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					NYS DOH - Procedure Codes Subject to APG Ancillary Policy
Free-Standing DTC and Amb Surg Ancillary Policy (Effective July 1, 2011): To receive payment for the ancillary procedure codes listed below based on normal APG payment logic, modifier U6 must be coded at the
procedure line level. Column [H] shows how the procedure will pay at the line level when modifier U6 is coded on the procedure line level. If modifier U6 is NOT coded along with a procedure listed below, then
procedures that group to non-packaged ancillary APGs will pay zero and procedures that group to packaged ancillary APGs will receive a payment reduction at the procedure line level as listed below in column [I].
Each packaging ancillary will reduce the claim weight by procedure's APG weight, which essentially unpackages the ancillary by removing the portion of the claim's weight associated with the packaged line. APGs
NOT on this list will be reimbursed based on the normal APG payment logic whether or not modifier U6 is on the procedure line level. Please see the Modifier U6 policy for more information.
Hospital Based Ancillary Policy (Effective July 1, 2009): At this time, since hopsitals are not subject to the U6 modifier columns [H] and [I] do not apply to hospital claims. When hospitals bill the procedure codes
below the procedure codes will pay according to basic APG logic, whether or not modifier U6 is coded on the claim. However, hopsitals are required to include on APG clinic claims all ancillary services as defined by
this list, wheather or not the service was performed by the billing hopsital. For more information on the hospital ancillary billing policy see see section 4.4 of the APG Provider Manual.


    [A]                     [B]                [C]                         [D]                              [E]                 [F]               [G]                   [H]                              [I]
                                                                                                                                                                            Line Level Payment Action
                                                                                                                                                                                            Modifier U6 NOT coded on
                                                                                                                                                            Modifier U6 coded on line     line (provider not responsible
                                                                                                                                                             (performed in house or          for service. Lab/radiology
Procedure                                                                                              On APG Fee                              Packaged      provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description      APG                    APG Description                    Schedule?           APG Type             APG?        lab/radiology provider)                  directlly )
  31620     Endobronchial us add-on           288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL                  No      Radiologic Procedure          No       pay as normal on regional base          zero payment
                                                  AND VASCULAR OF LOWER EXTREMITIES                                                                                    rate

  37250     Iv us first vessel add-on         289 VASCULAR DIAGNOSTIC ULTRASOUND OF LOWER                   No      Radiologic Procedure          No       pay as normal on regional base          zero payment
                                                  EXTREMITIES                                                                                                          rate
  37251     Iv us each add vessel add-on      289 VASCULAR DIAGNOSTIC ULTRASOUND OF LOWER                   No      Radiologic Procedure          No       pay as normal on regional base          zero payment
                                                  EXTREMITIES                                                                                                          rate
  38790     Inject for lymphatic x-ray        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE                       No      Radiologic Procedure          No       pay as normal on regional base          zero payment
                                                                                                                                                                       rate
  47505     Injection for liver x-rays        287 DIGESTIVE RADIOLOGY                                       No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  51798     Us urine capacity measure         288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL                  No      Radiologic Procedure          No       pay as normal on regional base          zero payment
                                                  AND VASCULAR OF LOWER EXTREMITIES                                                                                    rate

  70030     X-ray eye for foreign body        471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70100     X-ray exam of jaw                 471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70110     X-ray exam of jaw                 471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70120     X-ray exam of mastoids            471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70130     X-ray exam of mastoids            471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70134     X-ray exam of middle ear          471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70140     X-ray exam of facial bones        471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70150     X-ray exam of facial bones        471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70160     X-ray exam of nasal bones         471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70190     X-ray exam of eye sockets         471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70200     X-ray exam of eye sockets         471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70210     X-ray exam of sinuses             471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70220     X-ray exam of sinuses             471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70240     X-ray exam pituitary saddle       471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70250     X-ray exam of skull               471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70260     X-ray exam of skull               471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70300     X-ray exam of teeth               471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70310     X-ray exam of teeth               471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70320     Full mouth x-ray of teeth         471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70328     X-ray exam of jaw joint           471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70330     X-ray exam of jaw joints          471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70336     Magnetic image jaw joint          293 MRI- JOINTS                                               No      Radiologic Procedure          No        pay as normal on statewide           zero payment
                                                                                                                                                                     base rate
  70350     X-ray head for orthodontia        471 PLAIN FILM                                                No      Ancillary                     Yes           package as normal           payment reduced based on
                                                                                                                                                                                               regional base rate
  70355     Panoramic x-ray of jaws           471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70360     X-ray exam of neck                471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70370     Throat x-ray & fluoroscopy        471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70380     X-ray exam of salivary gland      471 PLAIN FILM                                                No      Ancillary                     Yes            package as normal          payment reduced based on
                                                                                                                                                                                               regional base rate
  70450     Ct head/brain w/o dye             299 CAT SCAN - BRAIN                                          No      Radiologic Procedure          No        pay as normal on statewide           zero payment
                                                                                                                                                                     base rate
