTOR VIII, VW FACTOR, M            07/01/2006
                                                                                          RISTOCETIN COFACTOR           $30.46
I - Laboratory Billed by Physician85245        85245 - CLOTTING; FACTOR VIII, VW FACTOR, M            07/01/2006
                                                                                          RISTOCETIN COFACTOR           $30.46
5 - Independent Laboratory        85246                                                  M
                                               85246 - CLOTTING; FACTOR VIII, VW FACTOR ANTIGEN       07/01/2006        $30.46
                                  85246
H - Laboratory Billed by Outpatient Hospital                                             M
                                               85246 - CLOTTING; FACTOR VIII, VW FACTOR ANTIGEN       07/01/2006        $30.46
I - Laboratory Billed by Physician85246                                                  M
                                               85246 - CLOTTING; FACTOR VIII, VW FACTOR ANTIGEN       07/01/2006        $30.46
5 - Independent Laboratory        85247                                                  M             MULTIMETRIC ANALYSIS
                                               85247 - CLOTTING; FACTOR VIII, VON WILLEBRAND FACTOR,07/01/2006          $30.46
                                  85247
H - Laboratory Billed by Outpatient Hospital                                             M             MULTIMETRIC ANALYSIS
                                               85247 - CLOTTING; FACTOR VIII, VON WILLEBRAND FACTOR,07/01/2006          $30.46
I - Laboratory Billed by Physician85247                                                  M             MULTIMETRIC ANALYSIS
                                               85247 - CLOTTING; FACTOR VIII, VON WILLEBRAND FACTOR,07/01/2006          $30.46
5 - Independent Laboratory        85250                                                  M
                                               85250 - CLOTTING; FACTOR IX (PTC OR CHRISTMAS)         07/01/2006        $25.27


 4/22/2012                                                    79 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                     Level 3      Level 3   LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH      Pricing     Charge
                                  85250
H - Laboratory Billed by Outpatient Hospital                                              M
                                               85250 - CLOTTING; FACTOR IX (PTC OR CHRISTMAS)          07/01/2006          $25.27
I - Laboratory Billed by Physician85250                                                   M
                                               85250 - CLOTTING; FACTOR IX (PTC OR CHRISTMAS)          07/01/2006          $25.27
5 - Independent Laboratory        85260        85260 - CLOTTING; FACTOR X (STUART-PROWER) M            07/01/2006          $23.77
                                  85260
H - Laboratory Billed by Outpatient Hospital   85260 - CLOTTING; FACTOR X (STUART-PROWER) M            07/01/2006          $23.77
I - Laboratory Billed by Physician85260        85260 - CLOTTING; FACTOR X (STUART-PROWER) M            07/01/2006          $23.77
5 - Independent Laboratory        85270        85270 - CLOTTING; FACTOR XI (PTA)          M            07/01/2006          $23.77
                                  85270
H - Laboratory Billed by Outpatient Hospital   85270 - CLOTTING; FACTOR XI (PTA)          M            07/01/2006          $23.77
I - Laboratory Billed by Physician85270        85270 - CLOTTING; FACTOR XI (PTA)          M            07/01/2006          $23.77
5 - Independent Laboratory        85280        85280 - CLOTTING; FACTOR XII (HAGEMAN) M                07/01/2006          $25.69
                                  85280
H - Laboratory Billed by Outpatient Hospital   85280 - CLOTTING; FACTOR XII (HAGEMAN) M                07/01/2006          $25.69
I - Laboratory Billed by Physician85280        85280 - CLOTTING; FACTOR XII (HAGEMAN) M                07/01/2006          $25.69
5 - Independent Laboratory        85290                                                   M
                                               85290 - CLOTTING; FACTOR XIII (FIBRIN STABILIZING)      07/01/2006          $21.69
                                  85290
H - Laboratory Billed by Outpatient Hospital                                              M
                                               85290 - CLOTTING; FACTOR XIII (FIBRIN STABILIZING)      07/01/2006          $21.69
I - Laboratory Billed by Physician85290                                                   M
                                               85290 - CLOTTING; FACTOR XIII (FIBRIN STABILIZING)      07/01/2006          $21.69
5 - Independent Laboratory        85291                                                   M            07/01/2006
                                               85291 - CLOTTING; FACTOR XIII (FIBRIN STABILIZING), SCREEN SOLUBILITY       $11.80
                                  85291
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85291 - CLOTTING; FACTOR XIII (FIBRIN STABILIZING), SCREEN SOLUBILITY       $11.80
I - Laboratory Billed by Physician85291                                                   M            07/01/2006
                                               85291 - CLOTTING; FACTOR XIII (FIBRIN STABILIZING), SCREEN SOLUBILITY       $11.80
5 - Independent Laboratory        85292                                                   M            07/01/2006
                                               85292 - CLOTTING; PREKALLIKREIN ASSAY (FLETCHER FACTOR ASSAY)               $25.14
                                  85292
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85292 - CLOTTING; PREKALLIKREIN ASSAY (FLETCHER FACTOR ASSAY)               $25.14
I - Laboratory Billed by Physician85292                                                   M            07/01/2006
                                               85292 - CLOTTING; PREKALLIKREIN ASSAY (FLETCHER FACTOR ASSAY)               $25.14
5 - Independent Laboratory        85293                                                   M            07/01/2006          $25.14
                                               85293 - CLOTTING; HIGH MOLECULAR WEIGHT KININOGEN ASSAY (FITZGERALD FACTOR ASSAY)
                                  85293
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006          $25.14
                                               85293 - CLOTTING; HIGH MOLECULAR WEIGHT KININOGEN ASSAY (FITZGERALD FACTOR ASSAY)
I - Laboratory Billed by Physician85293                                                   M            07/01/2006          $25.14
                                               85293 - CLOTTING; HIGH MOLECULAR WEIGHT KININOGEN ASSAY (FITZGERALD FACTOR ASSAY)
5 - Independent Laboratory        85300                                                   M            07/01/2006
                                               85300 - CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ACTIVITY$14.58
                                  85300
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85300 - CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ACTIVITY$14.58
I - Laboratory Billed by Physician85300                                                   M            07/01/2006
                                               85300 - CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ACTIVITY$14.58
5 - Independent Laboratory        85301                                                   M            07/01/2006
                                               85301 - CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN$14.35ASSAY
                                  85301
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85301 - CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN$14.35ASSAY
I - Laboratory Billed by Physician85301                                                   M            07/01/2006
                                               85301 - CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN$14.35ASSAY
5 - Independent Laboratory        85302                                                   M            07/01/2006
                                               85302 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ANTIGEN           $15.96
                                  85302
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85302 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ANTIGEN           $15.96
I - Laboratory Billed by Physician85302                                                   M            07/01/2006
                                               85302 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ANTIGEN           $15.96
5 - Independent Laboratory        85303                                                   M            07/01/2006
                                               85303 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY          $18.35
                                  85303
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85303 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY          $18.35
I - Laboratory Billed by Physician85303                                                   M            07/01/2006
                                               85303 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY          $18.35
5 - Independent Laboratory        85305                                                   M            07/01/2006
                                               85305 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, TOTAL             $15.39
                                  85305
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85305 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, TOTAL             $15.39
I - Laboratory Billed by Physician85305                                                   M            07/01/2006
                                               85305 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, TOTAL             $15.39
5 - Independent Laboratory        85306                                                   M            07/01/2006
                                               85306 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE              $20.34
                                  85306
H - Laboratory Billed by Outpatient Hospital                                              M            07/01/2006
                                               85306 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE              $20.34
I - Laboratory Billed by Physician85306                                                   M            07/01/2006
                                               85306 - CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE              $20.34
5 - Independent Laboratory        85307                                                   M
                                               85307 - ACTIVATED PROTEIN C (APC) RESISTANCE ASSAY 07/01/2006               $20.34
                                  85307
H - Laboratory Billed by Outpatient Hospital                                              M
                                               85307 - ACTIVATED PROTEIN C (APC) RESISTANCE ASSAY 07/01/2006               $20.34
I - Laboratory Billed by Physician85307                                                   M
                                               85307 - ACTIVATED PROTEIN C (APC) RESISTANCE ASSAY 07/01/2006               $20.34
5 - Independent Laboratory        85335        85335 - FACTOR INHIBITOR TEST              M            07/01/2006          $17.09
                                  85335
H - Laboratory Billed by Outpatient Hospital   85335 - FACTOR INHIBITOR TEST              M            07/01/2006          $17.09
I - Laboratory Billed by Physician85335        85335 - FACTOR INHIBITOR TEST              M            07/01/2006          $17.09
5 - Independent Laboratory        85337        85337 - THROMBOMODULIN                     M            07/01/2006          $13.83
                                  85337
H - Laboratory Billed by Outpatient Hospital   85337 - THROMBOMODULIN                     M            07/01/2006          $13.83
I - Laboratory Billed by Physician85337        85337 - THROMBOMODULIN                     M            07/01/2006          $13.83
5 - Independent Laboratory        85345        85345 - COAGULATION TIME; LEE AND WHITE M               07/01/2006            $5.71
                                  85345
H - Laboratory Billed by Outpatient Hospital   85345 - COAGULATION TIME; LEE AND WHITE M               07/01/2006            $5.71
I - Laboratory Billed by Physician85345        85345 - COAGULATION TIME; LEE AND WHITE M               07/01/2006            $5.71
5 - Independent Laboratory        85347        85347 - COAGULATION TIME; ACTIVATED        M            07/01/2006            $5.65
                                  85347
H - Laboratory Billed by Outpatient Hospital   85347 - COAGULATION TIME; ACTIVATED        M            07/01/2006            $5.65
I - Laboratory Billed by Physician85347        85347 - COAGULATION TIME; ACTIVATED        M            07/01/2006            $5.65


 4/22/2012                                                     80 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing     Charge
5 - Independent Laboratory        85348        85348 - COAGULATION TIME; OTHER METHODS  M           07/01/2006           $4.94
                                  85348
H - Laboratory Billed by Outpatient Hospital   85348 - COAGULATION TIME; OTHER METHODS  M           07/01/2006           $4.94
I - Laboratory Billed by Physician85348        85348 - COAGULATION TIME; OTHER METHODS  M           07/01/2006           $4.94
5 - Independent Laboratory        85360        85360 - EUGLOBULIN LYSIS                 M           07/01/2006         $11.15
                                  85360
H - Laboratory Billed by Outpatient Hospital   85360 - EUGLOBULIN LYSIS                 M           07/01/2006         $11.15
I - Laboratory Billed by Physician85360        85360 - EUGLOBULIN LYSIS                 M           07/01/2006         $11.15
5 - Independent Laboratory        85362                                                 PRODUCTS (FDP)(FSP); AGGLUTINATION SLIDE, SEMIQU
                                               85362 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006           $9.14
                                  85362
H - Laboratory Billed by Outpatient Hospital                                            PRODUCTS (FDP)(FSP); AGGLUTINATION SLIDE, SEMIQU
                                               85362 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006           $9.14
I - Laboratory Billed by Physician85362                                                 PRODUCTS (FDP)(FSP); AGGLUTINATION SLIDE, SEMIQU
                                               85362 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006           $9.14
5 - Independent Laboratory        85366                                                 PRODUCTS (FDP)(FSP); PARACOAGULATION
                                               85366 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006         $11.43
                                  85366
H - Laboratory Billed by Outpatient Hospital                                            PRODUCTS (FDP)(FSP); PARACOAGULATION
                                               85366 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006         $11.43
I - Laboratory Billed by Physician85366                                                 PRODUCTS (FDP)(FSP); PARACOAGULATION
                                               85366 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006         $11.43
5 - Independent Laboratory        85370                                                 PRODUCTS (FDP)(FSP); QUANTITATIVE
                                               85370 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006         $15.08
                                  85370
H - Laboratory Billed by Outpatient Hospital                                            PRODUCTS (FDP)(FSP); QUANTITATIVE
                                               85370 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006         $15.08
I - Laboratory Billed by Physician85370                                                 PRODUCTS (FDP)(FSP); QUANTITATIVE
                                               85370 - FIBRIN(OGEN) DEGRADATION (SPLIT) M           07/01/2006         $15.08
5 - Independent Laboratory        85378                                                 M           07/01/2006           $9.47
                                               85378 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUALITATIVE OR SEMIQUANTITATIVE
                                  85378
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006           $9.47
                                               85378 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUALITATIVE OR SEMIQUANTITATIVE
I - Laboratory Billed by Physician85378                                                 M           07/01/2006           $9.47
                                               85378 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUALITATIVE OR SEMIQUANTITATIVE
5 - Independent Laboratory        85379                                                 M           07/01/2006
                                               85379 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE              $13.51
                                  85379
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85379 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE              $13.51
I - Laboratory Billed by Physician85379                                                 M           07/01/2006
                                               85379 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE              $13.51
5 - Independent Laboratory        85380                                                 M           07/01/2006         $13.51
                                               85380 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; ULTRASENSITIVE (EG, FOR EVALUATION FOR VE
                                  85380
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006         $13.51
                                               85380 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; ULTRASENSITIVE (EG, FOR EVALUATION FOR VE
I - Laboratory Billed by Physician85380                                                 M           07/01/2006         $13.51
                                               85380 - FIBRIN DEGRADATION PRODUCTS, D-DIMER; ULTRASENSITIVE (EG, FOR EVALUATION FOR VE
5 - Independent Laboratory        85384        85384 - FIBRINOGEN; ACTIVITY             M           07/01/2006         $11.28
                                  85384
H - Laboratory Billed by Outpatient Hospital   85384 - FIBRINOGEN; ACTIVITY             M           07/01/2006         $11.28
I - Laboratory Billed by Physician85384        85384 - FIBRINOGEN; ACTIVITY             M           07/01/2006         $11.28
5 - Independent Laboratory        85385        85385 - FIBRINOGEN; ANTIGEN              M           07/01/2006         $11.28
                                  85385
H - Laboratory Billed by Outpatient Hospital   85385 - FIBRINOGEN; ANTIGEN              M           07/01/2006         $11.28
I - Laboratory Billed by Physician85385        85385 - FIBRINOGEN; ANTIGEN              M           07/01/2006         $11.28
5 - Independent Laboratory        85390                                                 M           07/01/2006
                                               85390 - FIBRINOLYSINS OR COAGULOPATHY SCREEN, INTERPRETATION AND REPORT   $6.86
                                  85390
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85390 - FIBRINOLYSINS OR COAGULOPATHY SCREEN, INTERPRETATION AND REPORT   $6.86
I - Laboratory Billed by Physician85390                                                 M           07/01/2006
                                               85390 - FIBRINOLYSINS OR COAGULOPATHY SCREEN, INTERPRETATION AND REPORT   $6.86
5 - Independent Laboratory        85396        85396 - COAGULATION/FIBRINOLYSIS ASSAY, M            07/01/2006           $9.25
                                                                                        WHOLE BLOOD (EG, VISCOELASTIC CLOT ASSESSMENT
                                  85396
H - Laboratory Billed by Outpatient Hospital   85396 - COAGULATION/FIBRINOLYSIS ASSAY, M            07/01/2006           $9.25
                                                                                        WHOLE BLOOD (EG, VISCOELASTIC CLOT ASSESSMENT
5 - Independent Laboratory        85400                                                 M
                                               85400 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMIN 07/01/2006         $11.74
                                  85400
H - Laboratory Billed by Outpatient Hospital                                            M
                                               85400 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMIN 07/01/2006         $11.74
I - Laboratory Billed by Physician85400                                                 M
                                               85400 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMIN 07/01/2006         $11.74
5 - Independent Laboratory        85410                                                 M           07/01/2006
                                               85410 - FIBRINOLYTIC FACTORS AND INHIBITORS; ALPHA-2 ANTIPLASMIN        $10.23
                                  85410
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85410 - FIBRINOLYTIC FACTORS AND INHIBITORS; ALPHA-2 ANTIPLASMIN        $10.23
I - Laboratory Billed by Physician85410                                                 M           07/01/2006
                                               85410 - FIBRINOLYTIC FACTORS AND INHIBITORS; ALPHA-2 ANTIPLASMIN        $10.23
5 - Independent Laboratory        85415                                                 M           07/01/2006
                                               85415 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVATOR      $22.82
                                  85415
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85415 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVATOR      $22.82
I - Laboratory Billed by Physician85415                                                 M           07/01/2006
                                               85415 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVATOR      $22.82
5 - Independent Laboratory        85420                                                 M           07/01/2006           $8.67
                                               85420 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, EXCEPT ANTIGENIC ASSAY
                                  85420
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006           $8.67
                                               85420 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, EXCEPT ANTIGENIC ASSAY
I - Laboratory Billed by Physician85420                                                 M           07/01/2006           $8.67
                                               85420 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, EXCEPT ANTIGENIC ASSAY
5 - Independent Laboratory        85421                                                 M           07/01/2006
                                               85421 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, ANTIGENIC ASSAY $8.27
                                  85421
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85421 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, ANTIGENIC ASSAY $8.27
I - Laboratory Billed by Physician85421                                                 M           07/01/2006
                                               85421 - FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, ANTIGENIC ASSAY $8.27
5 - Independent Laboratory        85441        85441 - HEINZ BODIES; DIRECT             M           07/01/2006           $5.59
                                  85441
H - Laboratory Billed by Outpatient Hospital   85441 - HEINZ BODIES; DIRECT             M           07/01/2006           $5.59
I - Laboratory Billed by Physician85441        85441 - HEINZ BODIES; DIRECT             M           07/01/2006           $5.59
5 - Independent Laboratory        85445                                                 M
                                               85445 - HEINZ BODIES; INDUCED, ACETYL PHENYLHYDRAZINE07/01/2006           $9.04
                                  85445
H - Laboratory Billed by Outpatient Hospital                                            M
                                               85445 - HEINZ BODIES; INDUCED, ACETYL PHENYLHYDRAZINE07/01/2006           $9.04
I - Laboratory Billed by Physician85445                                                 M
                                               85445 - HEINZ BODIES; INDUCED, ACETYL PHENYLHYDRAZINE07/01/2006           $9.04


 4/22/2012                                                     81 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        85460                                                 M           07/01/2006        $10.27
                                               85460 - HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; DIFFERENTIAL LYSIS (K
                                  85460
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006        $10.27
                                               85460 - HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; DIFFERENTIAL LYSIS (K
I - Laboratory Billed by Physician85460                                                 M           07/01/2006        $10.27
                                               85460 - HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; DIFFERENTIAL LYSIS (K
5 - Independent Laboratory        85461                                                 M           07/01/2006
                                               85461 - HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; ROSETTE  $8.80
                                  85461
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85461 - HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; ROSETTE  $8.80
I - Laboratory Billed by Physician85461                                                 M           07/01/2006
                                               85461 - HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; ROSETTE  $8.80
5 - Independent Laboratory        85475        85475 - HEMOLYSIN, ACID                  M           07/01/2006        $11.78
                                  85475
H - Laboratory Billed by Outpatient Hospital   85475 - HEMOLYSIN, ACID                  M           07/01/2006        $11.78
I - Laboratory Billed by Physician85475        85475 - HEMOLYSIN, ACID                  M           07/01/2006        $11.78
5 - Independent Laboratory        85520        85520 - HEPARIN ASSAY                    M           07/01/2006        $11.61
                                  85520
H - Laboratory Billed by Outpatient Hospital   85520 - HEPARIN ASSAY                    M           07/01/2006        $11.61
I - Laboratory Billed by Physician85520        85520 - HEPARIN ASSAY                    M           07/01/2006        $11.61
5 - Independent Laboratory        85525        85525 - HEPARIN NEUTRALIZATION           M           07/01/2006        $15.72
                                  85525
H - Laboratory Billed by Outpatient Hospital   85525 - HEPARIN NEUTRALIZATION           M           07/01/2006        $15.72
I - Laboratory Billed by Physician85525        85525 - HEPARIN NEUTRALIZATION           M           07/01/2006        $15.72
5 - Independent Laboratory        85530        85530 - HEPARIN-PROTAMINE TOLERANCE TEST M           07/01/2006        $18.82
                                  85530
H - Laboratory Billed by Outpatient Hospital   85530 - HEPARIN-PROTAMINE TOLERANCE TEST M           07/01/2006        $18.82
I - Laboratory Billed by Physician85530        85530 - HEPARIN-PROTAMINE TOLERANCE TEST M           07/01/2006        $18.82
5 - Independent Laboratory        85536        85536 - IRON STAIN, PERIPHERAL BLOOD     M           07/01/2006          $8.59
                                  85536
H - Laboratory Billed by Outpatient Hospital   85536 - IRON STAIN, PERIPHERAL BLOOD     M           07/01/2006          $8.59
I - Laboratory Billed by Physician85536        85536 - IRON STAIN, PERIPHERAL BLOOD     M           07/01/2006          $8.59
5 - Independent Laboratory        85540                                                 M
                                               85540 - LEUKOCYTE ALKALINE PHOSPHATASE WITH COUNT07/01/2006            $11.42
                                  85540
H - Laboratory Billed by Outpatient Hospital                                            M
                                               85540 - LEUKOCYTE ALKALINE PHOSPHATASE WITH COUNT07/01/2006            $11.42
I - Laboratory Billed by Physician85540                                                 M
                                               85540 - LEUKOCYTE ALKALINE PHOSPHATASE WITH COUNT07/01/2006            $11.42
5 - Independent Laboratory        85547        85547 - MECHANICAL FRAGILITY, RBC        M           07/01/2006        $11.42
                                  85547
H - Laboratory Billed by Outpatient Hospital   85547 - MECHANICAL FRAGILITY, RBC        M           07/01/2006        $11.42
I - Laboratory Billed by Physician85547        85547 - MECHANICAL FRAGILITY, RBC        M           07/01/2006        $11.42
5 - Independent Laboratory        85549        85549 - MURAMIDASE                       M           07/01/2006        $24.90
                                  85549
H - Laboratory Billed by Outpatient Hospital   85549 - MURAMIDASE                       M           07/01/2006        $24.90
I - Laboratory Billed by Physician85549        85549 - MURAMIDASE                       M           07/01/2006        $24.90
5 - Independent Laboratory        85555                                                 M
                                               85555 - OSMOTIC FRAGILITY, RBC; UNINCUBATED          07/01/2006          $8.87
                                  85555
H - Laboratory Billed by Outpatient Hospital                                            M
                                               85555 - OSMOTIC FRAGILITY, RBC; UNINCUBATED          07/01/2006          $8.87
I - Laboratory Billed by Physician85555                                                 M
                                               85555 - OSMOTIC FRAGILITY, RBC; UNINCUBATED          07/01/2006          $8.87
5 - Independent Laboratory        85557        85557 - OSMOTIC FRAGILITY, RBC; INCUBATEDM           07/01/2006        $17.73
                                  85557
H - Laboratory Billed by Outpatient Hospital   85557 - OSMOTIC FRAGILITY, RBC; INCUBATEDM           07/01/2006        $17.73
I - Laboratory Billed by Physician85557        85557 - OSMOTIC FRAGILITY, RBC; INCUBATEDM           07/01/2006        $17.73
5 - Independent Laboratory        85576                                                 EACH AGENT 07/01/2006
                                               85576 - PLATELET, AGGREGATION (IN VITRO),M                             $28.51
                                  85576
H - Laboratory Billed by Outpatient Hospital                                            EACH AGENT 07/01/2006
                                               85576 - PLATELET, AGGREGATION (IN VITRO),M                             $28.51
I - Laboratory Billed by Physician85576                                                 EACH AGENT 07/01/2006
                                               85576 - PLATELET, AGGREGATION (IN VITRO),M                             $28.51
5 - Independent Laboratory        85597        85597 - PLATELET NEUTRALIZATION          M           07/01/2006        $23.86
                                  85597
H - Laboratory Billed by Outpatient Hospital   85597 - PLATELET NEUTRALIZATION          M           07/01/2006        $23.86
I - Laboratory Billed by Physician85597        85597 - PLATELET NEUTRALIZATION          M           07/01/2006        $23.86
5 - Independent Laboratory        85610        85610 - PROTHROMBIN TIME;                M           07/01/2006          $5.22
                                  85610
H - Laboratory Billed by Outpatient Hospital   85610 - PROTHROMBIN TIME;                M           07/01/2006          $5.22
I - Laboratory Billed by Physician85610        85610 - PROTHROMBIN TIME;                M           07/01/2006          $5.22
5 - Independent Laboratory        85611        85611 - PROTHROMBIN TIME; SUBSTITUTION, M            07/01/2006
                                                                                        PLASMA FRACTIONS, EACH          $5.23
                                  85611
H - Laboratory Billed by Outpatient Hospital   85611 - PROTHROMBIN TIME; SUBSTITUTION, M            07/01/2006
                                                                                        PLASMA FRACTIONS, EACH          $5.23
I - Laboratory Billed by Physician85611        85611 - PROTHROMBIN TIME; SUBSTITUTION, M            07/01/2006
                                                                                        PLASMA FRACTIONS, EACH          $5.23
5 - Independent Laboratory        85612                                                 M           07/01/2006
                                               85612 - RUSSELL VIPER VENOM TIME (INCLUDES VENOM); UNDILUTED           $12.70
                                  85612
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85612 - RUSSELL VIPER VENOM TIME (INCLUDES VENOM); UNDILUTED           $12.70
I - Laboratory Billed by Physician85612                                                 M           07/01/2006
                                               85612 - RUSSELL VIPER VENOM TIME (INCLUDES VENOM); UNDILUTED           $12.70
5 - Independent Laboratory        85613                                                 M           07/01/2006
                                               85613 - RUSSELL VIPER VENOM TIME (INCLUDES VENOM); DILUTED             $12.70
                                  85613
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85613 - RUSSELL VIPER VENOM TIME (INCLUDES VENOM); DILUTED             $12.70
I - Laboratory Billed by Physician85613                                                 M           07/01/2006
                                               85613 - RUSSELL VIPER VENOM TIME (INCLUDES VENOM); DILUTED             $12.70
5 - Independent Laboratory        85635        85635 - REPTILASE TEST                   M           07/01/2006        $13.07
                                  85635
H - Laboratory Billed by Outpatient Hospital   85635 - REPTILASE TEST                   M           07/01/2006        $13.07