  70460     Ct head/brain w/dye               299 CAT SCAN - BRAIN                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70470     Ct head/brain w/o & w/dye         299 CAT SCAN - BRAIN                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70480     Ct orbit/ear/fossa w/o dye        301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70481     Ct orbit/ear/fossa w/dye          301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70482     Ct orbit/ear/fossa w/o&w/dye      301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70486     Ct maxillofacial w/o dye          301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70487     Ct maxillofacial w/dye            301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70488     Ct maxillofacial w/o & w/dye      301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70490     Ct soft tissue neck w/o dye       301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70491     Ct soft tissue neck w/dye         301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70492     Ct sft tsue nck w/o & w/dye       301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70496     Ct angiography head               303 ANGIOGRAPHY, CEREBRAL                                     No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70498     Ct angiography neck               301 CAT SCAN - OTHER                                          No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate
  70540     Mri orbit/face/neck w/o dye       296 MRI- OTHER                                                No      Radiologic Procedure          No        pay as normal on statewide             zero payment
                                                                                                                                                                     base rate

                                                                                                                                                                                                                  page 1 of 34
                                                                                                                                                       Line Level Payment Action
                                                                                                                                                                       Modifier U6 NOT coded on
                                                                                                                                       Modifier U6 coded on line     line (provider not responsible
                                                                                                                                        (performed in house or          for service. Lab/radiology
Procedure                                                                               On APG Fee                          Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                 APG Description           Schedule?           APG Type         APG?      lab/radiology provider)                  directlly )
 70542      Mri orbit/face/neck w/dye      296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 70543      Mri orbt/fac/nck w/o & w/dye   296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 70544      Mr angiography head w/o dye  281 MAGNETIC RESONANCE ANGIOGRAPHY - HEAD          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                             AND/OR NECK                                                                                        base rate
 70545      Mr angiography head w/dye    281 MAGNETIC RESONANCE ANGIOGRAPHY - HEAD          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                             AND/OR NECK                                                                                        base rate
 70546      Mr angiograph head w/o&w/dye 281 MAGNETIC RESONANCE ANGIOGRAPHY - HEAD          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                             AND/OR NECK                                                                                        base rate
 70547      Mr angiography neck w/o dye  281 MAGNETIC RESONANCE ANGIOGRAPHY - HEAD          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                             AND/OR NECK                                                                                        base rate
 70548      Mr angiography neck w/dye    281 MAGNETIC RESONANCE ANGIOGRAPHY - HEAD          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                             AND/OR NECK                                                                                        base rate
 70549      Mr angiograph neck w/o&w/dye 281 MAGNETIC RESONANCE ANGIOGRAPHY - HEAD          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                             AND/OR NECK                                                                                        base rate
 70551      Mri brain w/o dye            297 MRI- BRAIN                                     No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 70552      Mri brain w/dye                297 MRI- BRAIN                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 70553      Mri brain w/o & w/dye          297 MRI- BRAIN                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 70555      Fmri brain by phys/psych       281 MAGNETIC RESONANCE ANGIOGRAPHY - HEAD        No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                               AND/OR NECK                                                                                      base rate
 70557      Mri brain w/o dye              297 MRI- BRAIN                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 70558      Mri brain w/dye                297 MRI- BRAIN                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 70559      Mri brain w/o & w/dye          297 MRI- BRAIN                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 71010      Chest x-ray                    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71015      Chest x-ray                    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71020      Chest x-ray                    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71021      Chest x-ray                    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71022      Chest x-ray                    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71023      Chest x-ray and fluoroscopy    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71030      Chest x-ray                    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71034      Chest x-ray and fluoroscopy    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71035      Chest x-ray                    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71100      X-ray exam of ribs             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71101      X-ray exam of ribs/chest       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71110      X-ray exam of ribs             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71111      X-ray exam of ribs/chest       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71120      X-ray exam of breastbone       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71130      X-ray exam of breastbone       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 71250      Ct thorax w/o dye              301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide           zero payment
                                                                                                                                                base rate
 71260      Ct thorax w/dye                301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 71270      Ct thorax w/o & w/dye          301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 71275      Ct angiography chest           302 ANGIOGRAPHY, OTHER                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 71550      Mri chest w/o dye              295 MRI- CHEST                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 71551      Mri chest w/dye                295 MRI- CHEST                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 71552      Mri chest w/o & w/dye          295 MRI- CHEST                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 71555      Mri angio chest w or w/o dye   282 MAGNETIC RESONANCE ANGIOGRAPHY - CHEST       No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72010      X-ray exam of spine            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72020      X-ray exam of spine            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72040      X-ray exam of neck spine       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72050      X-ray exam of neck spine       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72052      X-ray exam of neck spine       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72069      X-ray exam of trunk spine      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72070      X-ray exam of thoracic spine   471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72072      X-ray exam of thoracic spine   471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72074      X-ray exam of thoracic spine   471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72080      X-ray exam of trunk spine      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72090      X-ray exam of trunk spine      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72100      X-ray exam of lower spine      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72110      X-ray exam of lower spine      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72114      X-ray exam of lower spine      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72120      X-ray exam of lower spine      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72125      Ct neck spine w/o dye          298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide           zero payment