 4/22/2012                                                    82 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3      Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing    Charge
I - Laboratory Billed by Physician85635        85635 - REPTILASE TEST                   M           07/01/2006         $13.07
5 - Independent Laboratory        85651                                                 M           07/01/2006
                                               85651 - SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED                    $4.71
                                  85651
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85651 - SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED                    $4.71
I - Laboratory Billed by Physician85651                                                 M           07/01/2006
                                               85651 - SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED                    $4.71
5 - Independent Laboratory        85652                                                 M
                                               85652 - SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED   07/01/2006           $3.58
                                  85652
H - Laboratory Billed by Outpatient Hospital                                            M
                                               85652 - SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED   07/01/2006           $3.58
I - Laboratory Billed by Physician85652                                                 M
                                               85652 - SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED   07/01/2006           $3.58
5 - Independent Laboratory        85660        85660 - SICKLING OF RBC, REDUCTION       M           07/01/2006           $6.90
                                  85660
H - Laboratory Billed by Outpatient Hospital   85660 - SICKLING OF RBC, REDUCTION       M           07/01/2006           $6.90
I - Laboratory Billed by Physician85660        85660 - SICKLING OF RBC, REDUCTION       M           07/01/2006           $6.90
5 - Independent Laboratory        85670        85670 - THROMBIN TIME; PLASMA            M           07/01/2006           $7.67
                                  85670
H - Laboratory Billed by Outpatient Hospital   85670 - THROMBIN TIME; PLASMA            M           07/01/2006           $7.67
I - Laboratory Billed by Physician85670        85670 - THROMBIN TIME; PLASMA            M           07/01/2006           $7.67
5 - Independent Laboratory        85675        85675 - THROMBIN TIME; TITER             M           07/01/2006           $9.10
                                  85675
H - Laboratory Billed by Outpatient Hospital   85675 - THROMBIN TIME; TITER             M           07/01/2006           $9.10
I - Laboratory Billed by Physician85675        85675 - THROMBIN TIME; TITER             M           07/01/2006           $9.10
5 - Independent Laboratory        85705        85705 - THROMBOPLASTIN INHIBITION, TISSUEM           07/01/2006         $12.78
                                  85705
H - Laboratory Billed by Outpatient Hospital   85705 - THROMBOPLASTIN INHIBITION, TISSUEM           07/01/2006         $12.78
I - Laboratory Billed by Physician85705        85705 - THROMBOPLASTIN INHIBITION, TISSUEM           07/01/2006         $12.78
5 - Independent Laboratory        85730                                                 M           07/01/2006
                                               85730 - THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD         $7.96
                                  85730
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006
                                               85730 - THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD         $7.96
I - Laboratory Billed by Physician85730                                                 M           07/01/2006
                                               85730 - THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD         $7.96
5 - Independent Laboratory        85732                                                 M           07/01/2006           $8.59
                                               85732 - THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH
                                  85732
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006           $8.59
                                               85732 - THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH
I - Laboratory Billed by Physician85732                                                 M           07/01/2006           $8.59
                                               85732 - THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH
5 - Independent Laboratory        85810        85810 - VISCOSITY                        M           07/01/2006         $15.50
                                  85810
H - Laboratory Billed by Outpatient Hospital   85810 - VISCOSITY                        M           07/01/2006         $15.50
I - Laboratory Billed by Physician85810        85810 - VISCOSITY                        M           07/01/2006         $15.50
5 - Independent Laboratory        86000                                                 M           07/01/2006            FEVER, ROCKY M
                                               86000 - AGGLUTININS, FEBRILE (EG, BRUCELLA, FRANCISELLA, MURINE TYPHUS, Q$9.26
                                  86000
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006            FEVER, ROCKY M
                                               86000 - AGGLUTININS, FEBRILE (EG, BRUCELLA, FRANCISELLA, MURINE TYPHUS, Q$9.26
I - Laboratory Billed by Physician86000                                                 M           07/01/2006            FEVER, ROCKY M
                                               86000 - AGGLUTININS, FEBRILE (EG, BRUCELLA, FRANCISELLA, MURINE TYPHUS, Q$9.26
5 - Independent Laboratory        86001                                                 M           07/01/2006           $6.94
                                               86001 - ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN
                                  86001
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006           $6.94
                                               86001 - ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN
I - Laboratory Billed by Physician86001                                                 M           07/01/2006           $6.94
                                               86001 - ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN
5 - Independent Laboratory        86003                                                 M           07/01/2006           $6.94
                                               86003 - ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN
                                  86003
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006           $6.94
                                               86003 - ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN
I - Laboratory Billed by Physician86003                                                 M           07/01/2006           $6.94
                                               86003 - ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN
5 - Independent Laboratory        86005                                                 M           07/01/2006         $10.58
                                               86005 - ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (DIPSTICK, PADDLE OR DIS
                                  86005
H - Laboratory Billed by Outpatient Hospital                                            M           07/01/2006         $10.58
                                               86005 - ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (DIPSTICK, PADDLE OR DIS
I - Laboratory Billed by Physician86005                                                 M           07/01/2006         $10.58
                                               86005 - ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (DIPSTICK, PADDLE OR DIS
5 - Independent Laboratory        86021                                                 M
                                               86021 - ANTIBODY IDENTIFICATION; LEUKOCYTE ANTIBODIES07/01/2006         $19.98
                                  86021
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86021 - ANTIBODY IDENTIFICATION; LEUKOCYTE ANTIBODIES07/01/2006         $19.98
I - Laboratory Billed by Physician86021                                                 M
                                               86021 - ANTIBODY IDENTIFICATION; LEUKOCYTE ANTIBODIES07/01/2006         $19.98
5 - Independent Laboratory        86022                                                 M
                                               86022 - ANTIBODY IDENTIFICATION; PLATELET ANTIBODIES 07/01/2006         $24.38
                                  86022
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86022 - ANTIBODY IDENTIFICATION; PLATELET ANTIBODIES 07/01/2006         $24.38
I - Laboratory Billed by Physician86022                                                 M
                                               86022 - ANTIBODY IDENTIFICATION; PLATELET ANTIBODIES 07/01/2006         $24.38
5 - Independent Laboratory        86023                                                 M            IMMUNOGLOBULIN ASSAY
                                               86023 - ANTIBODY IDENTIFICATION; PLATELET ASSOCIATED07/01/2006          $16.53
                                  86023
H - Laboratory Billed by Outpatient Hospital                                            M            IMMUNOGLOBULIN ASSAY
                                               86023 - ANTIBODY IDENTIFICATION; PLATELET ASSOCIATED07/01/2006          $16.53
I - Laboratory Billed by Physician86023                                                 M            IMMUNOGLOBULIN ASSAY
                                               86023 - ANTIBODY IDENTIFICATION; PLATELET ASSOCIATED07/01/2006          $16.53
5 - Independent Laboratory        86038        86038 - ANTINUCLEAR ANTIBODIES (ANA);    M           07/01/2006         $16.05
                                  86038
H - Laboratory Billed by Outpatient Hospital   86038 - ANTINUCLEAR ANTIBODIES (ANA);    M           07/01/2006         $16.05
I - Laboratory Billed by Physician86038        86038 - ANTINUCLEAR ANTIBODIES (ANA);    M           07/01/2006         $16.05
5 - Independent Laboratory        86039                                                 M
                                               86039 - ANTINUCLEAR ANTIBODIES (ANA); TITER          07/01/2006         $14.82
                                  86039
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86039 - ANTINUCLEAR ANTIBODIES (ANA); TITER          07/01/2006         $14.82
I - Laboratory Billed by Physician86039                                                 M
                                               86039 - ANTINUCLEAR ANTIBODIES (ANA); TITER          07/01/2006         $14.82
5 - Independent Laboratory        86060        86060 - ANTISTREPTOLYSIN 0; TITER        M           07/01/2006           $9.69


 4/22/2012                                                     83 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH      Pricing   Charge
                                  86060
H - Laboratory Billed by Outpatient Hospital   86060 - ANTISTREPTOLYSIN 0; TITER        M            07/01/2006          $9.69
I - Laboratory Billed by Physician86060        86060 - ANTISTREPTOLYSIN 0; TITER        M            07/01/2006          $9.69
5 - Independent Laboratory        86063        86063 - ANTISTREPTOLYSIN 0; SCREEN       M            07/01/2006          $7.67
                                  86063
H - Laboratory Billed by Outpatient Hospital   86063 - ANTISTREPTOLYSIN 0; SCREEN       M            07/01/2006          $7.67
I - Laboratory Billed by Physician86063        86063 - ANTISTREPTOLYSIN 0; SCREEN       M            07/01/2006          $7.67
5 - Independent Laboratory        86077                                                 M            07/01/2006        $22.34
                                               86077 - BLOOD BANK PHYSICIAN SERVICES; DIFFICULT CROSS MATCH AND/OR EVALUATION OF IRRE
                                  86077
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006        $22.34
                                               86077 - BLOOD BANK PHYSICIAN SERVICES; DIFFICULT CROSS MATCH AND/OR EVALUATION OF IRRE
5 - Independent Laboratory        86078                                                 M             OF TRANSFUSION REACTION INCLUDING
                                               86078 - BLOOD BANK PHYSICIAN SERVICES; INVESTIGATION07/01/2006          $23.59
                                  86078
H - Laboratory Billed by Outpatient Hospital                                            M             OF TRANSFUSION REACTION INCLUDING
                                               86078 - BLOOD BANK PHYSICIAN SERVICES; INVESTIGATION07/01/2006          $23.59
5 - Independent Laboratory        86079                                                 M            07/01/2006        $23.27
                                               86079 - BLOOD BANK PHYSICIAN SERVICES; AUTHORIZATION FOR DEVIATION FROM STANDARD BLOO
                                  86079
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006        $23.27
                                               86079 - BLOOD BANK PHYSICIAN SERVICES; AUTHORIZATION FOR DEVIATION FROM STANDARD BLOO
5 - Independent Laboratory        86140        86140 - C-REACTIVE PROTEIN;              M            07/01/2006          $6.87
                                  86140
H - Laboratory Billed by Outpatient Hospital   86140 - C-REACTIVE PROTEIN;              M            07/01/2006          $6.87
I - Laboratory Billed by Physician86140        86140 - C-REACTIVE PROTEIN;              M            07/01/2006          $6.87
5 - Independent Laboratory        86141                                                 M
                                               86141 - C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 07/01/2006         $17.19
                                  86141
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86141 - C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 07/01/2006         $17.19
I - Laboratory Billed by Physician86141                                                 M
                                               86141 - C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 07/01/2006         $17.19
5 - Independent Laboratory        86146                                                 M
                                               86146 - BETA 2 GLYCOPROTEIN I ANTIBODY, EACH          07/01/2006        $33.76
                                  86146
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86146 - BETA 2 GLYCOPROTEIN I ANTIBODY, EACH          07/01/2006        $33.76
I - Laboratory Billed by Physician86146                                                 M
                                               86146 - BETA 2 GLYCOPROTEIN I ANTIBODY, EACH          07/01/2006        $33.76
5 - Independent Laboratory        86147                                                 M            07/01/2006
                                               86147 - CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY, EACH IG CLASS              $33.76
                                  86147
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86147 - CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY, EACH IG CLASS              $33.76
I - Laboratory Billed by Physician86147                                                 M            07/01/2006
                                               86147 - CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY, EACH IG CLASS              $33.76
5 - Independent Laboratory        86148                                                 M            07/01/2006
                                               86148 - ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY                 $21.32
                                  86148
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86148 - ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY                 $21.32
I - Laboratory Billed by Physician86148                                                 M            07/01/2006
                                               86148 - ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY                 $21.32
5 - Independent Laboratory        86155        86155 - CHEMOTAXIS ASSAY, SPECIFY METHOD M            07/01/2006        $21.21
                                  86155
H - Laboratory Billed by Outpatient Hospital   86155 - CHEMOTAXIS ASSAY, SPECIFY METHOD M            07/01/2006        $21.21
I - Laboratory Billed by Physician86155        86155 - CHEMOTAXIS ASSAY, SPECIFY METHOD M            07/01/2006        $21.21
5 - Independent Laboratory        86156        86156 - COLD AGGLUTININ; SCREEN          M            07/01/2006          $8.89
                                  86156
H - Laboratory Billed by Outpatient Hospital   86156 - COLD AGGLUTININ; SCREEN          M            07/01/2006          $8.89
I - Laboratory Billed by Physician86156        86156 - COLD AGGLUTININ; SCREEN          M            07/01/2006          $8.89
5 - Independent Laboratory        86157        86157 - COLD AGGLUTININ; TITER           M            07/01/2006        $10.71
                                  86157
H - Laboratory Billed by Outpatient Hospital   86157 - COLD AGGLUTININ; TITER           M            07/01/2006        $10.71
I - Laboratory Billed by Physician86157        86157 - COLD AGGLUTININ; TITER           M            07/01/2006        $10.71
5 - Independent Laboratory        86160                                                 M
                                               86160 - COMPLEMENT; ANTIGEN, EACH COMPONENT           07/01/2006        $15.94
                                  86160
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86160 - COMPLEMENT; ANTIGEN, EACH COMPONENT           07/01/2006        $15.94
I - Laboratory Billed by Physician86160                                                 M
                                               86160 - COMPLEMENT; ANTIGEN, EACH COMPONENT           07/01/2006        $15.94
5 - Independent Laboratory        86161                                                 M            07/01/2006
                                               86161 - COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT                 $15.94
                                  86161
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86161 - COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT                 $15.94
I - Laboratory Billed by Physician86161                                                 M            07/01/2006
                                               86161 - COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT                 $15.94
5 - Independent Laboratory        86162                                                 M
                                               86162 - COMPLEMENT; TOTAL HEMOLYTIC (CH50)            07/01/2006        $26.97
                                  86162
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86162 - COMPLEMENT; TOTAL HEMOLYTIC (CH50)            07/01/2006        $26.97
I - Laboratory Billed by Physician86162                                                 M
                                               86162 - COMPLEMENT; TOTAL HEMOLYTIC (CH50)            07/01/2006        $26.97
5 - Independent Laboratory        86171                                                 M
                                               86171 - COMPLEMENT FIXATION TESTS, EACH ANTIGEN       07/01/2006        $12.84
                                  86171
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86171 - COMPLEMENT FIXATION TESTS, EACH ANTIGEN       07/01/2006        $12.84
I - Laboratory Billed by Physician86171                                                 M
                                               86171 - COMPLEMENT FIXATION TESTS, EACH ANTIGEN       07/01/2006        $12.84
5 - Independent Laboratory        86185                                                 M
                                               86185 - COUNTERIMMUNOELECTROPHORESIS, EACH ANTIGEN    07/01/2006        $11.88
                                  86185
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86185 - COUNTERIMMUNOELECTROPHORESIS, EACH ANTIGEN    07/01/2006        $11.88
I - Laboratory Billed by Physician86185                                                 M
                                               86185 - COUNTERIMMUNOELECTROPHORESIS, EACH ANTIGEN    07/01/2006        $11.88
5 - Independent Laboratory        86200                                                 M
                                               86200 - CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY 07/01/2006         $17.00
                                  86200
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86200 - CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY 07/01/2006         $17.00
I - Laboratory Billed by Physician86200                                                 M
                                               86200 - CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY 07/01/2006         $17.00
5 - Independent Laboratory        86215        86215 - DEOXYRIBONUCLEASE, ANTIBODY M                 07/01/2006        $17.58
                                  86215
H - Laboratory Billed by Outpatient Hospital   86215 - DEOXYRIBONUCLEASE, ANTIBODY M                 07/01/2006        $17.58
I - Laboratory Billed by Physician86215        86215 - DEOXYRIBONUCLEASE, ANTIBODY M                 07/01/2006        $17.58


 4/22/2012                                                     84 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing     Charge
5 - Independent Laboratory        86225                                                M             OR DOUBLE
                                               86225 - DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; NATIVE07/01/2006 STRANDED $18.24
                                  86225
H - Laboratory Billed by Outpatient Hospital                                           M             OR DOUBLE
                                               86225 - DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; NATIVE07/01/2006 STRANDED $18.24
I - Laboratory Billed by Physician86225                                                M             OR DOUBLE
                                               86225 - DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; NATIVE07/01/2006 STRANDED $18.24
5 - Independent Laboratory        86226                                                M             STRANDED
                                               86226 - DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; SINGLE07/01/2006          $16.07
                                  86226
H - Laboratory Billed by Outpatient Hospital                                           M             STRANDED
                                               86226 - DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; SINGLE07/01/2006          $16.07
I - Laboratory Billed by Physician86226                                                M             STRANDED
                                               86226 - DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; SINGLE07/01/2006          $16.07
5 - Independent Laboratory        86235                                                M            07/01/2006         $23.81
                                               86235 - EXTRACTABLE NUCLEAR ANTIGEN, ANTIBODY TO, ANY METHOD (EG, NRNP, SS-A, SS-B, SM, R
                                  86235
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $23.81
                                               86235 - EXTRACTABLE NUCLEAR ANTIGEN, ANTIBODY TO, ANY METHOD (EG, NRNP, SS-A, SS-B, SM, R
I - Laboratory Billed by Physician86235                                                M            07/01/2006         $23.81
                                               86235 - EXTRACTABLE NUCLEAR ANTIGEN, ANTIBODY TO, ANY METHOD (EG, NRNP, SS-A, SS-B, SM, R
5 - Independent Laboratory        86243        86243 - FC RECEPTOR                     M            07/01/2006         $27.25
                                  86243
H - Laboratory Billed by Outpatient Hospital   86243 - FC RECEPTOR                     M            07/01/2006         $27.25
I - Laboratory Billed by Physician86243        86243 - FC RECEPTOR                     M            07/01/2006         $27.25
5 - Independent Laboratory        86255                                                M            SCREEN, EACH ANTIBODY
                                               86255 - FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; 07/01/2006            $16.00
                                  86255
H - Laboratory Billed by Outpatient Hospital                                           M            SCREEN, EACH ANTIBODY
                                               86255 - FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; 07/01/2006            $16.00
I - Laboratory Billed by Physician86255                                                M            SCREEN, EACH ANTIBODY
                                               86255 - FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; 07/01/2006            $16.00
5 - Independent Laboratory        86256                                                M            TITER, EACH ANTIBODY
                                               86256 - FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; 07/01/2006            $16.00
                                  86256
H - Laboratory Billed by Outpatient Hospital                                           M            TITER, EACH ANTIBODY
                                               86256 - FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; 07/01/2006            $16.00
I - Laboratory Billed by Physician86256                                                M            TITER, EACH ANTIBODY
                                               86256 - FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; 07/01/2006            $16.00
5 - Independent Laboratory        86277                                                M
                                               86277 - GROWTH HORMONE, HUMAN (HGH), ANTIBODY        07/01/2006         $20.89
                                  86277
H - Laboratory Billed by Outpatient Hospital                                           M
                                               86277 - GROWTH HORMONE, HUMAN (HGH), ANTIBODY        07/01/2006         $20.89
I - Laboratory Billed by Physician86277                                                M
                                               86277 - GROWTH HORMONE, HUMAN (HGH), ANTIBODY        07/01/2006         $20.89
5 - Independent Laboratory        86280                                                M
                                               86280 - HEMAGGLUTINATION INHIBITION TEST (HAI)       07/01/2006         $10.87
                                  86280
H - Laboratory Billed by Outpatient Hospital                                           M
                                               86280 - HEMAGGLUTINATION INHIBITION TEST (HAI)       07/01/2006         $10.87
I - Laboratory Billed by Physician86280                                                M
                                               86280 - HEMAGGLUTINATION INHIBITION TEST (HAI)       07/01/2006         $10.87
5 - Independent Laboratory        86294                                                M             OR SEMIQUANTITATIVE (EG, BLADDER TU
                                               86294 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE07/01/2006            $26.04
                                  86294
H - Laboratory Billed by Outpatient Hospital                                           M             OR SEMIQUANTITATIVE (EG, BLADDER TU
                                               86294 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE07/01/2006            $26.04
I - Laboratory Billed by Physician86294                                                M             OR SEMIQUANTITATIVE (EG, BLADDER TU
                                               86294 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE07/01/2006            $26.04
5 - Independent Laboratory        86300                                                M            07/01/2006
                                               86300 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)    $27.62
                                  86300
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               86300 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)    $27.62
I - Laboratory Billed by Physician86300                                                M            07/01/2006
                                               86300 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)    $27.62
5 - Independent Laboratory        86301                                                M            07/01/2006
                                               86301 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9            $27.62
                                  86301
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               86301 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9            $27.62
I - Laboratory Billed by Physician86301                                                M            07/01/2006
                                               86301 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9            $27.62
5 - Independent Laboratory        86304                                                M            07/01/2006
                                               86304 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125             $27.62
                                  86304
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               86304 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125             $27.62
I - Laboratory Billed by Physician86304                                                M            07/01/2006
                                               86304 - IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125             $27.62
5 - Independent Laboratory        86308                                                M
                                               86308 - HETEROPHILE ANTIBODIES; SCREENING            07/01/2006           $6.87
                                  86308
H - Laboratory Billed by Outpatient Hospital                                           M
                                               86308 - HETEROPHILE ANTIBODIES; SCREENING            07/01/2006           $6.87
I - Laboratory Billed by Physician86308                                                M
                                               86308 - HETEROPHILE ANTIBODIES; SCREENING            07/01/2006           $6.87
5 - Independent Laboratory        86309        86309 - HETEROPHILE ANTIBODIES; TITER   M            07/01/2006           $8.59
                                  86309
H - Laboratory Billed by Outpatient Hospital   86309 - HETEROPHILE ANTIBODIES; TITER   M            07/01/2006           $8.59
I - Laboratory Billed by Physician86309        86309 - HETEROPHILE ANTIBODIES; TITER   M            07/01/2006           $8.59
5 - Independent Laboratory        86310                                                M            07/01/2006            AND
                                               86310 - HETEROPHILE ANTIBODIES; TITERS AFTER ABSORPTION WITH BEEF CELLS$9.79 GUINEA PIG
                                  86310
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            AND
                                               86310 - HETEROPHILE ANTIBODIES; TITERS AFTER ABSORPTION WITH BEEF CELLS$9.79 GUINEA PIG
I - Laboratory Billed by Physician86310                                                M            07/01/2006            AND
                                               86310 - HETEROPHILE ANTIBODIES; TITERS AFTER ABSORPTION WITH BEEF CELLS$9.79 GUINEA PIG
5 - Independent Laboratory        86316                                                M            07/01/2006         $27.62
                                               86316 - IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549),
                                  86316
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $27.62
                                               86316 - IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549),
I - Laboratory Billed by Physician86316                                                M            07/01/2006         $27.62
                                               86316 - IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549),
5 - Independent Laboratory        86317                                                M            QUANTITATIVE, NOT OTHERWISE SPECIF
                                               86317 - IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY,07/01/2006            $19.90
                                  86317
H - Laboratory Billed by Outpatient Hospital                                           M            QUANTITATIVE, NOT OTHERWISE SPECIF
                                               86317 - IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY,07/01/2006            $19.90
I - Laboratory Billed by Physician86317                                                M            QUANTITATIVE, NOT OTHERWISE SPECIF
                                               86317 - IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY,07/01/2006            $19.90
5 - Independent Laboratory        86318                                                M            QUALITATIVE OR SEMIQUANTITATIVE, SIN
                                               86318 - IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY,07/01/2006            $17.19
                                  86318
H - Laboratory Billed by Outpatient Hospital                                           M            QUALITATIVE OR SEMIQUANTITATIVE, SIN
                                               86318 - IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY,07/01/2006            $17.19
I - Laboratory Billed by Physician86318                                                M            QUALITATIVE OR SEMIQUANTITATIVE, SIN
                                               86318 - IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY,07/01/2006            $17.19
5 - Independent Laboratory        86320        86320 - IMMUNOELECTROPHORESIS; SERUM M               07/01/2006         $29.75
                                  86320
H - Laboratory Billed by Outpatient Hospital   86320 - IMMUNOELECTROPHORESIS; SERUM M               07/01/2006         $29.75


 4/22/2012                                                     85 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing    Charge
I - Laboratory Billed by Physician86320        86320 - IMMUNOELECTROPHORESIS; SERUM M                07/01/2006         $29.75
5 - Independent Laboratory        86325        86325 - IMMUNOELECTROPHORESIS; OTHER M                07/01/2006         $29.68
                                                                                        FLUIDS (EG, URINE, CEREBROSPINAL FLUID) WITH CONC
                                  86325
H - Laboratory Billed by Outpatient Hospital   86325 - IMMUNOELECTROPHORESIS; OTHER M                07/01/2006         $29.68
                                                                                        FLUIDS (EG, URINE, CEREBROSPINAL FLUID) WITH CONC
I - Laboratory Billed by Physician86325        86325 - IMMUNOELECTROPHORESIS; OTHER M                07/01/2006         $29.68
                                                                                        FLUIDS (EG, URINE, CEREBROSPINAL FLUID) WITH CONC
5 - Independent Laboratory        86327                                                 M            07/01/2006
                                               86327 - IMMUNOELECTROPHORESIS; CROSSED (2-DIMENSIONAL ASSAY)             $30.12
                                  86327
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86327 - IMMUNOELECTROPHORESIS; CROSSED (2-DIMENSIONAL ASSAY)             $30.12
I - Laboratory Billed by Physician86327                                                 M            07/01/2006
                                               86327 - IMMUNOELECTROPHORESIS; CROSSED (2-DIMENSIONAL ASSAY)             $30.12
5 - Independent Laboratory        86329                                                 M
                                               86329 - IMMUNODIFFUSION; NOT ELSEWHERE SPECIFIED 07/01/2006              $18.64
                                  86329
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86329 - IMMUNODIFFUSION; NOT ELSEWHERE SPECIFIED 07/01/2006              $18.64
I - Laboratory Billed by Physician86329                                                 M
                                               86329 - IMMUNODIFFUSION; NOT ELSEWHERE SPECIFIED 07/01/2006              $18.64
5 - Independent Laboratory        86331                                                 M            07/01/2006         $15.91
                                               86331 - IMMUNODIFFUSION; GEL DIFFUSION, QUALITATIVE (OUCHTERLONY), EACH ANTIGEN OR ANTIB
                                  86331
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $15.91
                                               86331 - IMMUNODIFFUSION; GEL DIFFUSION, QUALITATIVE (OUCHTERLONY), EACH ANTIGEN OR ANTIB
I - Laboratory Billed by Physician86331                                                 M            07/01/2006         $15.91
                                               86331 - IMMUNODIFFUSION; GEL DIFFUSION, QUALITATIVE (OUCHTERLONY), EACH ANTIGEN OR ANTIB
5 - Independent Laboratory        86332        86332 - IMMUNE COMPLEX ASSAY             M            07/01/2006         $32.35
                                  86332
H - Laboratory Billed by Outpatient Hospital   86332 - IMMUNE COMPLEX ASSAY             M            07/01/2006         $32.35
I - Laboratory Billed by Physician86332        86332 - IMMUNE COMPLEX ASSAY             M            07/01/2006         $32.35
5 - Independent Laboratory        86334                                                 M
                                               86334 - IMMUNOFIXATION ELECTROPHORESIS; SERUM         07/01/2006         $29.65
                                  86334
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86334 - IMMUNOFIXATION ELECTROPHORESIS; SERUM         07/01/2006         $29.65
I - Laboratory Billed by Physician86334                                                 M
                                               86334 - IMMUNOFIXATION ELECTROPHORESIS; SERUM         07/01/2006         $29.65
5 - Independent Laboratory        86335                                                 M            07/01/2006         $38.95
                                               86335 - IMMUNOFIXATION ELECTROPHORESIS; OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CS
                                  86335
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $38.95
                                               86335 - IMMUNOFIXATION ELECTROPHORESIS; OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CS
I - Laboratory Billed by Physician86335                                                 M            07/01/2006         $38.95
                                               86335 - IMMUNOFIXATION ELECTROPHORESIS; OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CS
5 - Independent Laboratory        86336        86336 - INHIBIN A                        M            07/01/2006         $20.68
                                  86336
H - Laboratory Billed by Outpatient Hospital   86336 - INHIBIN A                        M            07/01/2006         $20.68
I - Laboratory Billed by Physician86336        86336 - INHIBIN A                        M            07/01/2006         $20.68
5 - Independent Laboratory        86337        86337 - INSULIN ANTIBODIES               M            07/01/2006         $22.04
                                  86337
H - Laboratory Billed by Outpatient Hospital   86337 - INSULIN ANTIBODIES               M            07/01/2006         $22.04
I - Laboratory Billed by Physician86337        86337 - INSULIN ANTIBODIES               M            07/01/2006         $22.04
5 - Independent Laboratory        86340        86340 - INTRINSIC FACTOR ANTIBODIES      M            07/01/2006         $20.01
                                  86340
H - Laboratory Billed by Outpatient Hospital   86340 - INTRINSIC FACTOR ANTIBODIES      M            07/01/2006         $20.01
I - Laboratory Billed by Physician86340        86340 - INTRINSIC FACTOR ANTIBODIES      M            07/01/2006         $20.01
5 - Independent Laboratory        86341        86341 - ISLET CELL ANTIBODY              M            07/01/2006         $26.27
                                  86341
H - Laboratory Billed by Outpatient Hospital   86341 - ISLET CELL ANTIBODY              M            07/01/2006         $26.27
I - Laboratory Billed by Physician86341        86341 - ISLET CELL ANTIBODY              M            07/01/2006         $26.27
5 - Independent Laboratory        86343                                                 M
                                               86343 - LEUKOCYTE HISTAMINE RELEASE TEST (LHR)        07/01/2006         $16.54
                                  86343
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86343 - LEUKOCYTE HISTAMINE RELEASE TEST (LHR)        07/01/2006         $16.54
I - Laboratory Billed by Physician86343                                                 M
                                               86343 - LEUKOCYTE HISTAMINE RELEASE TEST (LHR)        07/01/2006         $16.54
5 - Independent Laboratory        86344        86344 - LEUKOCYTE PHAGOCYTOSIS           M            07/01/2006         $10.60
                                  86344
H - Laboratory Billed by Outpatient Hospital   86344 - LEUKOCYTE PHAGOCYTOSIS           M            07/01/2006         $10.60
I - Laboratory Billed by Physician86344        86344 - LEUKOCYTE PHAGOCYTOSIS           M            07/01/2006         $10.60
5 - Independent Laboratory        86353                                                 M            07/01/2006         $65.07
                                               86353 - LYMPHOCYTE TRANSFORMATION, MITOGEN (PHYTOMITOGEN) OR ANTIGEN INDUCED BLASTO
                                  86353
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $65.07
                                               86353 - LYMPHOCYTE TRANSFORMATION, MITOGEN (PHYTOMITOGEN) OR ANTIGEN INDUCED BLASTO
I - Laboratory Billed by Physician86353                                                 M            07/01/2006         $65.07
                                               86353 - LYMPHOCYTE TRANSFORMATION, MITOGEN (PHYTOMITOGEN) OR ANTIGEN INDUCED BLASTO
5 - Independent Laboratory        86355        86355 - B CELLS, TOTAL COUNT             M            07/01/2006         $18.77
                                  86355
H - Laboratory Billed by Outpatient Hospital   86355 - B CELLS, TOTAL COUNT             M            07/01/2006         $18.77
I - Laboratory Billed by Physician86355        86355 - B CELLS, TOTAL COUNT             M            07/01/2006         $18.77
5 - Independent Laboratory        86357                                                 M
                                               86357 - NATURAL KILLER (NK) CELLS, TOTAL COUNT        07/01/2006         $18.77
                                  86357
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86357 - NATURAL KILLER (NK) CELLS, TOTAL COUNT        07/01/2006         $18.77
I - Laboratory Billed by Physician86357                                                 M
                                               86357 - NATURAL KILLER (NK) CELLS, TOTAL COUNT        07/01/2006         $18.77
5 - Independent Laboratory        86359        86359 - T CELLS; TOTAL COUNT             M            07/01/2006         $18.97
                                  86359
H - Laboratory Billed by Outpatient Hospital   86359 - T CELLS; TOTAL COUNT             M            07/01/2006         $18.97
I - Laboratory Billed by Physician86359        86359 - T CELLS; TOTAL COUNT             M            07/01/2006         $18.97
5 - Independent Laboratory        86360                                                 M            07/01/2006
                                               86360 - T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO             $62.37
                                  86360
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86360 - T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO             $62.37
I - Laboratory Billed by Physician86360                                                 M            07/01/2006
                                               86360 - T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO             $62.37
5 - Independent Laboratory        86361        86361 - T CELLS; ABSOLUTE CD4 COUNT      M            07/01/2006         $35.54


 4/22/2012                                                     86 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                    Level 3       Level 3 LVL3 Allowed
                                                      Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH      Pricing   Charge
                                  86361
H - Laboratory Billed by Outpatient Hospital   86361 - T CELLS; ABSOLUTE CD4 COUNT       M             07/01/2006        $35.54
I - Laboratory Billed by Physician86361        86361 - T CELLS; ABSOLUTE CD4 COUNT       M             07/01/2006        $35.54
5 - Independent Laboratory        86367        86367 - STEM CELLS (IE, CD34), TOTAL COUNTM             07/01/2006        $18.77
                                  86367
H - Laboratory Billed by Outpatient Hospital   86367 - STEM CELLS (IE, CD34), TOTAL COUNTM             07/01/2006        $18.77
I - Laboratory Billed by Physician86367        86367 - STEM CELLS (IE, CD34), TOTAL COUNTM             07/01/2006        $18.77
5 - Independent Laboratory        86376                                                  M             07/01/2006
                                               86376 - MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH         $16.66
                                  86376
H - Laboratory Billed by Outpatient Hospital                                             M             07/01/2006
                                               86376 - MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH         $16.66
I - Laboratory Billed by Physician86376                                                  M             07/01/2006
                                               86376 - MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH         $16.66
5 - Independent Laboratory        86378                                                  M
                                               86378 - MIGRATION INHIBITORY FACTOR TEST (MIF)          07/01/2006        $26.13
                                  86378
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86378 - MIGRATION INHIBITORY FACTOR TEST (MIF)          07/01/2006        $26.13
I - Laboratory Billed by Physician86378                                                  M
                                               86378 - MIGRATION INHIBITORY FACTOR TEST (MIF)          07/01/2006        $26.13
5 - Independent Laboratory        86382        86382 - NEUTRALIZATION TEST, VIRAL        M             07/01/2006        $22.44
                                  86382
H - Laboratory Billed by Outpatient Hospital   86382 - NEUTRALIZATION TEST, VIRAL        M             07/01/2006        $22.44
I - Laboratory Billed by Physician86382        86382 - NEUTRALIZATION TEST, VIRAL        M             07/01/2006        $22.44
5 - Independent Laboratory        86384        86384 - NITROBLUE TETRAZOLIUM DYE TEST M  (NTD)         07/01/2006        $15.11
                                  86384
H - Laboratory Billed by Outpatient Hospital   86384 - NITROBLUE TETRAZOLIUM DYE TEST M  (NTD)         07/01/2006        $15.11
I - Laboratory Billed by Physician86384        86384 - NITROBLUE TETRAZOLIUM DYE TEST M  (NTD)         07/01/2006        $15.11
5 - Independent Laboratory        86403        86403 - PARTICLE AGGLUTINATION; SCREEN, M EACH ANTIBODY 07/01/2006        $13.53
                                  86403
H - Laboratory Billed by Outpatient Hospital   86403 - PARTICLE AGGLUTINATION; SCREEN, M EACH ANTIBODY 07/01/2006        $13.53
I - Laboratory Billed by Physician86403        86403 - PARTICLE AGGLUTINATION; SCREEN, M EACH ANTIBODY 07/01/2006        $13.53
5 - Independent Laboratory        86406                                                  M
                                               86406 - PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY 07/01/2006           $14.13
                                  86406
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86406 - PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY 07/01/2006           $14.13
I - Laboratory Billed by Physician86406                                                  M
                                               86406 - PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY 07/01/2006           $14.13
5 - Independent Laboratory        86430        86430 - RHEUMATOID FACTOR; QUALITATIVE M                07/01/2006          $7.53
                                  86430
H - Laboratory Billed by Outpatient Hospital   86430 - RHEUMATOID FACTOR; QUALITATIVE M                07/01/2006          $7.53
I - Laboratory Billed by Physician86430        86430 - RHEUMATOID FACTOR; QUALITATIVE M                07/01/2006          $7.53
5 - Independent Laboratory        86431        86431 - RHEUMATOID FACTOR; QUANTITATIVE   M             07/01/2006          $7.53
                                  86431
H - Laboratory Billed by Outpatient Hospital   86431 - RHEUMATOID FACTOR; QUANTITATIVE   M             07/01/2006          $7.53
I - Laboratory Billed by Physician86431        86431 - RHEUMATOID FACTOR; QUANTITATIVE   M             07/01/2006          $7.53
5 - Independent Laboratory        86480                                                  M             07/01/2006        $81.39
                                               86480 - TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY MEASUREMENT OF GAMMA INTERFERON AN
                                  86480
H - Laboratory Billed by Outpatient Hospital                                             M             07/01/2006        $81.39
                                               86480 - TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY MEASUREMENT OF GAMMA INTERFERON AN
I - Laboratory Billed by Physician86480                                                  M             07/01/2006        $81.39
                                               86480 - TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY MEASUREMENT OF GAMMA INTERFERON AN
5 - Independent Laboratory        86485        86485 - SKIN TEST; CANDIDA                M             07/01/2006        $15.81
                                  86485
H - Laboratory Billed by Outpatient Hospital   86485 - SKIN TEST; CANDIDA                M             07/01/2006        $15.81
I - Laboratory Billed by Physician86485        86485 - SKIN TEST; CANDIDA                M             07/01/2006        $15.81
5 - Independent Laboratory        86490        86490 - SKIN TEST; COCCIDIOIDOMYCOSIS M                 07/01/2006          $5.40
                                  86490
H - Laboratory Billed by Outpatient Hospital   86490 - SKIN TEST; COCCIDIOIDOMYCOSIS M                 07/01/2006          $5.40
5 - Independent Laboratory        86510        86510 - SKIN TEST; HISTOPLASMOSIS         M             07/01/2006          $5.93
                                  86510
H - Laboratory Billed by Outpatient Hospital   86510 - SKIN TEST; HISTOPLASMOSIS         M             07/01/2006          $5.93
5 - Independent Laboratory        86580                                                  M
                                               86580 - SKIN TEST; TUBERCULOSIS, INTRADERMAL            07/01/2006          $4.69
                                  86580
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86580 - SKIN TEST; TUBERCULOSIS, INTRADERMAL            07/01/2006          $4.69
5 - Independent Laboratory        86586        86586 - UNLISTED ANTIGEN, EACH            M             07/01/2006        $18.97
                                  86586
H - Laboratory Billed by Outpatient Hospital   86586 - UNLISTED ANTIGEN, EACH            M             07/01/2006        $18.97
I - Laboratory Billed by Physician86586        86586 - UNLISTED ANTIGEN, EACH            M             07/01/2006        $18.97
5 - Independent Laboratory        86590        86590 - STREPTOKINASE, ANTIBODY           M             07/01/2006        $11.61
                                  86590
H - Laboratory Billed by Outpatient Hospital   86590 - STREPTOKINASE, ANTIBODY           M             07/01/2006        $11.61
I - Laboratory Billed by Physician86590        86590 - STREPTOKINASE, ANTIBODY           M             07/01/2006        $11.61
5 - Independent Laboratory        86592                                                  M
                                               86592 - SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART) 07/01/2006          $5.66
                                  86592
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86592 - SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART) 07/01/2006          $5.66
I - Laboratory Billed by Physician86592                                                  M
                                               86592 - SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART) 07/01/2006          $5.66
5 - Independent Laboratory        86593        86593 - SYPHILIS TEST; QUANTITATIVE       M             07/01/2006          $5.85
                                  86593
H - Laboratory Billed by Outpatient Hospital   86593 - SYPHILIS TEST; QUANTITATIVE       M             07/01/2006          $5.85
I - Laboratory Billed by Physician86593        86593 - SYPHILIS TEST; QUANTITATIVE       M             07/01/2006          $5.85
5 - Independent Laboratory        86600        86600 - TOXOPLASMOSIS, DYE TEST           M             08/01/1982        $23.00
5 - Independent Laboratory        86602        86602 - ANTIBODY; ACTINOMYCES             M             07/01/2006        $13.51
                                  86602
H - Laboratory Billed by Outpatient Hospital   86602 - ANTIBODY; ACTINOMYCES             M             07/01/2006        $13.51


 4/22/2012                                                    87 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing   Charge
I - Laboratory Billed by Physician86602        86602 - ANTIBODY; ACTINOMYCES            M            07/01/2006        $13.51
5 - Independent Laboratory        86603        86603 - ANTIBODY; ADENOVIRUS             M            07/01/2006        $17.08
                                  86603
H - Laboratory Billed by Outpatient Hospital   86603 - ANTIBODY; ADENOVIRUS             M            07/01/2006        $17.08
I - Laboratory Billed by Physician86603        86603 - ANTIBODY; ADENOVIRUS             M            07/01/2006        $17.08
5 - Independent Laboratory        86606        86606 - ANTIBODY; ASPERGILLUS            M            07/01/2006        $19.98
                                  86606
H - Laboratory Billed by Outpatient Hospital   86606 - ANTIBODY; ASPERGILLUS            M            07/01/2006        $19.98
I - Laboratory Billed by Physician86606        86606 - ANTIBODY; ASPERGILLUS            M            07/01/2006        $19.98
5 - Independent Laboratory        86609                                                 M
                                               86609 - ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED  07/01/2006        $17.10
                                  86609
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86609 - ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED  07/01/2006        $17.10
I - Laboratory Billed by Physician86609                                                 M
                                               86609 - ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED  07/01/2006        $17.10
5 - Independent Laboratory        86611        86611 - ANTIBODY; BARTONELLA             M            07/01/2006        $13.51
                                  86611
H - Laboratory Billed by Outpatient Hospital   86611 - ANTIBODY; BARTONELLA             M            07/01/2006        $13.51
I - Laboratory Billed by Physician86611        86611 - ANTIBODY; BARTONELLA             M            07/01/2006        $13.51
5 - Independent Laboratory        86612        86612 - ANTIBODY; BLASTOMYCES            M            07/01/2006        $17.13
                                  86612
H - Laboratory Billed by Outpatient Hospital   86612 - ANTIBODY; BLASTOMYCES            M            07/01/2006        $17.13
I - Laboratory Billed by Physician86612        86612 - ANTIBODY; BLASTOMYCES            M            07/01/2006        $17.13
5 - Independent Laboratory        86615        86615 - ANTIBODY; BORDETELLA             M            07/01/2006        $17.51
                                  86615
H - Laboratory Billed by Outpatient Hospital   86615 - ANTIBODY; BORDETELLA             M            07/01/2006        $17.51
I - Laboratory Billed by Physician86615        86615 - ANTIBODY; BORDETELLA             M            07/01/2006        $17.51
5 - Independent Laboratory        86617        86617 - ANTIBODY; BORRELIA BURGDORFERIM               07/01/2006        $20.56
                                                                                        (LYME DISEASE) CONFIRMATORY TEST (EG, WESTERN B
                                  86617
H - Laboratory Billed by Outpatient Hospital   86617 - ANTIBODY; BORRELIA BURGDORFERIM               07/01/2006        $20.56
                                                                                        (LYME DISEASE) CONFIRMATORY TEST (EG, WESTERN B
I - Laboratory Billed by Physician86617        86617 - ANTIBODY; BORRELIA BURGDORFERIM               07/01/2006        $20.56
                                                                                        (LYME DISEASE) CONFIRMATORY TEST (EG, WESTERN B
5 - Independent Laboratory        86618        86618 - ANTIBODY; BORRELIA BURGDORFERIM               07/01/2006
                                                                                        (LYME DISEASE)                 $22.61
                                  86618
H - Laboratory Billed by Outpatient Hospital   86618 - ANTIBODY; BORRELIA BURGDORFERIM               07/01/2006
                                                                                        (LYME DISEASE)                 $22.61
I - Laboratory Billed by Physician86618        86618 - ANTIBODY; BORRELIA BURGDORFERIM               07/01/2006
                                                                                        (LYME DISEASE)                 $22.61
5 - Independent Laboratory        86619                                                 M
                                               86619 - ANTIBODY; BORRELIA (RELAPSING FEVER)          07/01/2006        $17.76
                                  86619
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86619 - ANTIBODY; BORRELIA (RELAPSING FEVER)          07/01/2006        $17.76
I - Laboratory Billed by Physician86619                                                 M
                                               86619 - ANTIBODY; BORRELIA (RELAPSING FEVER)          07/01/2006        $17.76
5 - Independent Laboratory        86622        86622 - ANTIBODY; BRUCELLA               M            07/01/2006        $11.86
                                  86622
H - Laboratory Billed by Outpatient Hospital   86622 - ANTIBODY; BRUCELLA               M            07/01/2006        $11.86
I - Laboratory Billed by Physician86622        86622 - ANTIBODY; BRUCELLA               M            07/01/2006        $11.86
5 - Independent Laboratory        86625        86625 - ANTIBODY; CAMPYLOBACTER          M            07/01/2006        $17.41
                                  86625
H - Laboratory Billed by Outpatient Hospital   86625 - ANTIBODY; CAMPYLOBACTER          M            07/01/2006        $17.41
I - Laboratory Billed by Physician86625        86625 - ANTIBODY; CAMPYLOBACTER          M            07/01/2006        $17.41
5 - Independent Laboratory        86628        86628 - ANTIBODY; CANDIDA                M            07/01/2006        $15.94
                                  86628
H - Laboratory Billed by Outpatient Hospital   86628 - ANTIBODY; CANDIDA                M            07/01/2006        $15.94
I - Laboratory Billed by Physician86628        86628 - ANTIBODY; CANDIDA                M            07/01/2006        $15.94
5 - Independent Laboratory        86631        86631 - ANTIBODY; CHLAMYDIA              M            07/01/2006        $15.69
                                  86631
H - Laboratory Billed by Outpatient Hospital   86631 - ANTIBODY; CHLAMYDIA              M            07/01/2006        $15.69
I - Laboratory Billed by Physician86631        86631 - ANTIBODY; CHLAMYDIA              M            07/01/2006        $15.69
5 - Independent Laboratory        86632        86632 - ANTIBODY; CHLAMYDIA, IGM         M            07/01/2006        $16.85
                                  86632
H - Laboratory Billed by Outpatient Hospital   86632 - ANTIBODY; CHLAMYDIA, IGM         M            07/01/2006        $16.85
I - Laboratory Billed by Physician86632        86632 - ANTIBODY; CHLAMYDIA, IGM         M            07/01/2006        $16.85
5 - Independent Laboratory        86635        86635 - ANTIBODY; COCCIDIOIDES           M            07/01/2006        $15.23
                                  86635
H - Laboratory Billed by Outpatient Hospital   86635 - ANTIBODY; COCCIDIOIDES           M            07/01/2006        $15.23
I - Laboratory Billed by Physician86635        86635 - ANTIBODY; COCCIDIOIDES           M            07/01/2006        $15.23
5 - Independent Laboratory        86638                                                 M
                                               86638 - ANTIBODY; COXIELLA BURNETII (Q FEVER)         07/01/2006        $16.09
                                  86638
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86638 - ANTIBODY; COXIELLA BURNETII (Q FEVER)         07/01/2006        $16.09
I - Laboratory Billed by Physician86638                                                 M
                                               86638 - ANTIBODY; COXIELLA BURNETII (Q FEVER)         07/01/2006        $16.09
5 - Independent Laboratory        86641        86641 - ANTIBODY; CRYPTOCOCCUS           M            07/01/2006        $19.13
                                  86641
H - Laboratory Billed by Outpatient Hospital   86641 - ANTIBODY; CRYPTOCOCCUS           M            07/01/2006        $19.13
I - Laboratory Billed by Physician86641        86641 - ANTIBODY; CRYPTOCOCCUS           M            07/01/2006        $19.13
5 - Independent Laboratory        86644        86644 - ANTIBODY; CYTOMEGALOVIRUS (CMV)  M            07/01/2006        $19.10
                                  86644
H - Laboratory Billed by Outpatient Hospital   86644 - ANTIBODY; CYTOMEGALOVIRUS (CMV)  M            07/01/2006        $19.10
I - Laboratory Billed by Physician86644        86644 - ANTIBODY; CYTOMEGALOVIRUS (CMV)  M            07/01/2006        $19.10
5 - Independent Laboratory        86645                                                 M
                                               86645 - ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM          07/01/2006        $22.36


 4/22/2012                                                    88 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH     Pricing   Charge
                                  86645
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86645 - ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM           07/01/2006        $22.36
I - Laboratory Billed by Physician86645                                                  M
                                               86645 - ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM           07/01/2006        $22.36
5 - Independent Laboratory        86648        86648 - ANTIBODY; DIPHTHERIA              M            07/01/2006        $20.19
                                  86648
H - Laboratory Billed by Outpatient Hospital   86648 - ANTIBODY; DIPHTHERIA              M            07/01/2006        $20.19
I - Laboratory Billed by Physician86648        86648 - ANTIBODY; DIPHTHERIA              M            07/01/2006        $20.19
5 - Independent Laboratory        86651                                                  M
                                               86651 - ANTIBODY; ENCEPHALITIS, CALIFORNIA (LA CROSSE) 07/01/2006        $17.51
                                  86651
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86651 - ANTIBODY; ENCEPHALITIS, CALIFORNIA (LA CROSSE) 07/01/2006        $17.51
I - Laboratory Billed by Physician86651                                                  M
                                               86651 - ANTIBODY; ENCEPHALITIS, CALIFORNIA (LA CROSSE) 07/01/2006        $17.51
5 - Independent Laboratory        86652        86652 - ANTIBODY; ENCEPHALITIS, EASTERN M EQUINE       07/01/2006        $17.51
                                  86652
H - Laboratory Billed by Outpatient Hospital   86652 - ANTIBODY; ENCEPHALITIS, EASTERN M EQUINE       07/01/2006        $17.51
I - Laboratory Billed by Physician86652        86652 - ANTIBODY; ENCEPHALITIS, EASTERN M EQUINE       07/01/2006        $17.51
5 - Independent Laboratory        86653        86653 - ANTIBODY; ENCEPHALITIS, ST. LOUIS M            07/01/2006        $17.51
                                  86653
H - Laboratory Billed by Outpatient Hospital   86653 - ANTIBODY; ENCEPHALITIS, ST. LOUIS M            07/01/2006        $17.51
I - Laboratory Billed by Physician86653        86653 - ANTIBODY; ENCEPHALITIS, ST. LOUIS M            07/01/2006        $17.51
5 - Independent Laboratory        86654        86654 - ANTIBODY; ENCEPHALITIS, WESTERNM  EQUINE       07/01/2006        $17.51
                                  86654
H - Laboratory Billed by Outpatient Hospital   86654 - ANTIBODY; ENCEPHALITIS, WESTERNM  EQUINE       07/01/2006        $17.51
I - Laboratory Billed by Physician86654        86654 - ANTIBODY; ENCEPHALITIS, WESTERNM  EQUINE       07/01/2006        $17.51
5 - Independent Laboratory        86658                                                  M            07/01/2006
                                               86658 - ANTIBODY; ENTEROVIRUS (EG, COXSACKIE, ECHO, POLIO)               $17.29
                                  86658
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               86658 - ANTIBODY; ENTEROVIRUS (EG, COXSACKIE, ECHO, POLIO)               $17.29
I - Laboratory Billed by Physician86658                                                  M            07/01/2006
                                               86658 - ANTIBODY; ENTEROVIRUS (EG, COXSACKIE, ECHO, POLIO)               $17.29
5 - Independent Laboratory        86663                                                  M            07/01/2006
                                               86663 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA)            $17.41
                                  86663
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               86663 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA)            $17.41
I - Laboratory Billed by Physician86663                                                  M            07/01/2006
                                               86663 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA)            $17.41
5 - Independent Laboratory        86664                                                  M            07/01/2006
                                               86664 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)        $20.31
                                  86664
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               86664 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)        $20.31
I - Laboratory Billed by Physician86664                                                  M            07/01/2006
                                               86664 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)        $20.31
5 - Independent Laboratory        86665                                                  M            07/01/2006
                                               86665 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)            $24.08
                                  86665
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               86665 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)            $24.08
I - Laboratory Billed by Physician86665                                                  M            07/01/2006
                                               86665 - ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)            $24.08
5 - Independent Laboratory        86666        86666 - ANTIBODY; EHRLICHIA               M            07/01/2006        $13.51
                                  86666
H - Laboratory Billed by Outpatient Hospital   86666 - ANTIBODY; EHRLICHIA               M            07/01/2006        $13.51
I - Laboratory Billed by Physician86666        86666 - ANTIBODY; EHRLICHIA               M            07/01/2006        $13.51
5 - Independent Laboratory        86668        86668 - ANTIBODY; FRANCISELLA TULARENSIS  M            07/01/2006        $13.80
                                  86668
H - Laboratory Billed by Outpatient Hospital   86668 - ANTIBODY; FRANCISELLA TULARENSIS  M            07/01/2006        $13.80
I - Laboratory Billed by Physician86668        86668 - ANTIBODY; FRANCISELLA TULARENSIS  M            07/01/2006        $13.80
5 - Independent Laboratory        86671                                                  M
                                               86671 - ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED 07/01/2006             $16.27
                                  86671
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86671 - ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED 07/01/2006             $16.27
I - Laboratory Billed by Physician86671                                                  M
                                               86671 - ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED 07/01/2006             $16.27
5 - Independent Laboratory        86674        86674 - ANTIBODY; GIARDIA LAMBLIA         M            07/01/2006        $19.53
                                  86674
H - Laboratory Billed by Outpatient Hospital   86674 - ANTIBODY; GIARDIA LAMBLIA         M            07/01/2006        $19.53
I - Laboratory Billed by Physician86674        86674 - ANTIBODY; GIARDIA LAMBLIA         M            07/01/2006        $19.53
5 - Independent Laboratory        86677        86677 - ANTIBODY; HELICOBACTER PYLORI M                07/01/2006        $19.27
                                  86677
H - Laboratory Billed by Outpatient Hospital   86677 - ANTIBODY; HELICOBACTER PYLORI M                07/01/2006        $19.27
I - Laboratory Billed by Physician86677        86677 - ANTIBODY; HELICOBACTER PYLORI M                07/01/2006        $19.27
5 - Independent Laboratory        86682                                                  M
                                               86682 - ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED07/01/2006            $17.26
                                  86682
H - Laboratory Billed by Outpatient Hospital                                             M
                                               86682 - ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED07/01/2006            $17.26
I - Laboratory Billed by Physician86682                                                  M
                                               86682 - ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED07/01/2006            $17.26
5 - Independent Laboratory        86684        86684 - ANTIBODY; HAEMOPHILUS INFLUENZA   M            07/01/2006        $21.03
                                  86684
H - Laboratory Billed by Outpatient Hospital   86684 - ANTIBODY; HAEMOPHILUS INFLUENZA   M            07/01/2006        $21.03
I - Laboratory Billed by Physician86684        86684 - ANTIBODY; HAEMOPHILUS INFLUENZA   M            07/01/2006        $21.03
5 - Independent Laboratory        86687        86687 - ANTIBODY; HTLV-I                  M            07/01/2006        $11.13
                                  86687
H - Laboratory Billed by Outpatient Hospital   86687 - ANTIBODY; HTLV-I                  M            07/01/2006        $11.13
I - Laboratory Billed by Physician86687        86687 - ANTIBODY; HTLV-I                  M            07/01/2006        $11.13
5 - Independent Laboratory        86688        86688 - ANTIBODY; HTLV-II                 M            07/01/2006        $18.59
                                  86688
H - Laboratory Billed by Outpatient Hospital   86688 - ANTIBODY; HTLV-II                 M            07/01/2006        $18.59
I - Laboratory Billed by Physician86688        86688 - ANTIBODY; HTLV-II                 M            07/01/2006        $18.59


 4/22/2012                                                     89 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        86689                                                   M           07/01/2006          BLOT)
                                               86689 - ANTIBODY; HTLV OR HIV ANTIBODY, CONFIRMATORY TEST (EG, WESTERN$25.70
                                  86689
H - Laboratory Billed by Outpatient Hospital                                              M           07/01/2006          BLOT)
                                               86689 - ANTIBODY; HTLV OR HIV ANTIBODY, CONFIRMATORY TEST (EG, WESTERN$25.70
I - Laboratory Billed by Physician86689                                                   M           07/01/2006          BLOT)
                                               86689 - ANTIBODY; HTLV OR HIV ANTIBODY, CONFIRMATORY TEST (EG, WESTERN$25.70
5 - Independent Laboratory        86692        86692 - ANTIBODY; HEPATITIS, DELTA AGENT M             07/01/2006        $22.78
                                  86692
H - Laboratory Billed by Outpatient Hospital   86692 - ANTIBODY; HEPATITIS, DELTA AGENT M             07/01/2006        $22.78
I - Laboratory Billed by Physician86692        86692 - ANTIBODY; HEPATITIS, DELTA AGENT M             07/01/2006        $22.78
5 - Independent Laboratory        86694                                                   M           07/01/2006
                                               86694 - ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST                 $19.10
                                  86694
H - Laboratory Billed by Outpatient Hospital                                              M           07/01/2006
                                               86694 - ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST                 $19.10
I - Laboratory Billed by Physician86694                                                   M           07/01/2006
                                               86694 - ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST                 $19.10
5 - Independent Laboratory        86695        86695 - ANTIBODY; HERPES SIMPLEX, TYPE 1 M             07/01/2006        $17.51
                                  86695
H - Laboratory Billed by Outpatient Hospital   86695 - ANTIBODY; HERPES SIMPLEX, TYPE 1 M             07/01/2006        $17.51
I - Laboratory Billed by Physician86695        86695 - ANTIBODY; HERPES SIMPLEX, TYPE 1 M             07/01/2006        $17.51
5 - Independent Laboratory        86696        86696 - ANTIBODY; HERPES SIMPLEX, TYPE 2 M             07/01/2006        $25.70
                                  86696
H - Laboratory Billed by Outpatient Hospital   86696 - ANTIBODY; HERPES SIMPLEX, TYPE 2 M             07/01/2006        $25.70
I - Laboratory Billed by Physician86696        86696 - ANTIBODY; HERPES SIMPLEX, TYPE 2 M             07/01/2006        $25.70
5 - Independent Laboratory        86698        86698 - ANTIBODY; HISTOPLASMA              M           07/01/2006        $16.59
                                  86698
H - Laboratory Billed by Outpatient Hospital   86698 - ANTIBODY; HISTOPLASMA              M           07/01/2006        $16.59
I - Laboratory Billed by Physician86698        86698 - ANTIBODY; HISTOPLASMA              M           07/01/2006        $16.59
5 - Independent Laboratory        86701        86701 - ANTIBODY; HIV-1                    M           07/01/2006        $11.79
                                  86701
H - Laboratory Billed by Outpatient Hospital   86701 - ANTIBODY; HIV-1                    M           07/01/2006        $11.79
I - Laboratory Billed by Physician86701        86701 - ANTIBODY; HIV-1                    M           07/01/2006        $11.79
5 - Independent Laboratory        86702        86702 - ANTIBODY; HIV-2                    M           07/01/2006        $17.94
                                  86702
H - Laboratory Billed by Outpatient Hospital   86702 - ANTIBODY; HIV-2                    M           07/01/2006        $17.94
I - Laboratory Billed by Physician86702        86702 - ANTIBODY; HIV-2                    M           07/01/2006        $17.94
5 - Independent Laboratory        86703                                                   M
                                               86703 - ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY        07/01/2006        $18.21
                                  86703
H - Laboratory Billed by Outpatient Hospital                                              M
                                               86703 - ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY        07/01/2006        $18.21
I - Laboratory Billed by Physician86703                                                   M
                                               86703 - ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY        07/01/2006        $18.21
5 - Independent Laboratory        86704                                                   M
                                               86704 - HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL       07/01/2006        $16.00
                                  86704
H - Laboratory Billed by Outpatient Hospital                                              M
                                               86704 - HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL       07/01/2006        $16.00
I - Laboratory Billed by Physician86704                                                   M
                                               86704 - HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL       07/01/2006        $16.00
5 - Independent Laboratory        86705                                                   M
                                               86705 - HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY07/01/2006        $15.62
                                  86705
H - Laboratory Billed by Outpatient Hospital                                              M
                                               86705 - HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY07/01/2006        $15.62
I - Laboratory Billed by Physician86705                                                   M
                                               86705 - HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY07/01/2006        $15.62
5 - Independent Laboratory        86706                                                   M
                                               86706 - HEPATITIS B SURFACE ANTIBODY (HBSAB)           07/01/2006        $14.26
                                  86706
H - Laboratory Billed by Outpatient Hospital                                              M
                                               86706 - HEPATITIS B SURFACE ANTIBODY (HBSAB)           07/01/2006        $14.26
I - Laboratory Billed by Physician86706                                                   M
                                               86706 - HEPATITIS B SURFACE ANTIBODY (HBSAB)           07/01/2006        $14.26
5 - Independent Laboratory        86707        86707 - HEPATITIS BE ANTIBODY (HBEAB)      M           07/01/2006        $15.35
                                  86707
H - Laboratory Billed by Outpatient Hospital   86707 - HEPATITIS BE ANTIBODY (HBEAB)      M           07/01/2006        $15.35
I - Laboratory Billed by Physician86707        86707 - HEPATITIS BE ANTIBODY (HBEAB)      M           07/01/2006        $15.35
5 - Independent Laboratory        86708        86708 - HEPATITIS A ANTIBODY (HAAB); TOTAL M           07/01/2006        $16.44
                                  86708
H - Laboratory Billed by Outpatient Hospital   86708 - HEPATITIS A ANTIBODY (HAAB); TOTAL M           07/01/2006        $16.44
I - Laboratory Billed by Physician86708        86708 - HEPATITIS A ANTIBODY (HAAB); TOTAL M           07/01/2006        $16.44
5 - Independent Laboratory        86709                                                   M
                                               86709 - HEPATITIS A ANTIBODY (HAAB); IGM ANTIBODY      07/01/2006        $14.94
                                  86709
H - Laboratory Billed by Outpatient Hospital                                              M
                                               86709 - HEPATITIS A ANTIBODY (HAAB); IGM ANTIBODY      07/01/2006        $14.94
I - Laboratory Billed by Physician86709                                                   M
                                               86709 - HEPATITIS A ANTIBODY (HAAB); IGM ANTIBODY      07/01/2006        $14.94
5 - Independent Laboratory        86710        86710 - ANTIBODY; INFLUENZA VIRUS          M           07/01/2006        $17.99
                                  86710
H - Laboratory Billed by Outpatient Hospital   86710 - ANTIBODY; INFLUENZA VIRUS          M           07/01/2006        $17.99
I - Laboratory Billed by Physician86710        86710 - ANTIBODY; INFLUENZA VIRUS          M           07/01/2006        $17.99
5 - Independent Laboratory        86713        86713 - ANTIBODY; LEGIONELLA               M           07/01/2006        $20.32
                                  86713
H - Laboratory Billed by Outpatient Hospital   86713 - ANTIBODY; LEGIONELLA               M           07/01/2006        $20.32
I - Laboratory Billed by Physician86713        86713 - ANTIBODY; LEGIONELLA               M           07/01/2006        $20.32
5 - Independent Laboratory        86717        86717 - ANTIBODY; LEISHMANIA               M           07/01/2006        $16.26
                                  86717
H - Laboratory Billed by Outpatient Hospital   86717 - ANTIBODY; LEISHMANIA               M           07/01/2006        $16.26
I - Laboratory Billed by Physician86717        86717 - ANTIBODY; LEISHMANIA               M           07/01/2006        $16.26
5 - Independent Laboratory        86720        86720 - ANTIBODY; LEPTOSPIRA               M           07/01/2006        $17.51
                                  86720
H - Laboratory Billed by Outpatient Hospital   86720 - ANTIBODY; LEPTOSPIRA               M           07/01/2006        $17.51