                                                                                                                                                base rate
 72126      Ct neck spine w/dye            298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
                                                                                                                                                                                            page 2 of 34
                                                                                                                                                       Line Level Payment Action
                                                                                                                                                                       Modifier U6 NOT coded on
                                                                                                                                       Modifier U6 coded on line     line (provider not responsible
                                                                                                                                        (performed in house or          for service. Lab/radiology
Procedure                                                                               On APG Fee                          Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                 APG Description           Schedule?           APG Type         APG?      lab/radiology provider)                  directlly )
 72127      Ct neck spine w/o & w/dye      298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72128      Ct chest spine w/o dye         298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72129      Ct chest spine w/dye           298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72130      Ct chest spine w/o & w/dye     298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72131      Ct lumbar spine w/o dye        298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72132      Ct lumbar spine w/dye          298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72133      Ct lumbar spine w/o & w/dye    298 CAT SCAN BACK                                No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72141      Mri neck spine w/o dye         294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72142      Mri neck spine w/dye           294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72146      Mri chest spine w/o dye        294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72147      Mri chest spine w/dye          294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72148      Mri lumbar spine w/o dye       294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72149      Mri lumbar spine w/dye         294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72156      Mri neck spine w/o & w/dye     294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72157      Mri chest spine w/o & w/dye    294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72158      Mri lumbar spine w/o & w/dye   294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72159      Mr angio spine w/o&w/dye       294 MRI- BACK                                    No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72170      X-ray exam of pelvis           471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72190      X-ray exam of pelvis           471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72191      Ct angiograph pelv w/o&w/dye   302 ANGIOGRAPHY, OTHER                           No       Radiologic Procedure     No       pay as normal on statewide           zero payment
                                                                                                                                                base rate
 72192      Ct pelvis w/o dye              301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72193      Ct pelvis w/dye                301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72194      Ct pelvis w/o & w/dye          301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72195      Mri pelvis w/o dye             296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72196      Mri pelvis w/dye               296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72197      Mri pelvis w/o & w/dye         296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 72198      Mr angio pelvis w/o & w/dye    283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER       No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                               SITES                                                                                            base rate
 72200      X-ray exam sacroiliac joints   471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72202      X-ray exam sacroiliac joints   471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 72220      X-ray exam of tailbone         471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73000      X-ray exam of collar bone      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73010      X-ray exam of shoulder blade   471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73020      X-ray exam of shoulder         471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73030      X-ray exam of shoulder         471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73050      X-ray exam of shoulders        471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73060      X-ray exam of humerus          471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73070      X-ray exam of elbow            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73080      X-ray exam of elbow            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73090      X-ray exam of forearm          471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73092      X-ray exam of arm infant       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73100      X-ray exam of wrist            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73110      X-ray exam of wrist            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73120      X-ray exam of hand             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73130      X-ray exam of hand             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73140      X-ray exam of finger(s)        471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73200      Ct upper extremity w/o dye     301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide           zero payment
                                                                                                                                                base rate
 73201      Ct upper extremity w/dye       301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73202      Ct uppr extremity w/o&w/dye    301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73206      Ct angio upr extrm w/o&w/dye   302 ANGIOGRAPHY, OTHER                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73218      Mri upper extremity w/o dye    296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73219      Mri upper extremity w/dye      296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73220      Mri uppr extremity w/o&w/dye   296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73221      Mri joint upr extrem w/o dye   293 MRI- JOINTS                                  No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73222      Mri joint upr extrem w/dye     293 MRI- JOINTS                                  No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73223      Mri joint upr extr w/o&w/dye   293 MRI- JOINTS                                  No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
                                                                                                                                                                                            page 3 of 34
                                                                                                                                                       Line Level Payment Action