 4/22/2012                                                     90 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3      Level 3     LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing       Charge
I - Laboratory Billed by Physician86720        86720 - ANTIBODY; LEPTOSPIRA             M           07/01/2006            $17.51
5 - Independent Laboratory        86723        86723 - ANTIBODY; LISTERIA MONOCYTOGENES M           07/01/2006            $17.51
                                  86723
H - Laboratory Billed by Outpatient Hospital   86723 - ANTIBODY; LISTERIA MONOCYTOGENES M           07/01/2006            $17.51
I - Laboratory Billed by Physician86723        86723 - ANTIBODY; LISTERIA MONOCYTOGENES M           07/01/2006            $17.51
5 - Independent Laboratory        86727                                                 M
                                               86727 - ANTIBODY; LYMPHOCYTIC CHORIOMENINGITIS       07/01/2006            $17.08
                                  86727
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86727 - ANTIBODY; LYMPHOCYTIC CHORIOMENINGITIS       07/01/2006            $17.08
I - Laboratory Billed by Physician86727                                                 M
                                               86727 - ANTIBODY; LYMPHOCYTIC CHORIOMENINGITIS       07/01/2006            $17.08
5 - Independent Laboratory        86729                                                 M
                                               86729 - ANTIBODY; LYMPHOGRANULOMA VENEREUM           07/01/2006            $15.86
                                  86729
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86729 - ANTIBODY; LYMPHOGRANULOMA VENEREUM           07/01/2006            $15.86
I - Laboratory Billed by Physician86729                                                 M
                                               86729 - ANTIBODY; LYMPHOGRANULOMA VENEREUM           07/01/2006            $15.86
5 - Independent Laboratory        86732        86732 - ANTIBODY; MUCORMYCOSIS           M           07/01/2006            $17.51
                                  86732
H - Laboratory Billed by Outpatient Hospital   86732 - ANTIBODY; MUCORMYCOSIS           M           07/01/2006            $17.51
I - Laboratory Billed by Physician86732        86732 - ANTIBODY; MUCORMYCOSIS           M           07/01/2006            $17.51
5 - Independent Laboratory        86735        86735 - ANTIBODY; MUMPS                  M           07/01/2006            $17.32
                                  86735
H - Laboratory Billed by Outpatient Hospital   86735 - ANTIBODY; MUMPS                  M           07/01/2006            $17.32
I - Laboratory Billed by Physician86735        86735 - ANTIBODY; MUMPS                  M           07/01/2006            $17.32
5 - Independent Laboratory        86738        86738 - ANTIBODY; MYCOPLASMA             M           07/01/2006            $17.58
                                  86738
H - Laboratory Billed by Outpatient Hospital   86738 - ANTIBODY; MYCOPLASMA             M           07/01/2006            $17.58
I - Laboratory Billed by Physician86738        86738 - ANTIBODY; MYCOPLASMA             M           07/01/2006            $17.58
5 - Independent Laboratory        86741        86741 - ANTIBODY; NEISSERIA MENINGITIDIS M           07/01/2006            $17.51
                                  86741
H - Laboratory Billed by Outpatient Hospital   86741 - ANTIBODY; NEISSERIA MENINGITIDIS M           07/01/2006            $17.51
I - Laboratory Billed by Physician86741        86741 - ANTIBODY; NEISSERIA MENINGITIDIS M           07/01/2006            $17.51
5 - Independent Laboratory        86744        86744 - ANTIBODY; NOCARDIA               M           07/01/2006            $17.51
                                  86744
H - Laboratory Billed by Outpatient Hospital   86744 - ANTIBODY; NOCARDIA               M           07/01/2006            $17.51
I - Laboratory Billed by Physician86744        86744 - ANTIBODY; NOCARDIA               M           07/01/2006            $17.51
5 - Independent Laboratory        86747        86747 - ANTIBODY; PARVOVIRUS             M           07/01/2006            $19.95
                                  86747
H - Laboratory Billed by Outpatient Hospital   86747 - ANTIBODY; PARVOVIRUS             M           07/01/2006            $19.95
I - Laboratory Billed by Physician86747        86747 - ANTIBODY; PARVOVIRUS             M           07/01/2006            $19.95
5 - Independent Laboratory        86750        86750 - ANTIBODY; PLASMODIUM (MALARIA) M             07/01/2006            $17.51
                                  86750
H - Laboratory Billed by Outpatient Hospital   86750 - ANTIBODY; PLASMODIUM (MALARIA) M             07/01/2006            $17.51
I - Laboratory Billed by Physician86750        86750 - ANTIBODY; PLASMODIUM (MALARIA) M             07/01/2006            $17.51
5 - Independent Laboratory        86753                                                 M
                                               86753 - ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED  07/01/2006            $16.45
                                  86753
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86753 - ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED  07/01/2006            $16.45
I - Laboratory Billed by Physician86753                                                 M
                                               86753 - ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED  07/01/2006            $16.45
5 - Independent Laboratory        86756        86756 - ANTIBODY; RESPIRATORY SYNCYTIALM  VIRUS      07/01/2006            $17.11
                                  86756
H - Laboratory Billed by Outpatient Hospital   86756 - ANTIBODY; RESPIRATORY SYNCYTIALM  VIRUS      07/01/2006            $17.11
I - Laboratory Billed by Physician86756        86756 - ANTIBODY; RESPIRATORY SYNCYTIALM  VIRUS      07/01/2006            $17.11
5 - Independent Laboratory        86757        86757 - ANTIBODY; RICKETTSIA             M           07/01/2006            $25.70
                                  86757
H - Laboratory Billed by Outpatient Hospital   86757 - ANTIBODY; RICKETTSIA             M           07/01/2006            $25.70
I - Laboratory Billed by Physician86757        86757 - ANTIBODY; RICKETTSIA             M           07/01/2006            $25.70
5 - Independent Laboratory        86759        86759 - ANTIBODY; ROTAVIRUS              M           07/01/2006            $17.51
                                  86759
H - Laboratory Billed by Outpatient Hospital   86759 - ANTIBODY; ROTAVIRUS              M           07/01/2006            $17.51
I - Laboratory Billed by Physician86759        86759 - ANTIBODY; ROTAVIRUS              M           07/01/2006            $17.51
5 - Independent Laboratory        86762        86762 - ANTIBODY; RUBELLA                M           07/01/2006            $19.10
                                  86762
H - Laboratory Billed by Outpatient Hospital   86762 - ANTIBODY; RUBELLA                M           07/01/2006            $19.10
I - Laboratory Billed by Physician86762        86762 - ANTIBODY; RUBELLA                M           07/01/2006            $19.10
5 - Independent Laboratory        86765        86765 - ANTIBODY; RUBEOLA                M           07/01/2006            $17.10
                                  86765
H - Laboratory Billed by Outpatient Hospital   86765 - ANTIBODY; RUBEOLA                M           07/01/2006            $17.10
I - Laboratory Billed by Physician86765        86765 - ANTIBODY; RUBEOLA                M           07/01/2006            $17.10
5 - Independent Laboratory        86768        86768 - ANTIBODY; SALMONELLA             M           07/01/2006            $17.51
                                  86768
H - Laboratory Billed by Outpatient Hospital   86768 - ANTIBODY; SALMONELLA             M           07/01/2006            $17.51
I - Laboratory Billed by Physician86768        86768 - ANTIBODY; SALMONELLA             M           07/01/2006            $17.51
5 - Independent Laboratory        86771        86771 - ANTIBODY; SHIGELLA               M           07/01/2006            $17.51
                                  86771
H - Laboratory Billed by Outpatient Hospital   86771 - ANTIBODY; SHIGELLA               M           07/01/2006            $17.51
I - Laboratory Billed by Physician86771        86771 - ANTIBODY; SHIGELLA               M           07/01/2006            $17.51
5 - Independent Laboratory        86774        86774 - ANTIBODY; TETANUS                M           07/01/2006            $19.65


 4/22/2012                                                     91 of 489                ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                       Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                   Medicaid/BH      Pricing   Charge
                                  86774
H - Laboratory Billed by Outpatient Hospital   86774 - ANTIBODY; TETANUS                    M             07/01/2006        $19.65
I - Laboratory Billed by Physician86774        86774 - ANTIBODY; TETANUS                    M             07/01/2006        $19.65
5 - Independent Laboratory        86777        86777 - ANTIBODY; TOXOPLASMA                 M             07/01/2006        $19.10
                                  86777
H - Laboratory Billed by Outpatient Hospital   86777 - ANTIBODY; TOXOPLASMA                 M             07/01/2006        $19.10
I - Laboratory Billed by Physician86777        86777 - ANTIBODY; TOXOPLASMA                 M             07/01/2006        $19.10
5 - Independent Laboratory        86778        86778 - ANTIBODY; TOXOPLASMA, IGM            M             07/01/2006        $19.11
                                  86778
H - Laboratory Billed by Outpatient Hospital   86778 - ANTIBODY; TOXOPLASMA, IGM            M             07/01/2006        $19.11
I - Laboratory Billed by Physician86778        86778 - ANTIBODY; TOXOPLASMA, IGM            M             07/01/2006        $19.11
5 - Independent Laboratory        86781                                                     M             07/01/2006
                                               86781 - ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA-ABS) $17.58
                                  86781
H - Laboratory Billed by Outpatient Hospital                                                M             07/01/2006
                                               86781 - ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA-ABS) $17.58
I - Laboratory Billed by Physician86781                                                     M             07/01/2006
                                               86781 - ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA-ABS) $17.58
5 - Independent Laboratory        86784        86784 - ANTIBODY; TRICHINELLA                M             07/01/2006        $16.67
                                  86784
H - Laboratory Billed by Outpatient Hospital   86784 - ANTIBODY; TRICHINELLA                M             07/01/2006        $16.67
I - Laboratory Billed by Physician86784        86784 - ANTIBODY; TRICHINELLA                M             07/01/2006        $16.67
5 - Independent Laboratory        86787        86787 - ANTIBODY; VARICELLA-ZOSTER           M             07/01/2006        $17.10
                                  86787
H - Laboratory Billed by Outpatient Hospital   86787 - ANTIBODY; VARICELLA-ZOSTER           M             07/01/2006        $17.10
I - Laboratory Billed by Physician86787        86787 - ANTIBODY; VARICELLA-ZOSTER           M             07/01/2006        $17.10
5 - Independent Laboratory        86788        86788 - ANTIBODY; WEST NILE VIRUS, IGM       M             01/01/2007        $22.36
                                  86788
H - Laboratory Billed by Outpatient Hospital   86788 - ANTIBODY; WEST NILE VIRUS, IGM       M             01/01/2007        $22.36
I - Laboratory Billed by Physician86788        86788 - ANTIBODY; WEST NILE VIRUS, IGM       M             01/01/2007        $22.36
5 - Independent Laboratory        86789        86789 - ANTIBODY; WEST NILE VIRUS            M             01/01/2007        $19.10
                                  86789
H - Laboratory Billed by Outpatient Hospital   86789 - ANTIBODY; WEST NILE VIRUS            M             01/01/2007        $19.10
I - Laboratory Billed by Physician86789        86789 - ANTIBODY; WEST NILE VIRUS            M             01/01/2007        $19.10
5 - Independent Laboratory        86790                                                     M
                                               86790 - ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED           07/01/2006        $17.10
                                  86790
H - Laboratory Billed by Outpatient Hospital                                                M
                                               86790 - ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED           07/01/2006        $17.10
I - Laboratory Billed by Physician86790                                                     M
                                               86790 - ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED           07/01/2006        $17.10
5 - Independent Laboratory        86793        86793 - ANTIBODY; YERSINIA                   M             07/01/2006        $17.51
                                  86793
H - Laboratory Billed by Outpatient Hospital   86793 - ANTIBODY; YERSINIA                   M             07/01/2006        $17.51
I - Laboratory Billed by Physician86793        86793 - ANTIBODY; YERSINIA                   M             07/01/2006        $17.51
5 - Independent Laboratory        86800        86800 - THYROGLOBULIN ANTIBODY               M             07/01/2006        $19.27
                                  86800
H - Laboratory Billed by Outpatient Hospital   86800 - THYROGLOBULIN ANTIBODY               M             07/01/2006        $19.27
I - Laboratory Billed by Physician86800        86800 - THYROGLOBULIN ANTIBODY               M             07/01/2006        $19.27
5 - Independent Laboratory        86803        86803 - HEPATITIS C ANTIBODY;                M             07/01/2006        $18.94
                                  86803
H - Laboratory Billed by Outpatient Hospital   86803 - HEPATITIS C ANTIBODY;                M             07/01/2006        $18.94
I - Laboratory Billed by Physician86803        86803 - HEPATITIS C ANTIBODY;                M             07/01/2006        $18.94
5 - Independent Laboratory        86804                                                     M             IMMUNOBLOT)
                                               86804 - HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, 07/01/2006              $20.56
                                  86804
H - Laboratory Billed by Outpatient Hospital                                                M             IMMUNOBLOT)
                                               86804 - HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, 07/01/2006              $20.56
I - Laboratory Billed by Physician86804                                                     M             IMMUNOBLOT)
                                               86804 - HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, 07/01/2006              $20.56
5 - Independent Laboratory        86805                                                     M             07/01/2006
                                               86805 - LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITH TITRATION $69.40
                                  86805
H - Laboratory Billed by Outpatient Hospital                                                M             07/01/2006
                                               86805 - LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITH TITRATION $69.40
I - Laboratory Billed by Physician86805                                                     M             07/01/2006
                                               86805 - LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITH TITRATION $69.40
5 - Independent Laboratory        86806                                                     M             07/01/2006
                                               86806 - LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITHOUT TITRATION       $63.17
                                  86806
H - Laboratory Billed by Outpatient Hospital                                                M             07/01/2006
                                               86806 - LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITHOUT TITRATION       $63.17
I - Laboratory Billed by Physician86806                                                     M             07/01/2006
                                               86806 - LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITHOUT TITRATION       $63.17
5 - Independent Laboratory        86807        86807 - SERUM SCREENING FOR CYTOTOXIC M                    07/01/2006        $52.53
                                                                                             PERCENT REACTIVE ANTIBODY (PRA); STANDARD METH
                                  86807
H - Laboratory Billed by Outpatient Hospital   86807 - SERUM SCREENING FOR CYTOTOXIC M                    07/01/2006        $52.53
                                                                                             PERCENT REACTIVE ANTIBODY (PRA); STANDARD METH
I - Laboratory Billed by Physician86807        86807 - SERUM SCREENING FOR CYTOTOXIC M                    07/01/2006        $52.53
                                                                                             PERCENT REACTIVE ANTIBODY (PRA); STANDARD METH
5 - Independent Laboratory        86808        86808 - SERUM SCREENING FOR CYTOTOXIC M                    07/01/2006        $39.40
                                                                                             PERCENT REACTIVE ANTIBODY (PRA); QUICK METHOD
                                  86808
H - Laboratory Billed by Outpatient Hospital   86808 - SERUM SCREENING FOR CYTOTOXIC M                    07/01/2006        $39.40
                                                                                             PERCENT REACTIVE ANTIBODY (PRA); QUICK METHOD
I - Laboratory Billed by Physician86808        86808 - SERUM SCREENING FOR CYTOTOXIC M                    07/01/2006        $39.40
                                                                                             PERCENT REACTIVE ANTIBODY (PRA); QUICK METHOD
5 - Independent Laboratory        86812                                                     M             07/01/2006
                                               86812 - HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN            $34.26
                                  86812
H - Laboratory Billed by Outpatient Hospital                                                M             07/01/2006
                                               86812 - HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN            $34.26
I - Laboratory Billed by Physician86812                                                     M             07/01/2006
                                               86812 - HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN            $34.26
5 - Independent Laboratory        86813                                                     M
                                               86813 - HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS          07/01/2006        $76.97
                                  86813
H - Laboratory Billed by Outpatient Hospital                                                M
                                               86813 - HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS          07/01/2006        $76.97
I - Laboratory Billed by Physician86813                                                     M
                                               86813 - HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS          07/01/2006        $76.97


 4/22/2012                                                     92 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing     Charge
5 - Independent Laboratory        86816        86816 - HLA TYPING; DR/DQ, SINGLE ANTIGENM            07/01/2006          $36.97
                                  86816
H - Laboratory Billed by Outpatient Hospital   86816 - HLA TYPING; DR/DQ, SINGLE ANTIGENM            07/01/2006          $36.97
I - Laboratory Billed by Physician86816        86816 - HLA TYPING; DR/DQ, SINGLE ANTIGENM            07/01/2006          $36.97
5 - Independent Laboratory        86817                                                 M
                                               86817 - HLA TYPING; DR/DQ, MULTIPLE ANTIGENS          07/01/2006          $85.45
                                  86817
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86817 - HLA TYPING; DR/DQ, MULTIPLE ANTIGENS          07/01/2006          $85.45
I - Laboratory Billed by Physician86817                                                 M
                                               86817 - HLA TYPING; DR/DQ, MULTIPLE ANTIGENS          07/01/2006          $85.45
5 - Independent Laboratory        86821                                                 M
                                               86821 - HLA TYPING; LYMPHOCYTE CULTURE, MIXED (MLC) 07/01/2006            $74.94
                                  86821
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86821 - HLA TYPING; LYMPHOCYTE CULTURE, MIXED (MLC) 07/01/2006            $74.94
I - Laboratory Billed by Physician86821                                                 M
                                               86821 - HLA TYPING; LYMPHOCYTE CULTURE, MIXED (MLC) 07/01/2006            $74.94
5 - Independent Laboratory        86822                                                 M
                                               86822 - HLA TYPING; LYMPHOCYTE CULTURE, PRIMED (PLC)07/01/2006            $48.52
                                  86822
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86822 - HLA TYPING; LYMPHOCYTE CULTURE, PRIMED (PLC)07/01/2006            $48.52
I - Laboratory Billed by Physician86822                                                 M
                                               86822 - HLA TYPING; LYMPHOCYTE CULTURE, PRIMED (PLC)07/01/2006            $48.52
5 - Independent Laboratory        86850                                                 M
                                               86850 - ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE07/01/2006              $17.42
                                  86850
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86850 - ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE07/01/2006              $17.42
I - Laboratory Billed by Physician86850                                                 M
                                               86850 - ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE07/01/2006              $17.42
5 - Independent Laboratory        86860                                                 M
                                               86860 - ANTIBODY ELUTION (RBC), EACH ELUTION          07/01/2006          $23.66
                                  86860
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86860 - ANTIBODY ELUTION (RBC), EACH ELUTION          07/01/2006          $23.66
I - Laboratory Billed by Physician86860                                                 M
                                               86860 - ANTIBODY ELUTION (RBC), EACH ELUTION          07/01/2006          $23.66
5 - Independent Laboratory        86870                                                 M             PANEL FOR          $37.57
                                               86870 - ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH07/01/2006 EACH SERUM TECHNIQUE
                                  86870
H - Laboratory Billed by Outpatient Hospital                                            M             PANEL FOR          $37.57
                                               86870 - ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH07/01/2006 EACH SERUM TECHNIQUE
I - Laboratory Billed by Physician86870                                                 M             PANEL FOR          $37.57
                                               86870 - ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH07/01/2006 EACH SERUM TECHNIQUE
5 - Independent Laboratory        86880                                                 M            07/01/2006
                                               86880 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM $7.13
                                  86880
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86880 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM $7.13
I - Laboratory Billed by Physician86880                                                 M            07/01/2006
                                               86880 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM $7.13
5 - Independent Laboratory        86885                                                 M            07/01/2006           $7.59
                                               86885 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH ANTISERUM
                                  86885
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $7.59
                                               86885 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH ANTISERUM
I - Laboratory Billed by Physician86885                                                 M            07/01/2006           $7.59
                                               86885 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH ANTISERUM
5 - Independent Laboratory        86886                                                 M            07/01/2006           $6.87
                                               86886 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, TITER, EACH ANTISERUM
                                  86886
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $6.87
                                               86886 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, TITER, EACH ANTISERUM
I - Laboratory Billed by Physician86886                                                 M            07/01/2006           $6.87
                                               86886 - ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, TITER, EACH ANTISERUM
5 - Independent Laboratory        86890                                                 M            07/01/2006          $80.00
                                               86890 - AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND STORAGE; PREDEPO
                                  86890
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $80.00
                                               86890 - AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND STORAGE; PREDEPO
I - Laboratory Billed by Physician86890                                                 M            07/01/2006          $80.00
                                               86890 - AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND STORAGE; PREDEPO
5 - Independent Laboratory        86891                                                 M            07/01/2006
                                               86891 - AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND $125.00 STORAGE; INTRA- OR
                                  86891
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86891 - AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND $125.00 STORAGE; INTRA- OR
I - Laboratory Billed by Physician86891                                                 M            07/01/2006
                                               86891 - AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND $125.00 STORAGE; INTRA- OR
5 - Independent Laboratory        86900        86900 - BLOOD TYPING; ABO                M            07/01/2006           $3.96
                                  86900
H - Laboratory Billed by Outpatient Hospital   86900 - BLOOD TYPING; ABO                M            07/01/2006           $3.96
I - Laboratory Billed by Physician86900        86900 - BLOOD TYPING; ABO                M            07/01/2006           $3.96
5 - Independent Laboratory        86901        86901 - BLOOD TYPING; RH (D)             M            07/01/2006           $9.60
                                  86901
H - Laboratory Billed by Outpatient Hospital   86901 - BLOOD TYPING; RH (D)             M            07/01/2006           $9.60
I - Laboratory Billed by Physician86901        86901 - BLOOD TYPING; RH (D)             M            07/01/2006           $9.60
5 - Independent Laboratory        86903                                                 M            07/01/2006          $12.53
                                               86903 - BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE BLOOD UNIT USING REAGENT SERUM
                                  86903
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $12.53
                                               86903 - BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE BLOOD UNIT USING REAGENT SERUM
I - Laboratory Billed by Physician86903                                                 M            07/01/2006          $12.53
                                               86903 - BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE BLOOD UNIT USING REAGENT SERUM
5 - Independent Laboratory        86904                                                 M            07/01/2006          $12.62
                                               86904 - BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING PATIENT SERUM, PER UN
                                  86904
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $12.62
                                               86904 - BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING PATIENT SERUM, PER UN
I - Laboratory Billed by Physician86904                                                 M            07/01/2006          $12.62
                                               86904 - BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING PATIENT SERUM, PER UN
5 - Independent Laboratory        86905                                                 M            07/01/2006
                                               86905 - BLOOD TYPING; RBC ANTIGENS, OTHER THAN ABO OR RH (D), EACH         $5.07
                                  86905
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86905 - BLOOD TYPING; RBC ANTIGENS, OTHER THAN ABO OR RH (D), EACH         $5.07
I - Laboratory Billed by Physician86905                                                 M            07/01/2006
                                               86905 - BLOOD TYPING; RBC ANTIGENS, OTHER THAN ABO OR RH (D), EACH         $5.07
5 - Independent Laboratory        86906                                                 M
                                               86906 - BLOOD TYPING; RH PHENOTYPING, COMPLETE        07/01/2006          $10.29
                                  86906
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86906 - BLOOD TYPING; RH PHENOTYPING, COMPLETE        07/01/2006          $10.29
I - Laboratory Billed by Physician86906                                                 M
                                               86906 - BLOOD TYPING; RH PHENOTYPING, COMPLETE        07/01/2006          $10.29
5 - Independent Laboratory        86910                                                 M            07/01/2006          MN
                                               86910 - BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; ABO, RH AND $28.67
                                  86910
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          MN
                                               86910 - BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; ABO, RH AND $28.67


 4/22/2012                                                     93 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3      Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing     Charge
I - Laboratory Billed by Physician86910                                                 M            07/01/2006          MN
                                               86910 - BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; ABO, RH AND $28.67
5 - Independent Laboratory        86911                                                 M            07/01/2006           $8.14
                                               86911 - BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; EACH ADDITIONAL ANTIGEN SYST
                                  86911
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $8.14
                                               86911 - BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; EACH ADDITIONAL ANTIGEN SYST
I - Laboratory Billed by Physician86911                                                 M            07/01/2006           $8.14
                                               86911 - BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; EACH ADDITIONAL ANTIGEN SYST
5 - Independent Laboratory        86920                                                 M            07/01/2006
                                               86920 - COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE           $19.75
                                  86920
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86920 - COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE           $19.75
I - Laboratory Billed by Physician86920                                                 M            07/01/2006
                                               86920 - COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE           $19.75
5 - Independent Laboratory        86921                                                 M            07/01/2006
                                               86921 - COMPATIBILITY TEST EACH UNIT; INCUBATION TECHNIQUE               $20.00
                                  86921
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86921 - COMPATIBILITY TEST EACH UNIT; INCUBATION TECHNIQUE               $20.00
I - Laboratory Billed by Physician86921                                                 M            07/01/2006
                                               86921 - COMPATIBILITY TEST EACH UNIT; INCUBATION TECHNIQUE               $20.00
5 - Independent Laboratory        86922                                                 M            07/01/2006
                                               86922 - COMPATIBILITY TEST EACH UNIT; ANTIGLOBULIN TECHNIQUE             $12.00
                                  86922
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86922 - COMPATIBILITY TEST EACH UNIT; ANTIGLOBULIN TECHNIQUE             $12.00
I - Laboratory Billed by Physician86922                                                 M            07/01/2006
                                               86922 - COMPATIBILITY TEST EACH UNIT; ANTIGLOBULIN TECHNIQUE             $12.00
5 - Independent Laboratory        86923                                                 M
                                               86923 - COMPATIBILITY TEST EACH UNIT; ELECTRONIC      07/01/2006         $12.91
                                  86923
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86923 - COMPATIBILITY TEST EACH UNIT; ELECTRONIC      07/01/2006         $12.91
I - Laboratory Billed by Physician86923                                                 M
                                               86923 - COMPATIBILITY TEST EACH UNIT; ELECTRONIC      07/01/2006         $12.91
5 - Independent Laboratory        86927                                                 M
                                               86927 - FRESH FROZEN PLASMA, THAWING, EACH UNIT       07/01/2006         $11.00
                                  86927
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86927 - FRESH FROZEN PLASMA, THAWING, EACH UNIT       07/01/2006         $11.00
I - Laboratory Billed by Physician86927                                                 M
                                               86927 - FRESH FROZEN PLASMA, THAWING, EACH UNIT       07/01/2006         $11.00
5 - Independent Laboratory        86930                                                 M            07/01/2006
                                               86930 - FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION)        $100.00
                                  86930
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006
                                               86930 - FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION)        $100.00
I - Laboratory Billed by Physician86930                                                 M            07/01/2006
                                               86930 - FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION)        $100.00
5 - Independent Laboratory        86931        86931 - FROZEN BLOOD, EACH UNIT; THAWING M            07/01/2006        $110.00
                                  86931
H - Laboratory Billed by Outpatient Hospital   86931 - FROZEN BLOOD, EACH UNIT; THAWING M            07/01/2006        $110.00
I - Laboratory Billed by Physician86931        86931 - FROZEN BLOOD, EACH UNIT; THAWING M            07/01/2006        $110.00
5 - Independent Laboratory        86932                                                 M            07/01/2006        $120.00
                                               86932 - FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) AND THAWING
                                  86932
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006        $120.00
                                               86932 - FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) AND THAWING
I - Laboratory Billed by Physician86932                                                 M            07/01/2006        $120.00
                                               86932 - FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) AND THAWING
5 - Independent Laboratory        86940                                                 M
                                               86940 - HEMOLYSINS AND AGGLUTININS; AUTO, SCREEN, EACH07/01/2006         $10.89
                                  86940
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86940 - HEMOLYSINS AND AGGLUTININS; AUTO, SCREEN, EACH07/01/2006         $10.89
I - Laboratory Billed by Physician86940                                                 M
                                               86940 - HEMOLYSINS AND AGGLUTININS; AUTO, SCREEN, EACH07/01/2006         $10.89
5 - Independent Laboratory        86941                                                 M
                                               86941 - HEMOLYSINS AND AGGLUTININS; INCUBATED         07/01/2006         $16.07
                                  86941
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86941 - HEMOLYSINS AND AGGLUTININS; INCUBATED         07/01/2006         $16.07
I - Laboratory Billed by Physician86941                                                 M
                                               86941 - HEMOLYSINS AND AGGLUTININS; INCUBATED         07/01/2006         $16.07
5 - Independent Laboratory        86945                                                 M
                                               86945 - IRRADIATION OF BLOOD PRODUCT, EACH UNIT       07/01/2006         $30.00
                                  86945
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86945 - IRRADIATION OF BLOOD PRODUCT, EACH UNIT       07/01/2006         $30.00
I - Laboratory Billed by Physician86945                                                 M
                                               86945 - IRRADIATION OF BLOOD PRODUCT, EACH UNIT       07/01/2006         $30.00
5 - Independent Laboratory        86950        86950 - LEUKOCYTE TRANSFUSION            M            07/01/2006         $55.00
                                  86950
H - Laboratory Billed by Outpatient Hospital   86950 - LEUKOCYTE TRANSFUSION            M            07/01/2006         $55.00
I - Laboratory Billed by Physician86950        86950 - LEUKOCYTE TRANSFUSION            M            07/01/2006         $55.00
5 - Independent Laboratory        86960                                                 M            07/01/2006         $12.91
                                               86960 - VOLUME REDUCTION OF BLOOD OR BLOOD PRODUCT (EG, RED BLOOD CELLS OR PLATELETS
                                  86960
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $12.91
                                               86960 - VOLUME REDUCTION OF BLOOD OR BLOOD PRODUCT (EG, RED BLOOD CELLS OR PLATELETS
I - Laboratory Billed by Physician86960                                                 M            07/01/2006         $12.91
                                               86960 - VOLUME REDUCTION OF BLOOD OR BLOOD PRODUCT (EG, RED BLOOD CELLS OR PLATELETS
5 - Independent Laboratory        86965                                                 M
                                               86965 - POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS  07/01/2006         $14.00
                                  86965
H - Laboratory Billed by Outpatient Hospital                                            M
                                               86965 - POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS  07/01/2006         $14.00
I - Laboratory Billed by Physician86965                                                 M
                                               86965 - POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS  07/01/2006         $14.00
5 - Independent Laboratory        86970                                                 M            07/01/2006         $16.00
                                               86970 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
                                  86970
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $16.00
                                               86970 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
I - Laboratory Billed by Physician86970                                                 M            07/01/2006         $16.00
                                               86970 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
5 - Independent Laboratory        86971                                                 M            07/01/2006         $16.00
                                               86971 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
                                  86971
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $16.00
                                               86971 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
I - Laboratory Billed by Physician86971                                                 M            07/01/2006         $16.00
                                               86971 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
5 - Independent Laboratory        86972                                                 M            07/01/2006         $15.00
                                               86972 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
                                  86972
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006         $15.00
                                               86972 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
I - Laboratory Billed by Physician86972                                                 M            07/01/2006         $15.00
                                               86972 - PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR
5 - Independent Laboratory        86975                                                  IN          07/01/2006         $10.00
                                               86975 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; INCUBATION WITH D


 4/22/2012                                                     94 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                             Medicaid/BH      Pricing    Charge
                                  86975
H - Laboratory Billed by Outpatient Hospital                                           IN           07/01/2006         $10.00
                                               86975 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; INCUBATION WITH D
I - Laboratory Billed by Physician86975                                                IN           07/01/2006         $10.00
                                               86975 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; INCUBATION WITH D
5 - Independent Laboratory        86976                                                IN           07/01/2006           $8.00
                                               86976 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; BY DILUTION
                                  86976
H - Laboratory Billed by Outpatient Hospital                                           IN           07/01/2006           $8.00
                                               86976 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; BY DILUTION
I - Laboratory Billed by Physician86976                                                IN           07/01/2006           $8.00
                                               86976 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; BY DILUTION
5 - Independent Laboratory        86977                                                IN           07/01/2006         $10.00
                                               86977 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; INCUBATION WITH IN
                                  86977
H - Laboratory Billed by Outpatient Hospital                                           IN           07/01/2006         $10.00
                                               86977 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; INCUBATION WITH IN
I - Laboratory Billed by Physician86977                                                IN           07/01/2006         $10.00
                                               86977 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; INCUBATION WITH IN
5 - Independent Laboratory        86978                                                IN           07/01/2006         $22.00
                                               86978 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; BY DIFFERENTIAL R
                                  86978
H - Laboratory Billed by Outpatient Hospital                                           IN           07/01/2006         $22.00
                                               86978 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; BY DIFFERENTIAL R
I - Laboratory Billed by Physician86978                                                IN           07/01/2006         $22.00
                                               86978 - PRETREATMENT OF SERUM FOR USEM RBC ANTIBODY IDENTIFICATION; BY DIFFERENTIAL R
5 - Independent Laboratory        86985                                                M            UNIT
                                               86985 - SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH 07/01/2006           $21.00
                                  86985
H - Laboratory Billed by Outpatient Hospital                                           M            UNIT
                                               86985 - SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH 07/01/2006           $21.00
I - Laboratory Billed by Physician86985                                                M            UNIT
                                               86985 - SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH 07/01/2006           $21.00
5 - Independent Laboratory        87001                                                M            07/01/2006
                                               87001 - ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION              $17.55
                                  87001
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               87001 - ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION              $17.55
I - Laboratory Billed by Physician87001                                                M            07/01/2006
                                               87001 - ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION              $17.55
5 - Independent Laboratory        87003                                                M            07/01/2006         $22.34
                                               87003 - ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION AND DISSECTION
                                  87003
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $22.34
                                               87003 - ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION AND DISSECTION
I - Laboratory Billed by Physician87003                                                M            07/01/2006         $22.34
                                               87003 - ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION AND DISSECTION
5 - Independent Laboratory        87015                                                M            07/01/2006
                                               87015 - CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS                   $8.86
                                  87015
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               87015 - CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS                   $8.86
I - Laboratory Billed by Physician87015                                                M            07/01/2006
                                               87015 - CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS                   $8.86
5 - Independent Laboratory        87040                                                M            07/01/2006         $12.35
                                               87040 - CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATIO
                                  87040
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $12.35
                                               87040 - CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATIO
I - Laboratory Billed by Physician87040                                                M            07/01/2006         $12.35
                                               87040 - CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATIO
5 - Independent Laboratory        87045                                                M            07/01/2006         $12.52
                                               87045 - CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION
                                  87045
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $12.52
                                               87045 - CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION
I - Laboratory Billed by Physician87045                                                M            07/01/2006         $12.52
                                               87045 - CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION
5 - Independent Laboratory        87046                                                M            07/01/2006         $12.52
                                               87046 - CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMP
                                  87046
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $12.52
                                               87046 - CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMP
I - Laboratory Billed by Physician87046                                                M            07/01/2006         $12.52
                                               87046 - CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMP
5 - Independent Laboratory        87070                                                M            07/01/2006         $10.00
                                               87070 - CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WIT
                                  87070
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $10.00
                                               87070 - CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WIT
I - Laboratory Billed by Physician87070                                                M            07/01/2006         $10.00
                                               87070 - CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WIT
5 - Independent Laboratory        87071                                                M            07/01/2006         $12.52
                                               87071 - CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIF
                                  87071
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $12.52
                                               87071 - CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIF
I - Laboratory Billed by Physician87071                                                M            07/01/2006         $12.52
                                               87071 - CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIF
5 - Independent Laboratory        87073                                                M            07/01/2006         $12.52
                                               87073 - CULTURE, BACTERIAL; QUANTITATIVE, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDEN
                                  87073
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $12.52
                                               87073 - CULTURE, BACTERIAL; QUANTITATIVE, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDEN
I - Laboratory Billed by Physician87073                                                M            07/01/2006         $12.52
                                               87073 - CULTURE, BACTERIAL; QUANTITATIVE, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDEN
5 - Independent Laboratory        87075                                                EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRE
                                               87075 - CULTURE, BACTERIAL; ANY SOURCE, M            07/01/2006         $12.56
                                  87075
H - Laboratory Billed by Outpatient Hospital                                           EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRE
                                               87075 - CULTURE, BACTERIAL; ANY SOURCE, M            07/01/2006         $12.56
I - Laboratory Billed by Physician87075                                                EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRE
                                               87075 - CULTURE, BACTERIAL; ANY SOURCE, M            07/01/2006         $12.56
5 - Independent Laboratory        87076                                                M            07/01/2006         $10.73
                                               87076 - CULTURE, BACTERIAL; ANAEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITI
                                  87076
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $10.73
                                               87076 - CULTURE, BACTERIAL; ANAEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITI
I - Laboratory Billed by Physician87076                                                M            07/01/2006         $10.73
                                               87076 - CULTURE, BACTERIAL; ANAEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITI
5 - Independent Laboratory        87077                                                M            07/01/2006         $10.73
                                               87077 - CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE
                                  87077
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $10.73
                                               87077 - CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE
I - Laboratory Billed by Physician87077                                                M            07/01/2006         $10.73
                                               87077 - CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE
5 - Independent Laboratory        87081                                                M            07/01/2006
                                               87081 - CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; $8.80
                                  87081
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006
                                               87081 - CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; $8.80
I - Laboratory Billed by Physician87081                                                M            07/01/2006
                                               87081 - CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; $8.80
5 - Independent Laboratory        87084                                                M            07/01/2006         $11.43
                                               87084 - CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; WITH COLONY ESTIM
                                  87084
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006         $11.43
                                               87084 - CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; WITH COLONY ESTIM
I - Laboratory Billed by Physician87084                                                M            07/01/2006         $11.43
                                               87084 - CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; WITH COLONY ESTIM


 4/22/2012                                                    95 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                   Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                                Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        87086                                                  M            07/01/2006
                                               87086 - CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE             $10.72
                                  87086
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               87086 - CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE             $10.72
I - Laboratory Billed by Physician87086                                                  M            07/01/2006
                                               87086 - CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE             $10.72
5 - Independent Laboratory        87088                                                  M            07/01/2006        $10.74
                                               87088 - CULTURE, BACTERIAL; WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF EACH ISOLAT
                                  87088
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $10.74
                                               87088 - CULTURE, BACTERIAL; WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF EACH ISOLAT
I - Laboratory Billed by Physician87088                                                  M            07/01/2006        $10.74
                                               87088 - CULTURE, BACTERIAL; WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF EACH ISOLAT
5 - Independent Laboratory        87101                                                  M            07/01/2006        $10.23
                                               87101 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
                                  87101
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $10.23
                                               87101 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
I - Laboratory Billed by Physician87101                                                  M            07/01/2006        $10.23
                                               87101 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
5 - Independent Laboratory        87102                                                  M            07/01/2006        $11.15
                                               87102 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
                                  87102
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $11.15
                                               87102 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
I - Laboratory Billed by Physician87102                                                  M            07/01/2006        $11.15
                                               87102 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
5 - Independent Laboratory        87103                                                  M            07/01/2006        $11.97
                                               87103 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
                                  87103
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $11.97
                                               87103 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
I - Laboratory Billed by Physician87103                                                  M            07/01/2006        $11.97
                                               87103 - CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOL
5 - Independent Laboratory        87106                                                  M            07/01/2006
                                               87106 - CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST $13.70
                                  87106
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               87106 - CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST $13.70
I - Laboratory Billed by Physician87106                                                  M            07/01/2006
                                               87106 - CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST $13.70
5 - Independent Laboratory        87107                                                  M            07/01/2006
                                               87107 - CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; MOLD $13.70
                                  87107
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               87107 - CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; MOLD $13.70
I - Laboratory Billed by Physician87107                                                  M            07/01/2006
                                               87107 - CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; MOLD $13.70
5 - Independent Laboratory        87109        87109 - CULTURE, MYCOPLASMA, ANY SOURCE   M            07/01/2006        $20.43
                                  87109
H - Laboratory Billed by Outpatient Hospital   87109 - CULTURE, MYCOPLASMA, ANY SOURCE   M            07/01/2006        $20.43
I - Laboratory Billed by Physician87109        87109 - CULTURE, MYCOPLASMA, ANY SOURCE   M            07/01/2006        $20.43
5 - Independent Laboratory        87110        87110 - CULTURE, CHLAMYDIA, ANY SOURCE M               07/01/2006        $26.00
                                  87110
H - Laboratory Billed by Outpatient Hospital   87110 - CULTURE, CHLAMYDIA, ANY SOURCE M               07/01/2006        $26.00
I - Laboratory Billed by Physician87110        87110 - CULTURE, CHLAMYDIA, ANY SOURCE M               07/01/2006        $26.00
5 - Independent Laboratory        87116                                                  M            07/01/2006        $14.35
                                               87116 - CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, AFB, MYCOBACTERIA) ANY SOUR
                                  87116
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $14.35
                                               87116 - CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, AFB, MYCOBACTERIA) ANY SOUR
I - Laboratory Billed by Physician87116                                                  M            07/01/2006        $14.35
                                               87116 - CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, AFB, MYCOBACTERIA) ANY SOUR
5 - Independent Laboratory        87118                                                  M            07/01/2006
                                               87118 - CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH ISOLATE $14.53
                                  87118
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               87118 - CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH ISOLATE $14.53
I - Laboratory Billed by Physician87118                                                  M            07/01/2006
                                               87118 - CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH ISOLATE $14.53
5 - Independent Laboratory        87140                                                  M            07/01/2006
                                               87140 - CULTURE, TYPING; IMMUNOFLUORESCENT METHOD, EACH ANTISERUM          $7.40
                                  87140
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               87140 - CULTURE, TYPING; IMMUNOFLUORESCENT METHOD, EACH ANTISERUM          $7.40
I - Laboratory Billed by Physician87140                                                  M            07/01/2006
                                               87140 - CULTURE, TYPING; IMMUNOFLUORESCENT METHOD, EACH ANTISERUM          $7.40
5 - Independent Laboratory        87143                                                  M             (GLC) OR         $16.63
                                               87143 - CULTURE, TYPING; GAS LIQUID CHROMATOGRAPHY07/01/2006 HIGH PRESSURE LIQUID CHROM
                                  87143
H - Laboratory Billed by Outpatient Hospital                                             M             (GLC) OR         $16.63
                                               87143 - CULTURE, TYPING; GAS LIQUID CHROMATOGRAPHY07/01/2006 HIGH PRESSURE LIQUID CHROM
I - Laboratory Billed by Physician87143                                                  M             (GLC) OR         $16.63
                                               87143 - CULTURE, TYPING; GAS LIQUID CHROMATOGRAPHY07/01/2006 HIGH PRESSURE LIQUID CHROM
5 - Independent Laboratory        87147                                                  M            THAN IMMUNOFLUORESENCE (EG, AGGLU
                                               87147 - CULTURE, TYPING; IMMUNOLOGIC METHOD, OTHER 07/01/2006              $6.87
                                  87147
H - Laboratory Billed by Outpatient Hospital                                             M            THAN IMMUNOFLUORESENCE (EG, AGGLU
                                               87147 - CULTURE, TYPING; IMMUNOLOGIC METHOD, OTHER 07/01/2006              $6.87
I - Laboratory Billed by Physician87147                                                  M            THAN IMMUNOFLUORESENCE (EG, AGGLU
                                               87147 - CULTURE, TYPING; IMMUNOLOGIC METHOD, OTHER 07/01/2006              $6.87
5 - Independent Laboratory        87149                                                  M            07/01/2006
                                               87149 - CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID PROBE            $26.62
                                  87149
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               87149 - CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID PROBE            $26.62
I - Laboratory Billed by Physician87149                                                  M            07/01/2006
                                               87149 - CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID PROBE            $26.62
5 - Independent Laboratory        87152                                                  M             GEL TYPING
                                               87152 - CULTURE, TYPING; IDENTIFICATION BY PULSE FIELD07/01/2006           $6.94
                                  87152
H - Laboratory Billed by Outpatient Hospital                                             M             GEL TYPING
                                               87152 - CULTURE, TYPING; IDENTIFICATION BY PULSE FIELD07/01/2006           $6.94
I - Laboratory Billed by Physician87152                                                  M             GEL TYPING
                                               87152 - CULTURE, TYPING; IDENTIFICATION BY PULSE FIELD07/01/2006           $6.94
5 - Independent Laboratory        87158        87158 - CULTURE, TYPING; OTHER METHODS M               07/01/2006          $6.94
                                  87158
H - Laboratory Billed by Outpatient Hospital   87158 - CULTURE, TYPING; OTHER METHODS M               07/01/2006          $6.94
I - Laboratory Billed by Physician87158        87158 - CULTURE, TYPING; OTHER METHODS M               07/01/2006          $6.94
5 - Independent Laboratory        87164                                                  M            07/01/2006        $14.26
                                               87164 - DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, SKIN); INCLUDES SPE
                                  87164
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $14.26
                                               87164 - DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, SKIN); INCLUDES SPE
I - Laboratory Billed by Physician87164                                                  M            07/01/2006        $14.26
                                               87164 - DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, SKIN); INCLUDES SPE
5 - Independent Laboratory        87166                                                  M            07/01/2006        $14.99
                                               87166 - DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, SKIN); WITHOUT COLLE
                                  87166
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $14.99
                                               87166 - DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, SKIN); WITHOUT COLLE


 4/22/2012                                                     96 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3      Level 3   LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing      Charge
I - Laboratory Billed by Physician87166                                                M            07/01/2006          $14.99
                                               87166 - DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, SKIN); WITHOUT COLLE
5 - Independent Laboratory        87168                                                M
                                               87168 - MACROSCOPIC EXAMINATION; ARTHROPOD           07/01/2006            $5.66
                                  87168
H - Laboratory Billed by Outpatient Hospital                                           M
                                               87168 - MACROSCOPIC EXAMINATION; ARTHROPOD           07/01/2006            $5.66
I - Laboratory Billed by Physician87168                                                M
                                               87168 - MACROSCOPIC EXAMINATION; ARTHROPOD           07/01/2006            $5.66
5 - Independent Laboratory        87169                                                M
                                               87169 - MACROSCOPIC EXAMINATION; PARASITE            07/01/2006            $5.66
                                  87169
H - Laboratory Billed by Outpatient Hospital                                           M
                                               87169 - MACROSCOPIC EXAMINATION; PARASITE            07/01/2006            $5.66
I - Laboratory Billed by Physician87169                                                M
                                               87169 - MACROSCOPIC EXAMINATION; PARASITE            07/01/2006            $5.66
5 - Independent Laboratory        87172                                                M
                                               87172 - PINWORM EXAM (EG, CELLOPHANE TAPE PREP)      07/01/2006            $5.66
                                  87172
H - Laboratory Billed by Outpatient Hospital                                           M
                                               87172 - PINWORM EXAM (EG, CELLOPHANE TAPE PREP)      07/01/2006            $5.66
I - Laboratory Billed by Physician87172                                                M
                                               87172 - PINWORM EXAM (EG, CELLOPHANE TAPE PREP)      07/01/2006            $5.66
5 - Independent Laboratory        87176                                                M
                                               87176 - HOMOGENIZATION, TISSUE, FOR CULTURE          07/01/2006            $7.81
                                  87176
H - Laboratory Billed by Outpatient Hospital                                           M
                                               87176 - HOMOGENIZATION, TISSUE, FOR CULTURE          07/01/2006            $7.81
I - Laboratory Billed by Physician87176                                                M
                                               87176 - HOMOGENIZATION, TISSUE, FOR CULTURE          07/01/2006            $7.81
5 - Independent Laboratory        87177                                                M            07/01/2006          $11.81
                                               87177 - OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION
                                  87177
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006          $11.81
                                               87177 - OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION
I - Laboratory Billed by Physician87177                                                M            07/01/2006          $11.81
                                               87177 - OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION
5 - Independent Laboratory        87181                                                M            07/01/2006            $1.21
                                               87181 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR DILUTION METHOD, PER AGENT (EG
                                  87181
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $1.21
                                               87181 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR DILUTION METHOD, PER AGENT (EG
I - Laboratory Billed by Physician87181                                                M            07/01/2006            $1.21
                                               87181 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR DILUTION METHOD, PER AGENT (EG
5 - Independent Laboratory        87184                                                M            07/01/2006            $9.15
                                               87184 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER
                                  87184
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $9.15
                                               87184 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER
I - Laboratory Billed by Physician87184                                                M            07/01/2006            $9.15
                                               87184 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER
5 - Independent Laboratory        87185                                                M            07/01/2006            $1.21
                                               87185 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; ENZYME DETECTION (EG, BETA LACTAMAS
                                  87185
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $1.21
                                               87185 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; ENZYME DETECTION (EG, BETA LACTAMAS
I - Laboratory Billed by Physician87185                                                M            07/01/2006            $1.21
                                               87185 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; ENZYME DETECTION (EG, BETA LACTAMAS
5 - Independent Laboratory        87186                                                M            07/01/2006          $11.48
                                               87186 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIM
                                  87186
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006          $11.48
                                               87186 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIM
I - Laboratory Billed by Physician87186                                                M            07/01/2006          $11.48
                                               87186 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIM
5 - Independent Laboratory        87187                                                M            07/01/2006          $13.76
                                               87187 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION, MINIM
                                  87187
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006          $13.76
                                               87187 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION, MINIM
I - Laboratory Billed by Physician87187                                                M            07/01/2006          $13.76
                                               87187 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION, MINIM
5 - Independent Laboratory        87188                                                M            07/01/2006            $8.81
                                               87188 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MACROBROTH DILUTION METHOD, EACH A
                                  87188
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $8.81
                                               87188 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MACROBROTH DILUTION METHOD, EACH A
I - Laboratory Billed by Physician87188                                                M            07/01/2006            $8.81
                                               87188 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MACROBROTH DILUTION METHOD, EACH A
5 - Independent Laboratory        87190                                                M            07/01/2006            $7.51
                                               87190 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MYCOBACTERIA, PROPORTION METHOD, E
                                  87190
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $7.51
                                               87190 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MYCOBACTERIA, PROPORTION METHOD, E
I - Laboratory Billed by Physician87190                                                M            07/01/2006            $7.51
                                               87190 - SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MYCOBACTERIA, PROPORTION METHOD, E
5 - Independent Laboratory        87197                                                M
                                               87197 - SERUM BACTERICIDAL TITER (SCHLICTER TEST)    07/01/2006          $19.94
                                  87197
H - Laboratory Billed by Outpatient Hospital                                           M
                                               87197 - SERUM BACTERICIDAL TITER (SCHLICTER TEST)    07/01/2006          $19.94
I - Laboratory Billed by Physician87197                                                M
                                               87197 - SERUM BACTERICIDAL TITER (SCHLICTER TEST)    07/01/2006          $19.94
5 - Independent Laboratory        87205                                                M             GRAM OR              $5.66
                                               87205 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006 GIEMSA STAIN FOR BACTERIA,
                                  87205
H - Laboratory Billed by Outpatient Hospital                                           M             GRAM OR              $5.66
                                               87205 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006 GIEMSA STAIN FOR BACTERIA,
I - Laboratory Billed by Physician87205                                                M             GRAM OR              $5.66
                                               87205 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006 GIEMSA STAIN FOR BACTERIA,
5 - Independent Laboratory        87206                                                M             FLUORESCENT AND/OR ACID FAST STAIN
                                               87206 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $7.13
                                  87206
H - Laboratory Billed by Outpatient Hospital                                           M             FLUORESCENT AND/OR ACID FAST STAIN
                                               87206 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $7.13
I - Laboratory Billed by Physician87206                                                M             FLUORESCENT AND/OR ACID FAST STAIN
                                               87206 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $7.13
5 - Independent Laboratory        87207                                                M             SPECIAL STAIN FOR INCLUSION BODIES O
                                               87207 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $5.44
                                  87207
H - Laboratory Billed by Outpatient Hospital                                           M             SPECIAL STAIN FOR INCLUSION BODIES O
                                               87207 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $5.44
I - Laboratory Billed by Physician87207                                                M             SPECIAL STAIN FOR INCLUSION BODIES O
                                               87207 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $5.44
5 - Independent Laboratory        87209                                                M             COMPLEX            $16.16
                                               87209 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006 SPECIAL STAIN (EG, TRICHROM
                                  87209
H - Laboratory Billed by Outpatient Hospital                                           M             COMPLEX            $16.16
                                               87209 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006 SPECIAL STAIN (EG, TRICHROM
I - Laboratory Billed by Physician87209                                                M             COMPLEX            $16.16
                                               87209 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006 SPECIAL STAIN (EG, TRICHROM
5 - Independent Laboratory        87210                                                M             WET MOUNT FOR INFECTIOUS AGENTS (E
                                               87210 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $5.66
                                  87210
H - Laboratory Billed by Outpatient Hospital                                           M             WET MOUNT FOR INFECTIOUS AGENTS (E
                                               87210 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $5.66
I - Laboratory Billed by Physician87210                                                M             WET MOUNT FOR INFECTIOUS AGENTS (E
                                               87210 - SMEAR, PRIMARY SOURCE WITH INTERPRETATION; 07/01/2006              $5.66
5 - Independent Laboratory        87220                                                M            07/01/2006            $5.66
                                               87220 - TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI O


 4/22/2012                                                     97 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing    Charge
                                  87220
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           $5.66
                                               87220 - TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI O
I - Laboratory Billed by Physician87220                                                 M            07/01/2006           $5.66
                                               87220 - TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI O
5 - Independent Laboratory        87230                                                 CULTURE (EG, 07/01/2006
                                               87230 - TOXIN OR ANTITOXIN ASSAY, TISSUE M                                $26.21
                                                                                                     CLOSTRIDIUM DIFFICILE TOXIN)
                                  87230
H - Laboratory Billed by Outpatient Hospital                                            CULTURE (EG, 07/01/2006
                                               87230 - TOXIN OR ANTITOXIN ASSAY, TISSUE M                                $26.21
                                                                                                     CLOSTRIDIUM DIFFICILE TOXIN)
I - Laboratory Billed by Physician87230                                                 CULTURE (EG, 07/01/2006
                                               87230 - TOXIN OR ANTITOXIN ASSAY, TISSUE M                                $26.21
                                                                                                     CLOSTRIDIUM DIFFICILE TOXIN)
5 - Independent Laboratory        87250                                                 M             EGGS, OR           $25.95
                                               87250 - VIRUS ISOLATION; INOCULATION OF EMBRYONATED07/01/2006 SMALL ANIMAL, INCLUDES OBS
                                  87250
H - Laboratory Billed by Outpatient Hospital                                            M             EGGS, OR           $25.95
                                               87250 - VIRUS ISOLATION; INOCULATION OF EMBRYONATED07/01/2006 SMALL ANIMAL, INCLUDES OBS
I - Laboratory Billed by Physician87250                                                 M             EGGS, OR           $25.95
                                               87250 - VIRUS ISOLATION; INOCULATION OF EMBRYONATED07/01/2006 SMALL ANIMAL, INCLUDES OBS
5 - Independent Laboratory        87252                                                 M            07/01/2006          $34.60
                                               87252 - VIRUS ISOLATION; TISSUE CULTURE INOCULATION, OBSERVATION, AND PRESUMPTIVE IDENT
                                  87252
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $34.60
                                               87252 - VIRUS ISOLATION; TISSUE CULTURE INOCULATION, OBSERVATION, AND PRESUMPTIVE IDENT
I - Laboratory Billed by Physician87252                                                 M            07/01/2006          $34.60
                                               87252 - VIRUS ISOLATION; TISSUE CULTURE INOCULATION, OBSERVATION, AND PRESUMPTIVE IDENT
5 - Independent Laboratory        87253                                                 M            07/01/2006           IDENTIFICATION (E
                                               87253 - VIRUS ISOLATION; TISSUE CULTURE, ADDITIONAL STUDIES OR DEFINITIVE$26.81
                                  87253
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006           IDENTIFICATION (E
                                               87253 - VIRUS ISOLATION; TISSUE CULTURE, ADDITIONAL STUDIES OR DEFINITIVE$26.81
I - Laboratory Billed by Physician87253                                                 M            07/01/2006           IDENTIFICATION (E
                                               87253 - VIRUS ISOLATION; TISSUE CULTURE, ADDITIONAL STUDIES OR DEFINITIVE$26.81
5 - Independent Laboratory        87254                                                 M            VIAL) TECHNIQUE, INCLUDES IDENTIFICAT
                                               87254 - VIRUS ISOLATION; CENTRIFUGE ENHANCED (SHELL 07/01/2006            $25.95
                                  87254
H - Laboratory Billed by Outpatient Hospital                                            M            VIAL) TECHNIQUE, INCLUDES IDENTIFICAT
                                               87254 - VIRUS ISOLATION; CENTRIFUGE ENHANCED (SHELL 07/01/2006            $25.95
I - Laboratory Billed by Physician87254                                                 M            VIAL) TECHNIQUE, INCLUDES IDENTIFICAT
                                               87254 - VIRUS ISOLATION; CENTRIFUGE ENHANCED (SHELL 07/01/2006            $25.95
5 - Independent Laboratory        87255                                                 M            07/01/2006          $44.94
                                               87255 - VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC METHOD, OTHER THAN
                                  87255
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $44.94
                                               87255 - VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC METHOD, OTHER THAN
I - Laboratory Billed by Physician87255                                                 M            07/01/2006          $44.94
                                               87255 - VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC METHOD, OTHER THAN
5 - Independent Laboratory        87260                                                 M            07/01/2006          $15.92
                                               87260 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ADENOVIR
                                  87260
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87260 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ADENOVIR
I - Laboratory Billed by Physician87260                                                 M            07/01/2006          $15.92
                                               87260 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ADENOVIR
5 - Independent Laboratory        87265                                                 M            07/01/2006          $15.92
                                               87265 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; BORDETEL
                                  87265
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87265 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; BORDETEL
I - Laboratory Billed by Physician87265                                                 M            07/01/2006          $15.92
                                               87265 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; BORDETEL
5 - Independent Laboratory        87267                                                 M            07/01/2006          $15.92
                                               87267 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ENTEROVIR
                                  87267
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87267 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ENTEROVIR
I - Laboratory Billed by Physician87267                                                 M            07/01/2006          $15.92
                                               87267 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ENTEROVIR
5 - Independent Laboratory        87269                                                 M            07/01/2006          $15.92
                                               87269 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; GIARDIA
                                  87269
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87269 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; GIARDIA
I - Laboratory Billed by Physician87269                                                 M            07/01/2006          $15.92
                                               87269 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; GIARDIA
5 - Independent Laboratory        87270                                                 M            07/01/2006          $15.92
                                               87270 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CHLAMYDI
                                  87270
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87270 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CHLAMYDI
I - Laboratory Billed by Physician87270                                                 M            07/01/2006          $15.92
                                               87270 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CHLAMYDI
5 - Independent Laboratory        87271                                                 M            07/01/2006          $15.92
                                               87271 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CYTOMEGA
                                  87271
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87271 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CYTOMEGA
I - Laboratory Billed by Physician87271                                                 M            07/01/2006          $15.92
                                               87271 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CYTOMEGA
5 - Independent Laboratory        87272                                                 M            07/01/2006          $15.92
                                               87272 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CRYPTOSP
                                  87272
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87272 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CRYPTOSP
I - Laboratory Billed by Physician87272                                                 M            07/01/2006          $15.92
                                               87272 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CRYPTOSP
5 - Independent Laboratory        87273                                                 M            07/01/2006          $15.92
                                               87273 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; HERPES SI
                                  87273
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87273 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; HERPES SI
I - Laboratory Billed by Physician87273                                                 M            07/01/2006          $15.92
                                               87273 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; HERPES SI
5 - Independent Laboratory        87274                                                 M            07/01/2006          $15.92
                                               87274 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; HERPES SI
                                  87274
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87274 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; HERPES SI
I - Laboratory Billed by Physician87274                                                 M            07/01/2006          $15.92
                                               87274 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; HERPES SI
5 - Independent Laboratory        87275                                                 M            07/01/2006          $15.92
                                               87275 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA
                                  87275
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87275 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA
I - Laboratory Billed by Physician87275                                                 M            07/01/2006          $15.92
                                               87275 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA
5 - Independent Laboratory        87276                                                 M            07/01/2006          $15.92
                                               87276 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA
                                  87276
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87276 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA
I - Laboratory Billed by Physician87276                                                 M            07/01/2006          $15.92
                                               87276 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA
5 - Independent Laboratory        87277                                                 M            07/01/2006          $15.92
                                               87277 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; LEGIONELL
                                  87277
H - Laboratory Billed by Outpatient Hospital                                            M            07/01/2006          $15.92
                                               87277 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; LEGIONELL
I - Laboratory Billed by Physician87277                                                 M            07/01/2006          $15.92
                                               87277 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; LEGIONELL