                                                                                                                                                                       Modifier U6 NOT coded on
                                                                                                                                       Modifier U6 coded on line     line (provider not responsible
                                                                                                                                        (performed in house or          for service. Lab/radiology
Procedure                                                                               On APG Fee                          Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description            Schedule?           APG Type         APG?      lab/radiology provider)                  directlly )
 73225      Mr angio upr extr w/o&w/dye    283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER       No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                               SITES                                                                                            base rate
 73500      X-ray exam of hip              471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73510      X-ray exam of hip              471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73520      X-ray exam of hips             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73530      X-ray exam of hip              471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73540      X-ray exam of pelvis & hips    471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73550      X-ray exam of thigh            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73560      X-ray exam of knee 1 or 2      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73562      X-ray exam of knee 3           471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73564      X-ray exam knee 4 or more      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73565      X-ray exam of knees            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73590      X-ray exam of lower leg        471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73592      X-ray exam of leg infant       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73600      X-ray exam of ankle            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73610      X-ray exam of ankle            471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73620      X-ray exam of foot             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73630      X-ray exam of foot             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73650      X-ray exam of heel             471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73660      X-ray exam of toe(s)           471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 73700      Ct lower extremity w/o dye     301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide           zero payment
                                                                                                                                                base rate
 73701      Ct lower extremity w/dye       301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73702      Ct lwr extremity w/o&w/dye     301 CAT SCAN - OTHER                             No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73706      Ct angio lwr extr w/o&w/dye    302 ANGIOGRAPHY, OTHER                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73718      Mri lower extremity w/o dye    296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73719      Mri lower extremity w/dye      296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73720      Mri lwr extremity w/o&w/dye    296 MRI- OTHER                                   No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73721      Mri jnt of lwr extre w/o dye   293 MRI- JOINTS                                  No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73722      Mri joint of lwr extr w/dye    293 MRI- JOINTS                                  No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73723      Mri joint lwr extr w/o&w/dye   293 MRI- JOINTS                                  No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 73725      Mr ang lwr ext w or w/o dye    283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER       No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                               SITES                                                                                            base rate
 74000      X-ray exam of abdomen          471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 74010      X-ray exam of abdomen          471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 74020      X-ray exam of abdomen          471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 74022      X-ray exam series abdomen      471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 74150      Ct abdomen w/o dye             300 CAT SCAN - ABDOMEN                           No       Radiologic Procedure     No       pay as normal on statewide           zero payment
                                                                                                                                                base rate
 74160      Ct abdomen w/dye               300 CAT SCAN - ABDOMEN                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74170      Ct abdomen w/o & w/dye         300 CAT SCAN - ABDOMEN                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74175      Ct angio abdom w/o & w/dye     302 ANGIOGRAPHY, OTHER                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74176      Ct abd & pelvis w/o contrast   300 CAT SCAN - ABDOMEN                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74177      Ct abdomen&pelvis w/contrast   300 CAT SCAN - ABDOMEN                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74178      Ct abd&pelv 1+ section/regns   300 CAT SCAN - ABDOMEN                           No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74181      Mri abdomen w/o dye            292 MRI- ABDOMEN                                 No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74182      Mri abdomen w/dye              292 MRI- ABDOMEN                                 No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74183      Mri abdomen w/o & w/dye        292 MRI- ABDOMEN                                 No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74185      Mri angio abdom w orw/o dye    292 MRI- ABDOMEN                                 No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74210      Contrst x-ray exam of throat   471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 74220      Contrast x-ray esophagus       471 PLAIN FILM                                   No       Ancillary                Yes          package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 74230      Cine/vid x-ray throat/esoph    287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide           zero payment
                                                                                                                                                base rate
 74240      X-ray exam upper gi tract      287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74241      X-ray exam upper gi tract      287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74245      X-ray exam upper gi tract      287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74246      Contrst x-ray uppr gi tract    287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74247      Contrst x-ray uppr gi tract    287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74249      Contrst x-ray uppr gi tract    287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
 74250      X-ray exam of small bowel      287 DIGESTIVE RADIOLOGY                          No       Radiologic Procedure     No       pay as normal on statewide            zero payment
                                                                                                                                                base rate
                                                                                                                                                                                            page 4 of 34
                                                                                                                                                          Line Level Payment Action
                                                                                                                                                                          Modifier U6 NOT coded on
                                                                                                                                          Modifier U6 coded on line     line (provider not responsible
                                                                                                                                           (performed in house or          for service. Lab/radiology