 4/22/2012                                                     98 of 489               ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                               Level 3       Level 3 LVL3 Allowed
                                                      Level 3 HCPC Description
              Desc                    Code                                            Medicaid/BH     Pricing   Charge
5 - Independent Laboratory        87278                                              M            07/01/2006        $15.92
                                               87278 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; LEGIONELL
                                  87278
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87278 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; LEGIONELL
I - Laboratory Billed by Physician87278                                              M            07/01/2006        $15.92
                                               87278 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; LEGIONELL
5 - Independent Laboratory        87279                                              M            07/01/2006        $15.92
                                               87279 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; PARAINFLU
                                  87279
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87279 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; PARAINFLU
I - Laboratory Billed by Physician87279                                              M            07/01/2006        $15.92
                                               87279 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; PARAINFLU
5 - Independent Laboratory        87280                                              M            07/01/2006        $15.92
                                               87280 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; RESPIRATO
                                  87280
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87280 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; RESPIRATO
I - Laboratory Billed by Physician87280                                              M            07/01/2006        $15.92
                                               87280 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; RESPIRATO
5 - Independent Laboratory        87281                                              M            07/01/2006        $15.92
                                               87281 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; PNEUMOCY
                                  87281
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87281 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; PNEUMOCY
I - Laboratory Billed by Physician87281                                              M            07/01/2006        $15.92
                                               87281 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; PNEUMOCY
5 - Independent Laboratory        87283                                              M            07/01/2006        $15.92
                                               87283 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; RUBEOLA
                                  87283
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87283 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; RUBEOLA
I - Laboratory Billed by Physician87283                                              M            07/01/2006        $15.92
                                               87283 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; RUBEOLA
5 - Independent Laboratory        87285                                              M            07/01/2006        $15.92
                                               87285 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; TREPONEM
                                  87285
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87285 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; TREPONEM
I - Laboratory Billed by Physician87285                                              M            07/01/2006        $15.92
                                               87285 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; TREPONEM
5 - Independent Laboratory        87290                                              M            07/01/2006        $15.92
                                               87290 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; VARICELLA
                                  87290
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87290 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; VARICELLA
I - Laboratory Billed by Physician87290                                              M            07/01/2006        $15.92
                                               87290 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; VARICELLA
5 - Independent Laboratory        87299                                              M            07/01/2006        $15.92
                                               87299 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; NOT OTHE
                                  87299
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87299 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; NOT OTHE
I - Laboratory Billed by Physician87299                                              M            07/01/2006        $15.92
                                               87299 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; NOT OTHE
5 - Independent Laboratory        87300                                              M            07/01/2006        $15.92
                                               87300 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE, POLYVALE
                                  87300
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87300 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE, POLYVALE
I - Laboratory Billed by Physician87300                                              M            07/01/2006        $15.92
                                               87300 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE, POLYVALE
5 - Independent Laboratory        87301                                              M            07/01/2006        $15.92
                                               87301 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87301
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87301 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87301                                              M            07/01/2006        $15.92
                                               87301 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87305                                              M            01/01/2007        $15.92
                                               87305 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87305
H - Laboratory Billed by Outpatient Hospital                                         M            01/01/2007        $15.92
                                               87305 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87305                                              M            01/01/2007        $15.92
                                               87305 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87320                                              M            07/01/2006        $15.92
                                               87320 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87320
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87320 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87320                                              M            07/01/2006        $15.92
                                               87320 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87324                                              M            07/01/2006        $15.92
                                               87324 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87324
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87324 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87324                                              M            07/01/2006        $15.92
                                               87324 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87327                                              M            07/01/2006        $15.92
                                               87327 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87327
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87327 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87327                                              M            07/01/2006        $15.92
                                               87327 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87328                                              M            07/01/2006        $15.92
                                               87328 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87328
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87328 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87328                                              M            07/01/2006        $15.92
                                               87328 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87329                                              M            07/01/2006        $15.92
                                               87329 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87329
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87329 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87329                                              M            07/01/2006        $15.92
                                               87329 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87332                                              M            07/01/2006        $15.92
                                               87332 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87332
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87332 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87332                                              M            07/01/2006        $15.92
                                               87332 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87335                                              M            07/01/2006        $15.92
                                               87335 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87335
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87335 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87335                                              M            07/01/2006        $15.92
                                               87335 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87336                                              M            07/01/2006        $15.92
                                               87336 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87336
H - Laboratory Billed by Outpatient Hospital                                         M            07/01/2006        $15.92
                                               87336 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT


 4/22/2012                                                    99 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                               Level 3        Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                            Medicaid/BH      Pricing     Charge
I - Laboratory Billed by Physician87336                                               M            07/01/2006         $15.92
                                               87336 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87337                                               M            07/01/2006         $15.92
                                               87337 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87337
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87337 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87337                                               M            07/01/2006         $15.92
                                               87337 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87338                                               M            07/01/2006         $19.10
                                               87338 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87338
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $19.10
                                               87338 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87338                                               M            07/01/2006         $19.10
                                               87338 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87339                                               M            07/01/2006         $15.92
                                               87339 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87339
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87339 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87339                                               M            07/01/2006         $15.92
                                               87339 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87340                                               M            07/01/2006         $13.71
                                               87340 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87340
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $13.71
                                               87340 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87340                                               M            07/01/2006         $13.71
                                               87340 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87341                                               M            07/01/2006         $13.71
                                               87341 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87341
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $13.71
                                               87341 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87341                                               M            07/01/2006         $13.71
                                               87341 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87350                                               M            07/01/2006         $15.30
                                               87350 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87350
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.30
                                               87350 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87350                                               M            07/01/2006         $15.30
                                               87350 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87380                                               M            07/01/2006         $21.79
                                               87380 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87380
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $21.79
                                               87380 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87380                                               M            07/01/2006         $21.79
                                               87380 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87385                                               M            07/01/2006         $15.92
                                               87385 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87385
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87385 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87385                                               M            07/01/2006         $15.92
                                               87385 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87390                                               M            07/01/2006         $23.42
                                               87390 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87390
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $23.42
                                               87390 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87390                                               M            07/01/2006         $23.42
                                               87390 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87391                                               M            07/01/2006         $23.42
                                               87391 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87391
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $23.42
                                               87391 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87391                                               M            07/01/2006         $23.42
                                               87391 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87400                                               M            07/01/2006         $15.92
                                               87400 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87400
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87400 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87400                                               M            07/01/2006         $15.92
                                               87400 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87420                                               M            07/01/2006         $15.92
                                               87420 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87420
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87420 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87420                                               M            07/01/2006         $15.92
                                               87420 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87425                                               M            07/01/2006         $15.92
                                               87425 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87425
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87425 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87425                                               M            07/01/2006         $15.92
                                               87425 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87427                                               M            07/01/2006         $15.92
                                               87427 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87427
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87427 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87427                                               M            07/01/2006         $15.92
                                               87427 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87430                                               M            07/01/2006         $15.92
                                               87430 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
                                  87430
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87430 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
I - Laboratory Billed by Physician87430                                               M            07/01/2006         $15.92
                                               87430 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITAT
5 - Independent Laboratory        87449                                               M            07/01/2006         $15.92
                                               87449 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
                                  87449
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $15.92
                                               87449 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
I - Laboratory Billed by Physician87449                                               M            07/01/2006         $15.92
                                               87449 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
5 - Independent Laboratory        87450                                               M            07/01/2006         $12.72
                                               87450 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
                                  87450
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $12.72
                                               87450 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
I - Laboratory Billed by Physician87450                                               M            07/01/2006         $12.72
                                               87450 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
5 - Independent Laboratory        87451                                               M            07/01/2006         $12.72
                                               87451 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
                                  87451
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $12.72
                                               87451 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
I - Laboratory Billed by Physician87451                                               M            07/01/2006         $12.72
                                               87451 - INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATI
5 - Independent Laboratory        87470                                               M            07/01/2006         $26.62
                                               87470 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN


 4/22/2012                                                    100 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                               Level 3        Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                            Medicaid/BH      Pricing     Charge
                                  87470
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $26.62
                                               87470 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
I - Laboratory Billed by Physician87470                                               M            07/01/2006         $26.62
                                               87470 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
5 - Independent Laboratory        87471                                               M            07/01/2006         $46.59
                                               87471 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
                                  87471
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $46.59
                                               87471 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
I - Laboratory Billed by Physician87471                                               M            07/01/2006         $46.59
                                               87471 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
5 - Independent Laboratory        87472                                               M            07/01/2006         $56.86
                                               87472 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
                                  87472
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $56.86
                                               87472 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
I - Laboratory Billed by Physician87472                                               M            07/01/2006         $56.86
                                               87472 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AN
5 - Independent Laboratory        87475                                               M            07/01/2006         $26.62
                                               87475 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
                                  87475
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $26.62
                                               87475 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
I - Laboratory Billed by Physician87475                                               M            07/01/2006         $26.62
                                               87475 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
5 - Independent Laboratory        87476                                               M            07/01/2006         $46.59
                                               87476 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
                                  87476
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $46.59
                                               87476 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
I - Laboratory Billed by Physician87476                                               M            07/01/2006         $46.59
                                               87476 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
5 - Independent Laboratory        87477                                               M            07/01/2006         $56.86
                                               87477 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
                                  87477
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $56.86
                                               87477 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
I - Laboratory Billed by Physician87477                                               M            07/01/2006         $56.86
                                               87477 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI,
5 - Independent Laboratory        87480                                               M            07/01/2006         $26.62
                                               87480 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, DIRECT
                                  87480
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $26.62
                                               87480 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, DIRECT
I - Laboratory Billed by Physician87480                                               M            07/01/2006         $26.62
                                               87480 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, DIRECT
5 - Independent Laboratory        87481                                               M            07/01/2006         $46.59
                                               87481 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, AMPLIFI
                                  87481
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $46.59
                                               87481 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, AMPLIFI
I - Laboratory Billed by Physician87481                                               M            07/01/2006         $46.59
                                               87481 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, AMPLIFI
5 - Independent Laboratory        87482                                               M            07/01/2006         $55.41
                                               87482 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, QUANTI
                                  87482
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $55.41
                                               87482 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, QUANTI
I - Laboratory Billed by Physician87482                                               M            07/01/2006         $55.41
                                               87482 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, QUANTI
5 - Independent Laboratory        87485                                               M            07/01/2006         $26.62
                                               87485 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
                                  87485
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $26.62
                                               87485 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
I - Laboratory Billed by Physician87485                                               M            07/01/2006         $26.62
                                               87485 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
5 - Independent Laboratory        87486                                               M            07/01/2006         $46.59
                                               87486 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
                                  87486
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $46.59
                                               87486 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
I - Laboratory Billed by Physician87486                                               M            07/01/2006         $46.59
                                               87486 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
5 - Independent Laboratory        87487                                               M            07/01/2006         $56.86
                                               87487 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
                                  87487
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $56.86
                                               87487 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
I - Laboratory Billed by Physician87487                                               M            07/01/2006         $56.86
                                               87487 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE,
5 - Independent Laboratory        87490                                               M            07/01/2006         $26.62
                                               87490 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
                                  87490
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $26.62
                                               87490 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
I - Laboratory Billed by Physician87490                                               M            07/01/2006         $26.62
                                               87490 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
5 - Independent Laboratory        87491                                               M            07/01/2006         $46.59
                                               87491 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
                                  87491
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $46.59
                                               87491 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
I - Laboratory Billed by Physician87491                                               M            07/01/2006         $46.59
                                               87491 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
5 - Independent Laboratory        87492                                               M            07/01/2006         $21.78
                                               87492 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
                                  87492
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $21.78
                                               87492 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
I - Laboratory Billed by Physician87492                                               M            07/01/2006         $21.78
                                               87492 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS
5 - Independent Laboratory        87495                                               M            07/01/2006         $26.62
                                               87495 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, DIREC
                                  87495
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $26.62
                                               87495 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, DIREC
I - Laboratory Billed by Physician87495                                               M            07/01/2006         $26.62
                                               87495 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, DIREC
5 - Independent Laboratory        87496                                               M            07/01/2006         $46.59
                                               87496 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, AMPL
                                  87496
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $46.59
                                               87496 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, AMPL
I - Laboratory Billed by Physician87496                                               M            07/01/2006         $46.59
                                               87496 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, AMPL
5 - Independent Laboratory        87497                                               M            07/01/2006         $56.86
                                               87497 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, QUAN
                                  87497
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $56.86
                                               87497 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, QUAN
I - Laboratory Billed by Physician87497                                               M            07/01/2006         $56.86
                                               87497 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, QUAN
5 - Independent Laboratory        87498                                               M            01/01/2007         $46.58
                                               87498 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ENTEROVIRUS, AMPLIFIED P
                                  87498
H - Laboratory Billed by Outpatient Hospital                                          M            01/01/2007         $46.58
                                               87498 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ENTEROVIRUS, AMPLIFIED P
I - Laboratory Billed by Physician87498                                               M            01/01/2007         $46.58
                                               87498 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ENTEROVIRUS, AMPLIFIED P


 4/22/2012                                                     101 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                               Level 3        Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                            Medicaid/BH      Pricing     Charge
5 - Independent Laboratory        87510                                               M            07/01/2006           $26.62
                                               87510 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
                                  87510
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87510 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
I - Laboratory Billed by Physician87510                                               M            07/01/2006           $26.62
                                               87510 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
5 - Independent Laboratory        87511                                               M            07/01/2006           $46.59
                                               87511 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
                                  87511
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87511 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
I - Laboratory Billed by Physician87511                                               M            07/01/2006           $46.59
                                               87511 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
5 - Independent Laboratory        87512                                               M            07/01/2006           $55.41
                                               87512 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
                                  87512
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $55.41
                                               87512 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
I - Laboratory Billed by Physician87512                                               M            07/01/2006           $55.41
                                               87512 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS,
5 - Independent Laboratory        87515                                               M            07/01/2006           $26.62
                                               87515 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, DIRECT
                                  87515
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87515 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, DIRECT
I - Laboratory Billed by Physician87515                                               M            07/01/2006           $26.62
                                               87515 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, DIRECT
5 - Independent Laboratory        87516                                               M            07/01/2006           $46.59
                                               87516 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, AMPLIF
                                  87516
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87516 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, AMPLIF
I - Laboratory Billed by Physician87516                                               M            07/01/2006           $46.59
                                               87516 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, AMPLIF
5 - Independent Laboratory        87517                                               M            07/01/2006           $56.86
                                               87517 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, QUANT
                                  87517
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $56.86
                                               87517 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, QUANT
I - Laboratory Billed by Physician87517                                               M            07/01/2006           $56.86
                                               87517 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, QUANT
5 - Independent Laboratory        87520                                               M            07/01/2006           $26.62
                                               87520 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, DIRECT PROB
                                  87520
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87520 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, DIRECT PROB
I - Laboratory Billed by Physician87520                                               M            07/01/2006           $26.62
                                               87520 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, DIRECT PROB
5 - Independent Laboratory        87521                                               M            07/01/2006           $46.59
                                               87521 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, AMPLIFIED PR
                                  87521
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87521 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, AMPLIFIED PR
I - Laboratory Billed by Physician87521                                               M            07/01/2006           $46.59
                                               87521 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, AMPLIFIED PR
5 - Independent Laboratory        87522                                               M            07/01/2006           $56.86
                                               87522 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICAT
                                  87522
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $56.86
                                               87522 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICAT
I - Laboratory Billed by Physician87522                                               M            07/01/2006           $56.86
                                               87522 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICAT
5 - Independent Laboratory        87525                                               M            07/01/2006           $26.62
                                               87525 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, DIRECT PROB
                                  87525
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87525 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, DIRECT PROB
I - Laboratory Billed by Physician87525                                               M            07/01/2006           $26.62
                                               87525 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, DIRECT PROB
5 - Independent Laboratory        87526                                               M            07/01/2006           $46.59
                                               87526 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, AMPLIFIED PR
                                  87526
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87526 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, AMPLIFIED PR
I - Laboratory Billed by Physician87526                                               M            07/01/2006           $46.59
                                               87526 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, AMPLIFIED PR
5 - Independent Laboratory        87527                                               M            07/01/2006           $55.41
                                               87527 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, QUANTIFICAT
                                  87527
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $55.41
                                               87527 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, QUANTIFICAT
I - Laboratory Billed by Physician87527                                               M            07/01/2006           $55.41
                                               87527 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, QUANTIFICAT
5 - Independent Laboratory        87528                                               M            07/01/2006           $26.62
                                               87528 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, D
                                  87528
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87528 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, D
I - Laboratory Billed by Physician87528                                               M            07/01/2006           $26.62
                                               87528 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, D
5 - Independent Laboratory        87529                                               M            07/01/2006           $46.59
                                               87529 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, A
                                  87529
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87529 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, A
I - Laboratory Billed by Physician87529                                               M            07/01/2006           $46.59
                                               87529 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, A
5 - Independent Laboratory        87530                                               M            07/01/2006           $56.86
                                               87530 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, Q
                                  87530
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $56.86
                                               87530 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, Q
I - Laboratory Billed by Physician87530                                               M            07/01/2006           $56.86
                                               87530 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, Q
5 - Independent Laboratory        87531                                               M            07/01/2006           $26.62
                                               87531 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, DIRECT P
                                  87531
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87531 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, DIRECT P
I - Laboratory Billed by Physician87531                                               M            07/01/2006           $26.62
                                               87531 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, DIRECT P
5 - Independent Laboratory        87532                                               M            07/01/2006           $46.59
                                               87532 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, AMPLIFIE
                                  87532
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87532 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, AMPLIFIE
I - Laboratory Billed by Physician87532                                               M            07/01/2006           $46.59
                                               87532 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, AMPLIFIE
5 - Independent Laboratory        87533                                               M            07/01/2006           $55.41
                                               87533 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, QUANTIFI
                                  87533
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $55.41
                                               87533 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, QUANTIFI
I - Laboratory Billed by Physician87533                                               M            07/01/2006           $55.41
                                               87533 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, QUANTIFI
5 - Independent Laboratory        87534                                               M            07/01/2006           $26.62
                                               87534 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, DIRECT PROBE TECH
                                  87534
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87534 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, DIRECT PROBE TECH


 4/22/2012                                                     102 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                               Level 3        Level 3   LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                            Medicaid/BH      Pricing     Charge
I - Laboratory Billed by Physician87534                                               M            07/01/2006           $26.62
                                               87534 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, DIRECT PROBE TECH
5 - Independent Laboratory        87535                                               M            07/01/2006           $46.59
                                               87535 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, AMPLIFIED PROBE TE
                                  87535
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87535 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, AMPLIFIED PROBE TE
I - Laboratory Billed by Physician87535                                               M            07/01/2006           $46.59
                                               87535 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, AMPLIFIED PROBE TE
5 - Independent Laboratory        87536                                               M            07/01/2006          $112.95
                                               87536 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, QUANTIFICATION
                                  87536
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $112.95
                                               87536 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, QUANTIFICATION
I - Laboratory Billed by Physician87536                                               M            07/01/2006          $112.95
                                               87536 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, QUANTIFICATION
5 - Independent Laboratory        87537                                               M            07/01/2006           $26.62
                                               87537 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, DIRECT PROBE TECH
                                  87537
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87537 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, DIRECT PROBE TECH
I - Laboratory Billed by Physician87537                                               M            07/01/2006           $26.62
                                               87537 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, DIRECT PROBE TECH
5 - Independent Laboratory        87538                                               M            07/01/2006           $46.59
                                               87538 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, AMPLIFIED PROBE TE
                                  87538
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87538 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, AMPLIFIED PROBE TE
I - Laboratory Billed by Physician87538                                               M            07/01/2006           $46.59
                                               87538 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, AMPLIFIED PROBE TE
5 - Independent Laboratory        87539                                               M            07/01/2006           $56.86
                                               87539 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, QUANTIFICATION
                                  87539
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $56.86
                                               87539 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, QUANTIFICATION
I - Laboratory Billed by Physician87539                                               M            07/01/2006           $56.86
                                               87539 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, QUANTIFICATION
5 - Independent Laboratory        87540                                               M            07/01/2006           $26.62
                                               87540 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
                                  87540
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87540 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
I - Laboratory Billed by Physician87540                                               M            07/01/2006           $26.62
                                               87540 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
5 - Independent Laboratory        87541                                               M            07/01/2006           $46.59
                                               87541 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
                                  87541
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87541 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
I - Laboratory Billed by Physician87541                                               M            07/01/2006           $46.59
                                               87541 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
5 - Independent Laboratory        87542                                               M            07/01/2006           $55.41
                                               87542 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
                                  87542
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $55.41
                                               87542 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
I - Laboratory Billed by Physician87542                                               M            07/01/2006           $55.41
                                               87542 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA
5 - Independent Laboratory        87550                                               M            07/01/2006           $26.62
                                               87550 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
                                  87550
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87550 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
I - Laboratory Billed by Physician87550                                               M            07/01/2006           $26.62
                                               87550 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
5 - Independent Laboratory        87551                                               M            07/01/2006           $46.59
                                               87551 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
                                  87551
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87551 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
I - Laboratory Billed by Physician87551                                               M            07/01/2006           $46.59
                                               87551 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
5 - Independent Laboratory        87552                                               M            07/01/2006           $56.86
                                               87552 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
                                  87552
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $56.86
                                               87552 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
I - Laboratory Billed by Physician87552                                               M            07/01/2006           $56.86
                                               87552 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES,
5 - Independent Laboratory        87555                                               M            07/01/2006           $26.62
                                               87555 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
                                  87555
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87555 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
I - Laboratory Billed by Physician87555                                               M            07/01/2006           $26.62
                                               87555 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
5 - Independent Laboratory        87556                                               M            07/01/2006           $46.59
                                               87556 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
                                  87556
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87556 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
I - Laboratory Billed by Physician87556                                               M            07/01/2006           $46.59
                                               87556 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
5 - Independent Laboratory        87557                                               M            07/01/2006           $56.86
                                               87557 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
                                  87557
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $56.86
                                               87557 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
I - Laboratory Billed by Physician87557                                               M            07/01/2006           $56.86
                                               87557 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCUL
5 - Independent Laboratory        87560                                               M            07/01/2006           $26.62
                                               87560 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
                                  87560
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87560 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
I - Laboratory Billed by Physician87560                                               M            07/01/2006           $26.62
                                               87560 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
5 - Independent Laboratory        87561                                               M            07/01/2006           $46.59
                                               87561 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
                                  87561
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $46.59
                                               87561 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
I - Laboratory Billed by Physician87561                                               M            07/01/2006           $46.59
                                               87561 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
5 - Independent Laboratory        87562                                               M            07/01/2006           $56.86
                                               87562 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
                                  87562
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $56.86
                                               87562 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
I - Laboratory Billed by Physician87562                                               M            07/01/2006           $56.86
                                               87562 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INT
5 - Independent Laboratory        87580                                               M            07/01/2006           $26.62
                                               87580 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
                                  87580
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006           $26.62
                                               87580 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
I - Laboratory Billed by Physician87580                                               M            07/01/2006           $26.62
                                               87580 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
5 - Independent Laboratory        87581                                               M            07/01/2006           $46.59
                                               87581 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA


 4/22/2012                                                     103 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                               Level 3        Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                            Medicaid/BH      Pricing     Charge
                                  87581
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $46.59
                                               87581 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
I - Laboratory Billed by Physician87581                                               M            07/01/2006          $46.59
                                               87581 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
5 - Independent Laboratory        87582                                               M            07/01/2006          $55.41
                                               87582 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
                                  87582
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $55.41
                                               87582 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
I - Laboratory Billed by Physician87582                                               M            07/01/2006          $55.41
                                               87582 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIA
5 - Independent Laboratory        87590                                               M            07/01/2006          $26.62
                                               87590 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
                                  87590
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $26.62
                                               87590 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
I - Laboratory Billed by Physician87590                                               M            07/01/2006          $26.62
                                               87590 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
5 - Independent Laboratory        87591                                               M            07/01/2006          $46.59
                                               87591 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
                                  87591
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $46.59
                                               87591 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
I - Laboratory Billed by Physician87591                                               M            07/01/2006          $46.59
                                               87591 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
5 - Independent Laboratory        87592                                               M            07/01/2006          $56.86
                                               87592 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
                                  87592
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $56.86
                                               87592 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
I - Laboratory Billed by Physician87592                                               M            07/01/2006          $56.86
                                               87592 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE
5 - Independent Laboratory        87620                                               M            07/01/2006          $26.62
                                               87620 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
                                  87620
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $26.62
                                               87620 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
I - Laboratory Billed by Physician87620                                               M            07/01/2006          $26.62
                                               87620 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
5 - Independent Laboratory        87621                                               M            07/01/2006          $46.59
                                               87621 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
                                  87621
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $46.59
                                               87621 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
I - Laboratory Billed by Physician87621                                               M            07/01/2006          $46.59
                                               87621 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
5 - Independent Laboratory        87622                                               M            07/01/2006          $55.41
                                               87622 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
                                  87622
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $55.41
                                               87622 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
I - Laboratory Billed by Physician87622                                               M            07/01/2006          $55.41
                                               87622 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN,
5 - Independent Laboratory        87640                                               M            01/01/2007          $46.58
                                               87640 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREU
                                  87640
H - Laboratory Billed by Outpatient Hospital                                          M            01/01/2007          $46.58
                                               87640 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREU
I - Laboratory Billed by Physician87640                                               M            01/01/2007          $46.58
                                               87640 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREU
5 - Independent Laboratory        87641                                               M            01/01/2007          $46.58
                                               87641 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREU
                                  87641
H - Laboratory Billed by Outpatient Hospital                                          M            01/01/2007          $46.58
                                               87641 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREU
I - Laboratory Billed by Physician87641                                               M            01/01/2007          $46.58
                                               87641 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREU
5 - Independent Laboratory        87650                                               M            07/01/2006          $26.62
                                               87650 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
                                  87650
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $26.62
                                               87650 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
I - Laboratory Billed by Physician87650                                               M            07/01/2006          $26.62
                                               87650 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
5 - Independent Laboratory        87651                                               M            07/01/2006          $46.59
                                               87651 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
                                  87651
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $46.59
                                               87651 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
I - Laboratory Billed by Physician87651                                               M            07/01/2006          $46.59
                                               87651 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
5 - Independent Laboratory        87652                                               M            07/01/2006          $55.41
                                               87652 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
                                  87652
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $55.41
                                               87652 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
I - Laboratory Billed by Physician87652                                               M            07/01/2006          $55.41
                                               87652 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
5 - Independent Laboratory        87653                                               M            01/01/2007          $46.58
                                               87653 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
                                  87653
H - Laboratory Billed by Outpatient Hospital                                          M            01/01/2007          $46.58
                                               87653 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
I - Laboratory Billed by Physician87653                                               M            01/01/2007          $46.58
                                               87653 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP
5 - Independent Laboratory        87660                                               M            07/01/2006          $26.62
                                               87660 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); TRICHOMONAS VAGINALIS,
                                  87660
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $26.62
                                               87660 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); TRICHOMONAS VAGINALIS,
I - Laboratory Billed by Physician87660                                               M            07/01/2006          $26.62
                                               87660 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); TRICHOMONAS VAGINALIS,
5 - Independent Laboratory        87797                                               M            07/01/2006          $26.62
                                               87797 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
                                  87797
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $26.62
                                               87797 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
I - Laboratory Billed by Physician87797                                               M            07/01/2006          $26.62
                                               87797 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
5 - Independent Laboratory        87798                                               M            07/01/2006          $46.59
                                               87798 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
                                  87798
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $46.59
                                               87798 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
I - Laboratory Billed by Physician87798                                               M            07/01/2006          $46.59
                                               87798 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
5 - Independent Laboratory        87799                                               M            07/01/2006          $56.86
                                               87799 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
                                  87799
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $56.86
                                               87799 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
I - Laboratory Billed by Physician87799                                               M            07/01/2006          $56.86
                                               87799 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED
5 - Independent Laboratory        87800                                               M            07/01/2006          $53.23
                                               87800 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; DIR
                                  87800
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006          $53.23
                                               87800 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; DIR
I - Laboratory Billed by Physician87800                                               M            07/01/2006          $53.23
                                               87800 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; DIR


 4/22/2012                                                    104 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                             Medicaid/BH     Pricing    Charge
5 - Independent Laboratory        87801                                                M           07/01/2006         $93.17
                                               87801 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMP
                                  87801
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $93.17
                                               87801 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMP
I - Laboratory Billed by Physician87801                                                M           07/01/2006         $93.17
                                               87801 - INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMP
5 - Independent Laboratory        87802                                                M           07/01/2006         $15.92
                                               87802 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
                                  87802
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87802 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
I - Laboratory Billed by Physician87802                                                M           07/01/2006         $15.92
                                               87802 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
5 - Independent Laboratory        87803                                                M           07/01/2006         $15.92
                                               87803 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
                                  87803
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87803 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
I - Laboratory Billed by Physician87803                                                M           07/01/2006         $15.92
                                               87803 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
5 - Independent Laboratory        87804                                                M           07/01/2006         $15.92
                                               87804 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
                                  87804
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87804 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
I - Laboratory Billed by Physician87804                                                M           07/01/2006         $15.92
                                               87804 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
5 - Independent Laboratory        87807                                                M           07/01/2006         $15.92
                                               87807 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
                                  87807
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87807 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
I - Laboratory Billed by Physician87807                                                M           07/01/2006         $15.92
                                               87807 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
5 - Independent Laboratory        87808                                                M           01/01/2007         $15.92
                                               87808 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
                                  87808
H - Laboratory Billed by Outpatient Hospital                                           M           01/01/2007         $15.92
                                               87808 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
I - Laboratory Billed by Physician87808                                                M           01/01/2007         $15.92
                                               87808 - INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVA
5 - Independent Laboratory        87810                                                M           07/01/2006         $15.92
                                               87810 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; CH
                                  87810
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87810 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; CH
I - Laboratory Billed by Physician87810                                                M           07/01/2006         $15.92
                                               87810 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; CH
5 - Independent Laboratory        87850                                                M           07/01/2006         $15.92
                                               87850 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; NE
                                  87850
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87850 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; NE
I - Laboratory Billed by Physician87850                                                M           07/01/2006         $15.92
                                               87850 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; NE
5 - Independent Laboratory        87880                                                M           07/01/2006         $15.92
                                               87880 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; ST
                                  87880
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87880 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; ST
I - Laboratory Billed by Physician87880                                                M           07/01/2006         $15.92
                                               87880 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; ST
5 - Independent Laboratory        87899                                                M           07/01/2006         $15.92
                                               87899 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; NO
                                  87899
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $15.92
                                               87899 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; NO
I - Laboratory Billed by Physician87899                                                M           07/01/2006         $15.92
                                               87899 - INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; NO
5 - Independent Laboratory        87900                                                M           07/01/2006        $171.18
                                               87900 - INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION USING REGULARLY UPD
                                  87900
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006        $171.18
                                               87900 - INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION USING REGULARLY UPD
I - Laboratory Billed by Physician87900                                                M           07/01/2006        $171.18
                                               87900 - INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION USING REGULARLY UPD
5 - Independent Laboratory        87901                                                M           07/01/2006        $341.71
                                               87901 - INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA); HIV 1, REVERSE T
                                  87901
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006        $341.71
                                               87901 - INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA); HIV 1, REVERSE T
I - Laboratory Billed by Physician87901                                                M           07/01/2006        $341.71
                                               87901 - INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA); HIV 1, REVERSE T
5 - Independent Laboratory        87902                                                M           07/01/2006        $341.71
                                               87902 - INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C VIRU
                                  87902
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006        $341.71
                                               87902 - INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C VIRU
I - Laboratory Billed by Physician87902                                                M           07/01/2006        $341.71
                                               87902 - INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C VIRU
5 - Independent Laboratory        87903                                                M           07/01/2006        $648.58
                                               87903 - INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RES
                                  87903
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006        $648.58
                                               87903 - INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RES
I - Laboratory Billed by Physician87903                                                M           07/01/2006        $648.58
                                               87903 - INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RES
5 - Independent Laboratory        87904                                                M           07/01/2006         $34.60
                                               87904 - INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RES
                                  87904
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $34.60
                                               87904 - INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RES
I - Laboratory Billed by Physician87904                                                M           07/01/2006         $34.60
                                               87904 - INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RES
5 - Independent Laboratory        88104                                                M           07/01/2006         $24.45
                                               88104 - CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SME
                                  88104
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $24.45
                                               88104 - CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SME
5 - Independent Laboratory        88106                                                M           07/01/2006         $27.80
                                               88106 - CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SIMP
                                  88106
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $27.80
                                               88106 - CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SIMP
5 - Independent Laboratory        88107                                                M           07/01/2006         $34.33
                                               88107 - CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SME
                                  88107
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $34.33
                                               88107 - CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SME
5 - Independent Laboratory        88108        88108 - CYTOPATHOLOGY, CONCENTRATION M              07/01/2006         $30.81
                                                                                       TECHNIQUE, SMEARS AND INTERPRETATION (EG, SACC
                                  88108
H - Laboratory Billed by Outpatient Hospital   88108 - CYTOPATHOLOGY, CONCENTRATION M              07/01/2006         $30.81
                                                                                       TECHNIQUE, SMEARS AND INTERPRETATION (EG, SACC
5 - Independent Laboratory        88112                                                M           07/01/2006        $127.78
                                               88112 - CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE WITH INTERPRETATION
                                  88112
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006        $127.78
                                               88112 - CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE WITH INTERPRETATION
I - Laboratory Billed by Physician88112                                                M           07/01/2006        $127.78
                                               88112 - CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE WITH INTERPRETATION


 4/22/2012                                                     105 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3      Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                             Medicaid/BH     Pricing    Charge
5 - Independent Laboratory        88125                                                M
                                               88125 - CYTOPATHOLOGY, FORENSIC (EG, SPERM)         07/01/2006           $8.82
                                  88125
H - Laboratory Billed by Outpatient Hospital                                           M
                                               88125 - CYTOPATHOLOGY, FORENSIC (EG, SPERM)         07/01/2006           $8.82
5 - Independent Laboratory        88130                                                M
                                               88130 - SEX CHROMATIN IDENTIFICATION; BARR BODIES   07/01/2006         $19.97
                                  88130
H - Laboratory Billed by Outpatient Hospital                                           M
                                               88130 - SEX CHROMATIN IDENTIFICATION; BARR BODIES   07/01/2006         $19.97
I - Laboratory Billed by Physician88130                                                M
                                               88130 - SEX CHROMATIN IDENTIFICATION; BARR BODIES   07/01/2006         $19.97
5 - Independent Laboratory        88140                                                M           07/01/2006         $10.61
                                               88140 - SEX CHROMATIN IDENTIFICATION; PERIPHERAL BLOOD SMEAR, POLYMORPHONUCLEAR DRU
                                  88140
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $10.61
                                               88140 - SEX CHROMATIN IDENTIFICATION; PERIPHERAL BLOOD SMEAR, POLYMORPHONUCLEAR DRU
I - Laboratory Billed by Physician88140                                                M           07/01/2006         $10.61
                                               88140 - SEX CHROMATIN IDENTIFICATION; PERIPHERAL BLOOD SMEAR, POLYMORPHONUCLEAR DRU
5 - Independent Laboratory        88141                                                M           07/01/2006           $9.58
                                               88141 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), REQUIRING INTERPRE
                                  88141
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006           $9.58
                                               88141 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), REQUIRING INTERPRE
5 - Independent Laboratory        88142                                                M           07/01/2006         $26.89
                                               88142 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
                                  88142
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $26.89
                                               88142 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
I - Laboratory Billed by Physician88142                                                M           07/01/2006         $26.89
                                               88142 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
5 - Independent Laboratory        88143                                                M           07/01/2006         $26.89
                                               88143 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
                                  88143
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $26.89
                                               88143 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
I - Laboratory Billed by Physician88143                                                M           07/01/2006         $26.89
                                               88143 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
5 - Independent Laboratory        88147                                                M            SCREENING BY AUTOMATED SYSTEM UN
                                               88147 - CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL;07/01/2006           $15.11
                                  88147
H - Laboratory Billed by Outpatient Hospital                                           M            SCREENING BY AUTOMATED SYSTEM UN
                                               88147 - CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL;07/01/2006           $15.11
I - Laboratory Billed by Physician88147                                                M            SCREENING BY AUTOMATED SYSTEM UN
                                               88147 - CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL;07/01/2006           $15.11
5 - Independent Laboratory        88148                                                M            SCREENING BY AUTOMATED SYSTEM WI
                                               88148 - CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL;07/01/2006           $20.17
                                  88148
H - Laboratory Billed by Outpatient Hospital                                           M            SCREENING BY AUTOMATED SYSTEM WI
                                               88148 - CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL;07/01/2006           $20.17
I - Laboratory Billed by Physician88148                                                M            SCREENING BY AUTOMATED SYSTEM WI
                                               88148 - CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL;07/01/2006           $20.17
5 - Independent Laboratory        88150                                                M           07/01/2006         $14.76
                                               88150 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING UNDER PHYSICIAN S
                                  88150
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88150 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING UNDER PHYSICIAN S
I - Laboratory Billed by Physician88150                                                M           07/01/2006         $14.76
                                               88150 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING UNDER PHYSICIAN S
5 - Independent Laboratory        88152                                                M           07/01/2006         $14.76
                                               88152 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTE
                                  88152
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88152 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTE
I - Laboratory Billed by Physician88152                                                M           07/01/2006         $14.76
                                               88152 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTE
5 - Independent Laboratory        88153                                                M           07/01/2006         $14.76
                                               88153 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND RESCREE
                                  88153
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88153 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND RESCREE
I - Laboratory Billed by Physician88153                                                M           07/01/2006         $14.76
                                               88153 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND RESCREE
5 - Independent Laboratory        88154                                                M           07/01/2006         $14.76
                                               88154 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTE
                                  88154
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88154 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTE
I - Laboratory Billed by Physician88154                                                M           07/01/2006         $14.76
                                               88154 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTE
5 - Independent Laboratory        88155                                                M           07/01/2006            EVALUATION (EG,
                                               88155 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL, DEFINITIVE HORMONAL$7.39
                                  88155
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006            EVALUATION (EG,
                                               88155 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL, DEFINITIVE HORMONAL$7.39
I - Laboratory Billed by Physician88155                                                M           07/01/2006            EVALUATION (EG,
                                               88155 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL, DEFINITIVE HORMONAL$7.39
5 - Independent Laboratory        88160                                                M           07/01/2006         $23.14
                                               88160 - CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND INTERPRETATION
                                  88160
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $23.14
                                               88160 - CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND INTERPRETATION
5 - Independent Laboratory        88161                                                M           07/01/2006         $25.09
                                               88161 - CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; PREPARATION, SCREENING AND INTERPR
                                  88161
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $25.09
                                               88161 - CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; PREPARATION, SCREENING AND INTERPR
5 - Independent Laboratory        88162                                                M           07/01/2006         $30.76
                                               88162 - CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; EXTENDED STUDY INVOLVING OVER 5 SLID
                                  88162
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $30.76
                                               88162 - CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; EXTENDED STUDY INVOLVING OVER 5 SLID
5 - Independent Laboratory        88164                                                M           07/01/2006         $14.76
                                               88164 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); MANUAL SCREE
                                  88164
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88164 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); MANUAL SCREE
I - Laboratory Billed by Physician88164                                                M           07/01/2006         $14.76
                                               88164 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); MANUAL SCREE
5 - Independent Laboratory        88165                                                M           07/01/2006         $14.76
                                               88165 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
                                  88165
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88165 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
I - Laboratory Billed by Physician88165                                                M           07/01/2006         $14.76
                                               88165 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
5 - Independent Laboratory        88166                                                M           07/01/2006         $14.76
                                               88166 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
                                  88166
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88166 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
I - Laboratory Billed by Physician88166                                                M           07/01/2006         $14.76
                                               88166 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
5 - Independent Laboratory        88167                                                M           07/01/2006         $14.76
                                               88167 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
                                  88167
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006         $14.76
                                               88167 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
I - Laboratory Billed by Physician88167                                                M           07/01/2006         $14.76
                                               88167 - CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL S
5 - Independent Laboratory        88172                                                M           07/01/2006         $22.97
                                               88172 - CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC ST


 4/22/2012                                                     106 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                    Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                             Medicaid/BH     Pricing    Charge
                                  88172
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $22.97
                                               88172 - CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC ST
5 - Independent Laboratory        88173                                               M            07/01/2006         $60.82
                                               88173 - CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; INTERPRETATION AND REPORT
                                  88173
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $60.82
                                               88173 - CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; INTERPRETATION AND REPORT
5 - Independent Laboratory        88174                                               M            07/01/2006         $28.36
                                               88174 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
                                  88174
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $28.36
                                               88174 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
I - Laboratory Billed by Physician88174                                               M            07/01/2006         $28.36
                                               88174 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
5 - Independent Laboratory        88175                                               M            07/01/2006         $35.16
                                               88175 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
                                  88175
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006         $35.16
                                               88175 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
I - Laboratory Billed by Physician88175                                               M            07/01/2006         $35.16
                                               88175 - CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESE
5 - Independent Laboratory        88182                                               M
                                               88182 - FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS 07/01/2006          $39.20
                                  88182
H - Laboratory Billed by Outpatient Hospital                                          M
                                               88182 - FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS 07/01/2006          $39.20
5 - Independent Laboratory        88184                                               M            OR NUCLEAR MARKER, TECHNICAL COMP
                                               88184 - FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC,07/01/2006           $22.42
                                  88184
H - Laboratory Billed by Outpatient Hospital                                          M            OR NUCLEAR MARKER, TECHNICAL COMP
                                               88184 - FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC,07/01/2006           $22.42
5 - Independent Laboratory        88185                                               M            OR NUCLEAR MARKER, TECHNICAL COMP
                                               88185 - FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC,07/01/2006           $22.42
                                  88185
H - Laboratory Billed by Outpatient Hospital                                          M            OR NUCLEAR MARKER, TECHNICAL COMP
                                               88185 - FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC,07/01/2006           $22.42
5 - Independent Laboratory        88187                                               M            07/01/2006
                                               88187 - FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS                 $35.36
                                  88187
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006
                                               88187 - FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS                 $35.36
5 - Independent Laboratory        88188                                               M            07/01/2006
                                               88188 - FLOW CYTOMETRY, INTERPRETATION; 9 TO 15 MARKERS                $35.36
                                  88188
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006
                                               88188 - FLOW CYTOMETRY, INTERPRETATION; 9 TO 15 MARKERS                $35.36
5 - Independent Laboratory        88189                                               M            MARKERS
                                               88189 - FLOW CYTOMETRY, INTERPRETATION; 16 OR MORE 07/01/2006          $35.36
                                  88189
H - Laboratory Billed by Outpatient Hospital                                          M            MARKERS
                                               88189 - FLOW CYTOMETRY, INTERPRETATION; 16 OR MORE 07/01/2006          $35.36
5 - Independent Laboratory        88230                                               M            07/01/2006
                                               88230 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; LYMPHOCYTE       $154.63
                                  88230
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006
                                               88230 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; LYMPHOCYTE       $154.63
I - Laboratory Billed by Physician88230                                               M            07/01/2006
                                               88230 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; LYMPHOCYTE       $154.63
5 - Independent Laboratory        88233                                               M            07/01/2006        $186.80
                                               88233 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; SKIN OR OTHER SOLID TISSUE BIOPSY
                                  88233
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006        $186.80
                                               88233 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; SKIN OR OTHER SOLID TISSUE BIOPSY
I - Laboratory Billed by Physician88233                                               M            07/01/2006        $186.80
                                               88233 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; SKIN OR OTHER SOLID TISSUE BIOPSY
5 - Independent Laboratory        88235                                               M            07/01/2006        $195.45
                                               88235 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; AMNIOTIC FLUID OR CHORIONIC VILLUS
                                  88235
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006        $195.45
                                               88235 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; AMNIOTIC FLUID OR CHORIONIC VILLUS
I - Laboratory Billed by Physician88235                                               M            07/01/2006        $195.45
                                               88235 - TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; AMNIOTIC FLUID OR CHORIONIC VILLUS
5 - Independent Laboratory        88237                                               M            07/01/2006        $167.65
                                               88237 - TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE MARROW, BLOOD CELLS
                                  88237
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006        $167.65
                                               88237 - TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE MARROW, BLOOD CELLS
I - Laboratory Billed by Physician88237                                               M            07/01/2006        $167.65
                                               88237 - TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE MARROW, BLOOD CELLS
5 - Independent Laboratory        88239                                               M            07/01/2006
                                               88239 - TISSUE CULTURE FOR NEOPLASTIC DISORDERS; SOLID TUMOR          $195.81
                                  88239
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006
                                               88239 - TISSUE CULTURE FOR NEOPLASTIC DISORDERS; SOLID TUMOR          $195.81
I - Laboratory Billed by Physician88239                                               M            07/01/2006
                                               88239 - TISSUE CULTURE FOR NEOPLASTIC DISORDERS; SOLID TUMOR          $195.81
5 - Independent Laboratory        88240                                               M            CELLS, EACH CELL LINE
                                               88240 - CRYOPRESERVATION, FREEZING AND STORAGE OF07/01/2006            $13.40
                                  88240
H - Laboratory Billed by Outpatient Hospital                                          M            CELLS, EACH CELL LINE
                                               88240 - CRYOPRESERVATION, FREEZING AND STORAGE OF07/01/2006            $13.40
I - Laboratory Billed by Physician88240                                               M            CELLS, EACH CELL LINE
                                               88240 - CRYOPRESERVATION, FREEZING AND STORAGE OF07/01/2006            $13.40
5 - Independent Laboratory        88241                                               M            07/01/2006
                                               88241 - THAWING AND EXPANSION OF FROZEN CELLS, EACH ALIQUOT            $13.40
                                  88241
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006
                                               88241 - THAWING AND EXPANSION OF FROZEN CELLS, EACH ALIQUOT            $13.40
I - Laboratory Billed by Physician88241                                               M            07/01/2006
                                               88241 - THAWING AND EXPANSION OF FROZEN CELLS, EACH ALIQUOT            $13.40
5 - Independent Laboratory        88245                                               M            07/01/2006        $197.58
                                               88245 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE SISTER CHROMATID EXCH
                                  88245
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006        $197.58
                                               88245 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE SISTER CHROMATID EXCH
I - Laboratory Billed by Physician88245                                               M            07/01/2006        $197.58
                                               88245 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE SISTER CHROMATID EXCH
5 - Independent Laboratory        88248                                               M            07/01/2006        $229.86
                                               88248 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE BREAKAGE, SCORE 50-100
                                  88248
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006        $229.86
                                               88248 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE BREAKAGE, SCORE 50-100
I - Laboratory Billed by Physician88248                                               M            07/01/2006        $229.86
                                               88248 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE BREAKAGE, SCORE 50-100
5 - Independent Laboratory        88249                                               M            07/01/2006        $229.86
                                               88249 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; SCORE 100 CELLS, CLASTOGEN STR
                                  88249
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006        $229.86
                                               88249 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; SCORE 100 CELLS, CLASTOGEN STR
I - Laboratory Billed by Physician88249                                               M            07/01/2006        $229.86
                                               88249 - CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; SCORE 100 CELLS, CLASTOGEN STR
5 - Independent Laboratory        88261                                               M            07/01/2006
                                               88261 - CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING $234.58
                                  88261
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006
                                               88261 - CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING $234.58
I - Laboratory Billed by Physician88261                                               M            07/01/2006
                                               88261 - CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING $234.58
5 - Independent Laboratory        88262                                               M            07/01/2006        $165.43
                                               88262 - CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 KARYOTYPES, WITH BANDING
                                  88262
H - Laboratory Billed by Outpatient Hospital                                          M            07/01/2006        $165.43
                                               88262 - CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 KARYOTYPES, WITH BANDING


 4/22/2012                                                    107 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3       Level 3  LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH     Pricing    Charge
I - Laboratory Billed by Physician88262                                                  M           07/01/2006        $165.43
                                               88262 - CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 KARYOTYPES, WITH BANDING
5 - Independent Laboratory        88263        88263 - CHROMOSOME ANALYSIS; COUNT 45 M               07/01/2006        $199.47
                                                                                         CELLS FOR MOSAICISM, 2 KARYOTYPES, WITH BANDING
                                  88263
H - Laboratory Billed by Outpatient Hospital   88263 - CHROMOSOME ANALYSIS; COUNT 45 M               07/01/2006        $199.47
                                                                                         CELLS FOR MOSAICISM, 2 KARYOTYPES, WITH BANDING
I - Laboratory Billed by Physician88263        88263 - CHROMOSOME ANALYSIS; COUNT 45 M               07/01/2006        $199.47
                                                                                         CELLS FOR MOSAICISM, 2 KARYOTYPES, WITH BANDING
5 - Independent Laboratory        88264                                                  M
                                               88264 - CHROMOSOME ANALYSIS; ANALYZE 20-25 CELLS      07/01/2006        $165.43
                                  88264
H - Laboratory Billed by Outpatient Hospital                                             M
                                               88264 - CHROMOSOME ANALYSIS; ANALYZE 20-25 CELLS      07/01/2006        $165.43
I - Laboratory Billed by Physician88264                                                  M
                                               88264 - CHROMOSOME ANALYSIS; ANALYZE 20-25 CELLS      07/01/2006        $165.43
5 - Independent Laboratory        88267                                                  M           07/01/2006        $238.61
                                               88267 - CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR CHORIONIC VILLUS, COUNT 15 CELLS, 1 KARYO
                                  88267
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $238.61
                                               88267 - CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR CHORIONIC VILLUS, COUNT 15 CELLS, 1 KARYO
I - Laboratory Billed by Physician88267                                                  M           07/01/2006        $238.61
                                               88267 - CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR CHORIONIC VILLUS, COUNT 15 CELLS, 1 KARYO
5 - Independent Laboratory        88269                                                  M           07/01/2006        $220.76
                                               88269 - CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC FLUID CELLS, COUNT CELLS FROM 6-12 COL
                                  88269
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006        $220.76
                                               88269 - CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC FLUID CELLS, COUNT CELLS FROM 6-12 COL
I - Laboratory Billed by Physician88269                                                  M           07/01/2006        $220.76
                                               88269 - CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC FLUID CELLS, COUNT CELLS FROM 6-12 COL
5 - Independent Laboratory        88271                                                  M           07/01/2006
                                               88271 - MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH)               $28.43
                                  88271
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88271 - MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH)               $28.43
I - Laboratory Billed by Physician88271                                                  M           07/01/2006
                                               88271 - MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH)               $28.43
5 - Independent Laboratory        88272                                                  M           07/01/2006         $28.81
                                               88272 - MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 3-5 CELLS (E
                                  88272
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006         $28.81
                                               88272 - MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 3-5 CELLS (E
I - Laboratory Billed by Physician88272                                                  M           07/01/2006         $28.81
                                               88272 - MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 3-5 CELLS (E
5 - Independent Laboratory        88273                                                  M           07/01/2006         $28.81
                                               88273 - MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 10-30 CELLS
                                  88273
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006         $28.81
                                               88273 - MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 10-30 CELLS
I - Laboratory Billed by Physician88273                                                  M           07/01/2006         $28.81
                                               88273 - MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 10-30 CELLS
5 - Independent Laboratory        88274                                                  M           07/01/2006         $28.81
                                               88274 - MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 25-99 CELLS
                                  88274
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006         $28.81
                                               88274 - MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 25-99 CELLS
I - Laboratory Billed by Physician88274                                                  M           07/01/2006         $28.81
                                               88274 - MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 25-99 CELLS
5 - Independent Laboratory        88275                                                  M           07/01/2006         $28.81
                                               88275 - MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 100-300 CELLS
                                  88275
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006         $28.81
                                               88275 - MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 100-300 CELLS
I - Laboratory Billed by Physician88275                                                  M           07/01/2006         $28.81
                                               88275 - MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 100-300 CELLS
5 - Independent Laboratory        88280                                                  M           07/01/2006
                                               88280 - CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPES, EACH STUDY           $33.32
                                  88280
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88280 - CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPES, EACH STUDY           $33.32
I - Laboratory Billed by Physician88280                                                  M           07/01/2006
                                               88280 - CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPES, EACH STUDY           $33.32
5 - Independent Laboratory        88283                                                  M           07/01/2006         $91.05
                                               88283 - CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED BANDING TECHNIQUE (EG, NOR, C-BAND
                                  88283
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006         $91.05
                                               88283 - CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED BANDING TECHNIQUE (EG, NOR, C-BAND
I - Laboratory Billed by Physician88283                                                  M           07/01/2006         $91.05
                                               88283 - CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED BANDING TECHNIQUE (EG, NOR, C-BAND
5 - Independent Laboratory        88285                                                  M           07/01/2006
                                               88285 - CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED, EACH STUDY $25.21
                                  88285
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88285 - CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED, EACH STUDY $25.21
I - Laboratory Billed by Physician88285                                                  M           07/01/2006
                                               88285 - CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED, EACH STUDY $25.21
5 - Independent Laboratory        88289                                                  M           07/01/2006
                                               88289 - CHROMOSOME ANALYSIS; ADDITIONAL HIGH RESOLUTION STUDY            $45.70
                                  88289
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88289 - CHROMOSOME ANALYSIS; ADDITIONAL HIGH RESOLUTION STUDY            $45.70
I - Laboratory Billed by Physician88289                                                  M           07/01/2006
                                               88289 - CHROMOSOME ANALYSIS; ADDITIONAL HIGH RESOLUTION STUDY            $45.70
5 - Independent Laboratory        88291                                                  M           07/01/2006
                                               88291 - CYTOGENETICS AND MOLECULAR CYTOGENETICS, INTERPRETATION AND$11.52  REPORT
                                  88291
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88291 - CYTOGENETICS AND MOLECULAR CYTOGENETICS, INTERPRETATION AND$11.52  REPORT
5 - Independent Laboratory        88300                                                  M           07/01/2006
                                               88300 - LEVEL I - SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY               $9.50
                                  88300
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88300 - LEVEL I - SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY               $9.50
5 - Independent Laboratory        88302                                                  M           07/01/2006
                                               88302 - LEVEL II - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION $20.67
                                  88302
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88302 - LEVEL II - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION $20.67
5 - Independent Laboratory        88304                                                  M           07/01/2006
                                               88304 - LEVEL III - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION$27.22
                                  88304
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88304 - LEVEL III - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION$27.22
5 - Independent Laboratory        88305                                                  M           07/01/2006
                                               88305 - LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION $46.60
                                  88305
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88305 - LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION $46.60
5 - Independent Laboratory        88307                                                  M           07/01/2006
                                               88307 - LEVEL V - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION  $82.52
                                  88307
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88307 - LEVEL V - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION  $82.52
5 - Independent Laboratory        88309                                                  M           07/01/2006
                                               88309 - LEVEL VI - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION$115.65
                                  88309
H - Laboratory Billed by Outpatient Hospital                                             M           07/01/2006
                                               88309 - LEVEL VI - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION$115.65
5 - Independent Laboratory        88311        88311 - DECALCIFICATION PROCEDURE (LISTM              07/01/2006           $8.14
                                                                                         SEPARATELY IN ADDITION TO CODE FOR SURGICAL PAT
                                  88311
H - Laboratory Billed by Outpatient Hospital   88311 - DECALCIFICATION PROCEDURE (LISTM              07/01/2006           $8.14
                                                                                         SEPARATELY IN ADDITION TO CODE FOR SURGICAL PAT