Procedure                                                                                 On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG               APG Description               Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 74251      X-ray exam of small bowel      287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 74260      X-ray exam of small bowel      287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 74270      Contrast x-ray exam of colon   287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 74280      Contrast x-ray exam of colon   287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 74283      Contrast x-ray exam of colon   287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 74290      Contrast x-ray gallbladder     287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 74291      Contrast x-rays gallbladder    287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 74710      X-ray measurement of pelvis    471 PLAIN FILM                                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 75557      Cardiac mri for morph          296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 75559      Cardiac mri w/stress img       296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 75561      Cardiac mri for morph w/dye    296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 75563      Card mri w/stress img & dye    296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 75565      Card mri veloc flow mapping    296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 75635      Ct angio abdominal arteries    302 ANGIOGRAPHY, OTHER                             No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 76000      Fluoroscope examination        471 PLAIN FILM                                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 76001      Fluoroscope exam extensive     471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76010      X-ray nose to rectum           471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76098      X-ray exam breast specimen     471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76100      X-ray exam of body section     471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76101      Complex body section x-ray     471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76102      Complex body section x-rays    471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76120      Cine/video x-rays              471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76125      Cine/video x-rays add-on       471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 76380      CAT scan follow-up study       301 CAT SCAN - OTHER                               No       Radiologic Procedure     No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 76390      Mr spectroscopy                296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 76496      Fluoroscopic procedure         471 PLAIN FILM                                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 76497      Ct procedure                   301 CAT SCAN - OTHER                               No       Radiologic Procedure     No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 76498      Mri procedure                  296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 76499      Radiographic procedure         471 PLAIN FILM                                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 76506      Echo exam of head              288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base        zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76510      Ophth us b & quant a           288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76511      Ophth us quant a only          288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76512      Ophth us b w/non-quant a       288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76516      Echo exam of eye               288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76519      Echo exam of eye               288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76529      Echo exam of eye               288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76536      Us exam of head and neck       288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76604      Us exam chest                  288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76645      Us exam breast(s)              288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76700      Us exam abdom complete         288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76705      Echo exam of abdomen           288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76770      Us exam abdo back wall comp    288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76775      Us exam abdo back wall lim     288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76776      Us exam k transpl w/doppler    288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76800      Us exam spinal canal           288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76801      Ob us < 14 wks single fetus    470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76802      Ob us < 14 wks addl fetus      470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
                                                                                                                                                                                               page 5 of 34
                                                                                                                                                          Line Level Payment Action
                                                                                                                                                                          Modifier U6 NOT coded on
                                                                                                                                          Modifier U6 coded on line     line (provider not responsible
                                                                                                                                           (performed in house or          for service. Lab/radiology
Procedure                                                                                 On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG               APG Description               Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 76805      Ob us >/= 14 wks sngl fetus    470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76810      Ob us >/= 14 wks addl fetus    470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76811      Ob us detailed sngl fetus      470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76812      Ob us detailed addl fetus      470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76813      Ob us nuchal meas 1 gest       470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76814      Ob us nuchal meas add-on       470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76815      Ob us limited fetus(s)         470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76816      Ob us follow-up per fetus      470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76817      Transvaginal us obstetric      470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76818      Fetal biophys profile w/nst    470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76819      Fetal biophys profil w/o nst   470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76820      Umbilical artery echo          470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76821      Middle cerebral artery echo    470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76825      Echo exam of fetal heart       470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76826      Echo exam of fetal heart       470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76827      Echo exam of fetal heart       470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76828      Echo exam of fetal heart       470 OBSTETRICAL ULTRASOUND                         No       Ancillary                No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 76830      Transvaginal us non-ob         288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76856      Us exam pelvic complete        288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76857      Us exam pelvic limited         288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76870      Us exam scrotum                288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76872      Us transrectal                 288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76873      Echograp trans r pros study    288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76881      Us xtr non-vasc complete       288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76882      Us xtr non-vasc lmtd           288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76885      Us exam infant hips dynamic    288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76886      Us exam infant hips static     288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 76999      Echo examination procedure     288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 