 4/22/2012                                                     108 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                     Level 3       Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
             Desc                    Code                                                  Medicaid/BH      Pricing   Charge
5 - Independent Laboratory       88312                                                     M             CODE FOR          $35.83
                                               88312 - SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO07/01/2006 PRIMARY SERVICE); GROUP I
                                 88312
H - Laboratory Billed by Outpatient Hospital                                               M             CODE FOR          $35.83
                                               88312 - SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO07/01/2006 PRIMARY SERVICE); GROUP I
5 - Independent Laboratory       88313                                                     M             CODE FOR          $26.17
                                               88313 - SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO07/01/2006 PRIMARY SERVICE); GROUP II
                                 88313
H - Laboratory Billed by Outpatient Hospital                                               M             CODE FOR          $26.17
                                               88313 - SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO07/01/2006 PRIMARY SERVICE); GROUP II
5 - Independent Laboratory       88314                                                     M             CODE FOR          $44.08
                                               88314 - SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO07/01/2006 PRIMARY SERVICE); HISTOCH
                                 88314
H - Laboratory Billed by Outpatient Hospital                                               M             CODE FOR          $44.08
                                               88314 - SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO07/01/2006 PRIMARY SERVICE); HISTOCH
5 - Independent Laboratory       88318                                                     M            07/01/2006         $36.22
                                               88318 - DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL COMPONENTS (EG, COPPER, ZINC
                                 88318
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $36.22
                                               88318 - DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL COMPONENTS (EG, COPPER, ZINC
5 - Independent Laboratory       88319                                                     M            07/01/2006         $40.56
                                               88319 - DETERMINATIVE HISTOCHEMISTRY OR CYTOCHEMISTRY TO IDENTIFY ENZYME CONSTITUENT
                                 88319
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $40.56
                                               88319 - DETERMINATIVE HISTOCHEMISTRY OR CYTOCHEMISTRY TO IDENTIFY ENZYME CONSTITUENT
5 - Independent Laboratory       88321                                                     M            07/01/2006
                                               88321 - CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED ELSEWHERE       $35.26
                                 88321
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006
                                               88321 - CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED ELSEWHERE       $35.26
5 - Independent Laboratory       88323                                                     M            07/01/2006         $53.82
                                               88323 - CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPARATION OF SLIDES
                                 88323
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $53.82
                                               88323 - CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPARATION OF SLIDES
5 - Independent Laboratory       88325                                                     M            07/01/2006         $88.21
                                               88325 - CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND SPECIMENS, WITH REPO
                                 88325
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $88.21
                                               88325 - CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND SPECIMENS, WITH REPO
5 - Independent Laboratory       88329         88329 - PATHOLOGY CONSULTATION DURINGM       SURGERY;    07/01/2006         $22.52
                                 88329
H - Laboratory Billed by Outpatient Hospital   88329 - PATHOLOGY CONSULTATION DURINGM       SURGERY;    07/01/2006         $22.52
5 - Independent Laboratory       88331         88331 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006         $39.41
                                                                                            SURGERY; FIRST TISSUE BLOCK, WITH FROZEN SECTIO
                                 88331
H - Laboratory Billed by Outpatient Hospital   88331 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006         $39.41
                                                                                            SURGERY; FIRST TISSUE BLOCK, WITH FROZEN SECTIO
5 - Independent Laboratory       88332         88332 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006         $18.03
                                                                                            SURGERY; EACH ADDITIONAL TISSUE BLOCK WITH FRO
                                 88332
H - Laboratory Billed by Outpatient Hospital   88332 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006         $18.03
                                                                                            SURGERY; EACH ADDITIONAL TISSUE BLOCK WITH FRO
5 - Independent Laboratory       88333         88333 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006         $13.13
                                                                                            SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREP
                                 88333
H - Laboratory Billed by Outpatient Hospital   88333 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006         $13.13
                                                                                            SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREP
5 - Independent Laboratory       88334         88334 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006          $8.04
                                                                                            SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREP
                                 88334
H - Laboratory Billed by Outpatient Hospital   88334 - PATHOLOGY CONSULTATION DURINGM                   07/01/2006          $8.04
                                                                                            SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREP
5 - Independent Laboratory       88342                                                     M            07/01/2006         $39.96
                                               88342 - IMMUNOHISTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), EACH ANTIBODY
                                 88342
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $39.96
                                               88342 - IMMUNOHISTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), EACH ANTIBODY
5 - Independent Laboratory       88346                                                     M            07/01/2006
                                               88346 - IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD               $42.06
                                 88346
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006
                                               88346 - IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD               $42.06
5 - Independent Laboratory       88347                                                     M            07/01/2006
                                               88347 - IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; INDIRECT METHOD             $36.83
                                 88347
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006
                                               88347 - IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; INDIRECT METHOD             $36.83
5 - Independent Laboratory       88348         88348 - ELECTRON MICROSCOPY; DIAGNOSTIC     M            07/01/2006        $227.78
                                 88348
H - Laboratory Billed by Outpatient Hospital   88348 - ELECTRON MICROSCOPY; DIAGNOSTIC     M            07/01/2006        $227.78
5 - Independent Laboratory       88349         88349 - ELECTRON MICROSCOPY; SCANNINGM                   07/01/2006         $76.19
                                 88349
H - Laboratory Billed by Outpatient Hospital   88349 - ELECTRON MICROSCOPY; SCANNINGM                   07/01/2006         $76.19
5 - Independent Laboratory       88355                                                     M
                                               88355 - MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE           07/01/2006        $186.09
                                 88355
H - Laboratory Billed by Outpatient Hospital                                               M
                                               88355 - MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE           07/01/2006        $186.09
5 - Independent Laboratory       88356         88356 - MORPHOMETRIC ANALYSIS; NERVE M                   07/01/2006        $124.36
                                 88356
H - Laboratory Billed by Outpatient Hospital   88356 - MORPHOMETRIC ANALYSIS; NERVE M                   07/01/2006        $124.36
5 - Independent Laboratory       88358                                                     M
                                               88358 - MORPHOMETRIC ANALYSIS; TUMOR (EG, DNA PLOIDY)    07/01/2006        $102.54
                                 88358
H - Laboratory Billed by Outpatient Hospital                                               M
                                               88358 - MORPHOMETRIC ANALYSIS; TUMOR (EG, DNA PLOIDY)    07/01/2006        $102.54
5 - Independent Laboratory       88360                                                     M            07/01/2006         $76.08
                                               88360 - MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/ NEU, ESTROGEN R
                                 88360
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $76.08
                                               88360 - MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/ NEU, ESTROGEN R
5 - Independent Laboratory       88361                                                     M            07/01/2006         $74.54
                                               88361 - MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/ NEU, ESTROGEN R
                                 88361
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $74.54
                                               88361 - MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/ NEU, ESTROGEN R
5 - Independent Laboratory       88362         88362 - NERVE TEASING PREPARATIONS          M            07/01/2006        $119.48
                                 88362
H - Laboratory Billed by Outpatient Hospital   88362 - NERVE TEASING PREPARATIONS          M            07/01/2006        $119.48
5 - Independent Laboratory       88365                                                     M
                                               88365 - IN SITU HYBRIDIZATION (EG, FISH), EACH PROBE     07/01/2006         $67.07
                                 88365
H - Laboratory Billed by Outpatient Hospital                                               M
                                               88365 - IN SITU HYBRIDIZATION (EG, FISH), EACH PROBE     07/01/2006         $67.07
5 - Independent Laboratory       88367                                                     M            07/01/2006         $76.08
                                               88367 - MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE OR SEMI-QUANTITATIVE)
                                 88367
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $76.08
                                               88367 - MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE OR SEMI-QUANTITATIVE)
5 - Independent Laboratory       88368                                                     M            07/01/2006         $76.08
                                               88368 - MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE OR SEMI-QUANTITATIVE)
                                 88368
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $76.08
                                               88368 - MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE OR SEMI-QUANTITATIVE)
5 - Independent Laboratory       88371                                                     M            07/01/2006         $29.50
                                               88371 - PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT;
                                 88371
H - Laboratory Billed by Outpatient Hospital                                               M            07/01/2006         $29.50
                                               88371 - PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT;


 4/22/2012                                                     109 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                  Level 3        Level 3 LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                               Medicaid/BH      Pricing    Charge
I - Laboratory Billed by Physician88371                                                  M            07/01/2006        $29.50
                                               88371 - PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT;
5 - Independent Laboratory        88372                                                  M            07/01/2006        $30.20
                                               88372 - PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT; IMM
                                  88372
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $30.20
                                               88372 - PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT; IMM
I - Laboratory Billed by Physician88372                                                  M            07/01/2006        $30.20
                                               88372 - PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT; IMM
5 - Independent Laboratory        88385                                                  M            07/01/2006       $146.90
                                               88385 - ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 51 THROUGH 250 PROBES
                                  88385
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006       $146.90
                                               88385 - ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 51 THROUGH 250 PROBES
5 - Independent Laboratory        88386                                                  M            07/01/2006       $142.27
                                               88386 - ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 251 THROUGH 500 PROBES
                                  88386
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006       $142.27
                                               88386 - ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 251 THROUGH 500 PROBES
5 - Independent Laboratory        88400        88400 - BILIRUBIN, TOTAL, TRANSCUTANEOUS  M            07/01/2006          $6.67
                                  88400
H - Laboratory Billed by Outpatient Hospital   88400 - BILIRUBIN, TOTAL, TRANSCUTANEOUS  M            07/01/2006          $6.67
I - Laboratory Billed by Physician88400        88400 - BILIRUBIN, TOTAL, TRANSCUTANEOUS  M            07/01/2006          $6.67
5 - Independent Laboratory        89049                                                  M            07/01/2006       $104.15
                                               89049 - CAFFEINE HALOTHANE CONTRACTURE TEST (CHCT) FOR MALIGNANT HYPERTHERMIA SUSCE
                                  89049
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006       $104.05
                                               89049 - CAFFEINE HALOTHANE CONTRACTURE TEST (CHCT) FOR MALIGNANT HYPERTHERMIA SUSCE
5 - Independent Laboratory        89050        89050 - CELL COUNT, MISCELLANEOUS BODYM                07/01/2006           JOINT
                                                                                         FLUIDS (EG, CEREBROSPINAL FLUID,$6.28 FLUID), EXC
                                  89050
H - Laboratory Billed by Outpatient Hospital   89050 - CELL COUNT, MISCELLANEOUS BODYM                07/01/2006           JOINT
                                                                                         FLUIDS (EG, CEREBROSPINAL FLUID,$6.28 FLUID), EXC
I - Laboratory Billed by Physician89050        89050 - CELL COUNT, MISCELLANEOUS BODYM                07/01/2006           JOINT
                                                                                         FLUIDS (EG, CEREBROSPINAL FLUID,$6.28 FLUID), EXC
5 - Independent Laboratory        89051        89051 - CELL COUNT, MISCELLANEOUS BODYM                07/01/2006           JOINT
                                                                                         FLUIDS (EG, CEREBROSPINAL FLUID,$7.32 FLUID), EXC
                                  89051
H - Laboratory Billed by Outpatient Hospital   89051 - CELL COUNT, MISCELLANEOUS BODYM                07/01/2006           JOINT
                                                                                         FLUIDS (EG, CEREBROSPINAL FLUID,$7.32 FLUID), EXC
I - Laboratory Billed by Physician89051        89051 - CELL COUNT, MISCELLANEOUS BODYM                07/01/2006           JOINT
                                                                                         FLUIDS (EG, CEREBROSPINAL FLUID,$7.32 FLUID), EXC
5 - Independent Laboratory        89055                                                  M             SEMIQUANTITATIVE $5.66
                                               89055 - LEUKOCYTE ASSESSMENT, FECAL, QUALITATIVE OR07/01/2006
                                  89055
H - Laboratory Billed by Outpatient Hospital                                             M             SEMIQUANTITATIVE $5.66
                                               89055 - LEUKOCYTE ASSESSMENT, FECAL, QUALITATIVE OR07/01/2006
I - Laboratory Billed by Physician89055                                                  M             SEMIQUANTITATIVE $5.66
                                               89055 - LEUKOCYTE ASSESSMENT, FECAL, QUALITATIVE OR07/01/2006
5 - Independent Laboratory        89060                                                  M            07/01/2006          $9.49
                                               89060 - CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANAL
                                  89060
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006          $9.49
                                               89060 - CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANAL
I - Laboratory Billed by Physician89060                                                  M            07/01/2006          $9.49
                                               89060 - CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANAL
5 - Independent Laboratory        89100                                                  M            07/01/2006        $42.26
                                               89100 - DUODENAL INTUBATION AND ASPIRATION; SINGLE SPECIMEN (EG, SIMPLE BILE STUDY OR AF
                                  89100
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $42.26
                                               89100 - DUODENAL INTUBATION AND ASPIRATION; SINGLE SPECIMEN (EG, SIMPLE BILE STUDY OR AF
5 - Independent Laboratory        89105                                                  M            07/01/2006        $47.43
                                               89105 - DUODENAL INTUBATION AND ASPIRATION; COLLECTION OF MULTIPLE FRACTIONAL SPECIMEN
                                  89105
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $47.43
                                               89105 - DUODENAL INTUBATION AND ASPIRATION; COLLECTION OF MULTIPLE FRACTIONAL SPECIMEN
5 - Independent Laboratory        89125                                                  M            07/01/2006
                                               89125 - FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS                 $5.73
                                  89125
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006
                                               89125 - FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS                 $5.73
I - Laboratory Billed by Physician89125                                                  M            07/01/2006
                                               89125 - FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS                 $5.73
5 - Independent Laboratory        89130                                                  M            07/01/2006        $38.16
                                               89130 - GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, FOR CHEMICAL ANAL
                                  89130
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $38.16
                                               89130 - GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, FOR CHEMICAL ANAL
5 - Independent Laboratory        89132                                                  M            07/01/2006        $30.54
                                               89132 - GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, FOR CHEMICAL ANAL
                                  89132
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $30.54
                                               89132 - GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, FOR CHEMICAL ANAL
5 - Independent Laboratory        89135                                                  M            07/01/2006         GASTRIC SECRETO
                                               89135 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $46.47
                                  89135
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         GASTRIC SECRETO
                                               89135 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $46.47
5 - Independent Laboratory        89136                                                  M            07/01/2006         GASTRIC SECRETO
                                               89136 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $34.04
                                  89136
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         GASTRIC SECRETO
                                               89136 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $34.04
5 - Independent Laboratory        89140                                                  M            07/01/2006         GASTRIC SECRETO
                                               89140 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $52.21
                                  89140
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         GASTRIC SECRETO
                                               89140 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $52.21
5 - Independent Laboratory        89141                                                  M            07/01/2006         GASTRIC SECRETO
                                               89141 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $63.19
                                  89141
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006         GASTRIC SECRETO
                                               89141 - GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, $63.19
5 - Independent Laboratory        89160        89160 - MEAT FIBERS, FECES                M            07/01/2006          $4.89
                                  89160
H - Laboratory Billed by Outpatient Hospital   89160 - MEAT FIBERS, FECES                M            07/01/2006          $4.89
I - Laboratory Billed by Physician89160        89160 - MEAT FIBERS, FECES                M            07/01/2006          $4.89
5 - Independent Laboratory        89190        89190 - NASAL SMEAR FOR EOSINOPHILS       M            07/01/2006          $6.31
                                  89190
H - Laboratory Billed by Outpatient Hospital   89190 - NASAL SMEAR FOR EOSINOPHILS       M            07/01/2006          $6.31
I - Laboratory Billed by Physician89190        89190 - NASAL SMEAR FOR EOSINOPHILS       M            07/01/2006          $6.31
5 - Independent Laboratory        89220                                                  M            07/01/2006        $10.89
                                               89220 - SPUTUM, OBTAINING SPECIMEN, AEROSOL INDUCED TECHNIQUE (SEPARATE PROCEDURE)
                                  89220
H - Laboratory Billed by Outpatient Hospital                                             M            07/01/2006        $10.89
                                               89220 - SPUTUM, OBTAINING SPECIMEN, AEROSOL INDUCED TECHNIQUE (SEPARATE PROCEDURE)
I - Laboratory Billed by Physician89220                                                  M            07/01/2006        $10.89
                                               89220 - SPUTUM, OBTAINING SPECIMEN, AEROSOL INDUCED TECHNIQUE (SEPARATE PROCEDURE)
5 - Independent Laboratory        89225        89225 - STARCH GRANULES, FECES            M            07/01/2006          $4.44
                                  89225
H - Laboratory Billed by Outpatient Hospital   89225 - STARCH GRANULES, FECES            M            07/01/2006          $4.44
I - Laboratory Billed by Physician89225        89225 - STARCH GRANULES, FECES            M            07/01/2006          $4.44


 4/22/2012                                                     110 of 489              ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                Level 3       Level 3   LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                             Medicaid/BH     Pricing     Charge
5 - Independent Laboratory        89230                                                M
                                               89230 - SWEAT COLLECTION BY IONTOPHORESIS           07/01/2006            $9.18
                                  89230
H - Laboratory Billed by Outpatient Hospital                                           M
                                               89230 - SWEAT COLLECTION BY IONTOPHORESIS           07/01/2006            $9.18
I - Laboratory Billed by Physician89230                                                M
                                               89230 - SWEAT COLLECTION BY IONTOPHORESIS           07/01/2006            $9.18
5 - Independent Laboratory        89235        89235 - WATER LOAD TEST                 M           07/01/2006            $6.40
                                  89235
H - Laboratory Billed by Outpatient Hospital   89235 - WATER LOAD TEST                 M           07/01/2006            $6.40
I - Laboratory Billed by Physician89235        89235 - WATER LOAD TEST                 M           07/01/2006            $6.40
5 - Independent Laboratory        89300                                                M            SPERM INCLUDING HUHNER TEST (POST
                                               89300 - SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF 07/01/2006          $11.83
                                  89300
H - Laboratory Billed by Outpatient Hospital                                           M            SPERM INCLUDING HUHNER TEST (POST
                                               89300 - SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF 07/01/2006          $11.83
I - Laboratory Billed by Physician89300                                                M            SPERM INCLUDING HUHNER TEST (POST
                                               89300 - SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF 07/01/2006          $11.83
5 - Independent Laboratory        89310                                                M           07/01/2006
                                               89310 - SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) $11.43
                                  89310
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006
                                               89310 - SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) $11.43
I - Laboratory Billed by Physician89310                                                M           07/01/2006
                                               89310 - SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) $11.43
5 - Independent Laboratory        89320                                                M           07/01/2006          $16.00
                                               89320 - SEMEN ANALYSIS; COMPLETE (VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL)
                                  89320
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006          $16.00
                                               89320 - SEMEN ANALYSIS; COMPLETE (VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL)
I - Laboratory Billed by Physician89320                                                M           07/01/2006          $16.00
                                               89320 - SEMEN ANALYSIS; COMPLETE (VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL)
5 - Independent Laboratory        89321                                                M            SPERM
                                               89321 - SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF 07/01/2006          $16.00
                                  89321
H - Laboratory Billed by Outpatient Hospital                                           M            SPERM
                                               89321 - SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF 07/01/2006          $16.00
I - Laboratory Billed by Physician89321                                                M            SPERM
                                               89321 - SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF 07/01/2006          $16.00
5 - Independent Laboratory        89325        89325 - SPERM ANTIBODIES                M           07/01/2006          $14.16
                                  89325
H - Laboratory Billed by Outpatient Hospital   89325 - SPERM ANTIBODIES                M           07/01/2006          $14.16
I - Laboratory Billed by Physician89325        89325 - SPERM ANTIBODIES                M           07/01/2006          $14.16
5 - Independent Laboratory        89329                                                M
                                               89329 - SPERM EVALUATION; HAMSTER PENETRATION TEST  07/01/2006          $27.84
                                  89329
H - Laboratory Billed by Outpatient Hospital                                           M
                                               89329 - SPERM EVALUATION; HAMSTER PENETRATION TEST  07/01/2006          $27.84
I - Laboratory Billed by Physician89329                                                M
                                               89329 - SPERM EVALUATION; HAMSTER PENETRATION TEST  07/01/2006          $27.84
5 - Independent Laboratory        89330                                                M           07/01/2006          $13.14
                                               89330 - SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR WITHOUT SPINNBARK
                                  89330
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006          $13.14
                                               89330 - SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR WITHOUT SPINNBARK
I - Laboratory Billed by Physician89330                                                M           07/01/2006          $13.14
                                               89330 - SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR WITHOUT SPINNBARK
5 - Independent Laboratory        G0027                                                M            SPERM EXCLUDING HUHNER
                                               G0027 - SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF07/01/2006             $8.64
                                  G0027
H - Laboratory Billed by Outpatient Hospital                                           M            SPERM EXCLUDING HUHNER
                                               G0027 - SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF07/01/2006             $8.64
I - Laboratory Billed by PhysicianG0027                                                M            SPERM EXCLUDING HUHNER
                                               G0027 - SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF07/01/2006             $8.64
5 - Independent Laboratory        G0103                                                M           07/01/2006          $24.42
                                               G0103 - PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA), TOTAL
                                  G0103
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006          $24.42
                                               G0103 - PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA), TOTAL
I - Laboratory Billed by PhysicianG0103                                                M           07/01/2006          $24.42
                                               G0103 - PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA), TOTAL
5 - Independent Laboratory        G0107                                                M           07/01/2006            $4.31
                                               G0107 - COLORECTAL CANCER SCREENING; FECAL-OCCULT BLOOD TEST, 1-3 SIMULTANEOUS DETER
                                  G0107
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006            $4.31
                                               G0107 - COLORECTAL CANCER SCREENING; FECAL-OCCULT BLOOD TEST, 1-3 SIMULTANEOUS DETER
I - Laboratory Billed by PhysicianG0107                                                M           07/01/2006            $4.31
                                               G0107 - COLORECTAL CANCER SCREENING; FECAL-OCCULT BLOOD TEST, 1-3 SIMULTANEOUS DETER
5 - Independent Laboratory        G0123                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0123 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $26.89
                                  G0123
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006           SYSTEM), COLLECT
                                               G0123 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $26.89
I - Laboratory Billed by PhysicianG0123                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0123 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $26.89
5 - Independent Laboratory        G0143                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0143 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $26.89
                                  G0143
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006           SYSTEM), COLLECT
                                               G0143 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $26.89
I - Laboratory Billed by PhysicianG0143                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0143 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $26.89
5 - Independent Laboratory        G0144                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0144 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $28.36
                                  G0144
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006           SYSTEM), COLLECT
                                               G0144 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $28.36
I - Laboratory Billed by PhysicianG0144                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0144 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $28.36
5 - Independent Laboratory        G0145                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0145 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $35.16
                                  G0145
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006           SYSTEM), COLLECT
                                               G0145 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $35.16
I - Laboratory Billed by PhysicianG0145                                                M           07/01/2006           SYSTEM), COLLECT
                                               G0145 - SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING $35.16
5 - Independent Laboratory        G0147                                                M            OR VAGINAL, PERFORMED BY AUTOMATE
                                               G0147 - SCREENING CYTOPATHOLOGY SMEARS, CERVICAL07/01/2006              $15.11
                                  G0147
H - Laboratory Billed by Outpatient Hospital                                           M            OR VAGINAL, PERFORMED BY AUTOMATE
                                               G0147 - SCREENING CYTOPATHOLOGY SMEARS, CERVICAL07/01/2006              $15.11
I - Laboratory Billed by PhysicianG0147                                                M            OR VAGINAL, PERFORMED BY AUTOMATE
                                               G0147 - SCREENING CYTOPATHOLOGY SMEARS, CERVICAL07/01/2006              $15.11
5 - Independent Laboratory        G0148                                                M            OR VAGINAL, PERFORMED BY AUTOMATE
                                               G0148 - SCREENING CYTOPATHOLOGY SMEARS, CERVICAL 07/01/2006             $20.17
                                  G0148
H - Laboratory Billed by Outpatient Hospital                                           M            OR VAGINAL, PERFORMED BY AUTOMATE
                                               G0148 - SCREENING CYTOPATHOLOGY SMEARS, CERVICAL 07/01/2006             $20.17
I - Laboratory Billed by PhysicianG0148                                                M            OR VAGINAL, PERFORMED BY AUTOMATE
                                               G0148 - SCREENING CYTOPATHOLOGY SMEARS, CERVICAL 07/01/2006             $20.17
5 - Independent Laboratory        P2038                                                M           07/01/2006
                                               P2038 - MUCOPROTEIN, BLOOD (SEROMUCOID) (MEDICAL NECESSITY PROCEDURE)     $6.67
                                  P2038
H - Laboratory Billed by Outpatient Hospital                                           M           07/01/2006
                                               P2038 - MUCOPROTEIN, BLOOD (SEROMUCOID) (MEDICAL NECESSITY PROCEDURE)     $6.67


 4/22/2012                                                     111 of 489             ec55ec8b-938a-44e4-84c5-74cc909be7e9.xls
                                                     Consolidated Labs Fee Schedule


Level 3 Type of Service Code Level 3 HCPC                                                 Level 3       Level 3   LVL3 Allowed
                                                       Level 3 HCPC Description
              Desc                    Code                                              Medicaid/BH     Pricing      Charge
I - Laboratory Billed by PhysicianP2038                                                M            07/01/2006
                                               P2038 - MUCOPROTEIN, BLOOD (SEROMUCOID) (MEDICAL NECESSITY PROCEDURE)      $6.67
5 - Independent Laboratory        P3000        P3000 - SCREENING PAPANICOLAOU SMEAR,M               VAGINAL,             $14.76
                                                                                        CERVICAL OR 07/01/2006UP TO THREE SMEARS, BY TEC
                                  P3000
H - Laboratory Billed by Outpatient Hospital   P3000 - SCREENING PAPANICOLAOU SMEAR,M               VAGINAL,             $14.76
                                                                                        CERVICAL OR 07/01/2006UP TO THREE SMEARS, BY TEC
I - Laboratory Billed by PhysicianP3000        P3000 - SCREENING PAPANICOLAOU SMEAR,M               VAGINAL,             $14.76
                                                                                        CERVICAL OR 07/01/2006UP TO THREE SMEARS, BY TEC
5 - Independent Laboratory        P3001        P3001 - SCREENING PAPANICOLAOU SMEAR,M               VAGINAL,             $15.25
                                                                                        CERVICAL OR 07/01/2006UP TO THREE SMEARS, REQUIR
                                  P3001
H - Laboratory Billed by Outpatient Hospital   P3001 - SCREENING PAPANICOLAOU SMEAR,M               VAGINAL,             $15.25
                                                                                        CERVICAL OR 07/01/2006UP TO THREE SMEARS, REQUIR
I - Laboratory Billed by PhysicianP3001        P3001 - SCREENING PAPANICOLAOU SMEAR,M               VAGINAL,             $15.25
                                                                                        CERVICAL OR 07/01/2006UP TO THREE SMEARS, REQUIR
5 - Independent Laboratory        P9603                                                M            07/01/2006            $0.57
                                               P9603 - TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
                                  P9603
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $0.57
                                               P9603 - TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
I - Laboratory Billed by PhysicianP9603                                                M            07/01/2006            $0.57
                                               P9603 - TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
5 - Independent Laboratory        P9604                                                M            07/01/2006            $3.27
                                               P9604 - TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
                                  P9604
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $3.27
                                               P9604 - TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
I - Laboratory Billed by PhysicianP9604                                                M            07/01/2006            $3.27
                                               P9604 - TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
5 - Independent Laboratory        P9612                                                 OF          07/01/2006
                                               P9612 - CATHETERIZATION FOR COLLECTIONM SPECIMEN, SINGLE PATIENT, ALL $2.85PLACES OF SERVIC
                                  P9612
H - Laboratory Billed by Outpatient Hospital                                            OF          07/01/2006
                                               P9612 - CATHETERIZATION FOR COLLECTIONM SPECIMEN, SINGLE PATIENT, ALL $2.85PLACES OF SERVIC
I - Laboratory Billed by PhysicianP9612                                                 OF          07/01/2006
                                               P9612 - CATHETERIZATION FOR COLLECTIONM SPECIMEN, SINGLE PATIENT, ALL $2.85PLACES OF SERVIC
5 - Independent Laboratory        P9615                                                 OF           (S) (MULTIPLE PATIENTS)
                                               P9615 - CATHETERIZATION FOR COLLECTIONM SPECIMEN07/01/2006                 $2.85
                                  P9615
H - Laboratory Billed by Outpatient Hospital                                            OF           (S) (MULTIPLE PATIENTS)
                                               P9615 - CATHETERIZATION FOR COLLECTIONM SPECIMEN07/01/2006                 $2.85
I - Laboratory Billed by PhysicianP9615                                                 OF           (S) (MULTIPLE PATIENTS)
                                               P9615 - CATHETERIZATION FOR COLLECTIONM SPECIMEN07/01/2006                 $2.85
5 - Independent Laboratory        Q0111                                                M            07/01/2006            $5.66
                                               Q0111 - WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR SKIN SPECIMENS
                                  Q0111
H - Laboratory Billed by Outpatient Hospital                                           M            07/01/2006            $5.66
                                               Q0111 - WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR SKIN SPECIMENS
I - Laboratory Billed by PhysicianQ0111                                                M            07/01/2006            $5.66
                                               Q0111 - WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR SKIN SPECIMENS
5 - Independent Laboratory        Q0112                                                M
                                               Q0112 - ALL POTASSIUM HYDROXIDE (KOH) PREPARATIONS07/01/2006               $5.66
                                  Q0112
H - Laboratory Billed by Outpatient Hospital                                           M
                                               Q0112 - ALL POTASSIUM HYDRO