77055      Mammogram one breast           286 MAMMOGRAPHY                                    No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77056      Mammogram both breasts         286 MAMMOGRAPHY                                    No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77057      Mammogram screening            286 MAMMOGRAPHY                                    No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77058      Mri one breast                 296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77059      Mri both breasts               296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77072      X-rays for bone age            471 PLAIN FILM                                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 77073      X-rays bone length studies     471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 77074      X-rays bone survey limited     471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 77075      X-rays bone survey complete    471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 77076      X-rays bone survey infant      471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 77077      Joint survey single view       471 PLAIN FILM                                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 77078      Ct bone density axial          291 BONE DENSITOMETRY                              No       Radiologic Procedure     No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 77079      Ct bone density peripheral     291 BONE DENSITOMETRY                              No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77080      Dxa bone density axial         291 BONE DENSITOMETRY                              No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77081      Dxa bone density/peripheral    291 BONE DENSITOMETRY                              No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77082      Dxa bone density vert fx       291 BONE DENSITOMETRY                              No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77084      Magnetic image bone marrow     296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 77417      Radiology port film(s)         471 PLAIN FILM                                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 78000      Thyroid single uptake          330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE            No       Radiologic Procedure     No       pay as normal on regional base        zero payment
                                                                                                                                                     rate
 78001      Thyroid multiple uptakes       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE            No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                     rate
 78003      Thyroid suppress/stimul        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE            No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                     rate


                                                                                                                                                                                               page 6 of 34
                                                                                                                                                       Line Level Payment Action
                                                                                                                                                                       Modifier U6 NOT coded on
                                                                                                                                       Modifier U6 coded on line     line (provider not responsible
                                                                                                                                        (performed in house or          for service. Lab/radiology
Procedure                                                                              On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description           Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 78006      Thyroid imaging with uptake    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78007      Thyroid image mult uptakes     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78010      Thyroid imaging                330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78011      Thyroid imaging with flow      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78015      Thyroid met imaging            331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78016      Thyroid met imaging/studies    331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78018      Thyroid met imaging body       331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78070      Parathyroid nuclear imaging    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78075      Adrenal nuclear imaging        331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78099      Endocrine nuclear procedure    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78102      Bone marrow imaging ltd        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78103      Bone marrow imaging mult       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78104      Bone marrow imaging body       331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78110      Plasma volume single           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78111      Plasma volume multiple         331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78120      Red cell mass single           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78121      Red cell mass multiple         330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78122      Blood volume                   331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78130      Red cell survival study        331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78135      Red cell survival kinetics     332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78140      Red cell sequestration         332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78185      Spleen imaging                 330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78190      Platelet survival kinetics     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78191      Platelet survival              330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78195      Lymph system imaging           331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78199      Blood/lymph nuclear exam       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78201      Liver imaging                  330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78202      Liver imaging with flow        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78205      Liver imaging (3D)             330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78206      Liver image (3d) with flow     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78215      Liver and spleen imaging       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78216      Liver & spleen image/flow      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78220      Liver function study           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78223      Hepatobiliary imaging          331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78230      Salivary gland imaging         330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78231      Serial salivary imaging        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78232      Salivary gland function exam   330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78258      Esophageal motility study      331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78261      Gastric mucosa imaging         330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78262      Gastroesophageal reflux exam   331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78264      Gastric emptying study         331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78267      Breath tst attain/anal c-14    401 LEVEL II CHEMISTRY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78268      Breath test analysis c-14      401 LEVEL II CHEMISTRY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78270      Vit B-12 absorption exam       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78271      Vit b-12 absrp exam int fac    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78272      Vit b-12 absorp combined       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78278      Acute GI blood loss imaging    331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78282      GI protein loss exam           331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78290      Meckels divert exam            330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78291      Leveen/shunt patency exam      331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78299      GI nuclear procedure           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78300      Bone imaging limited area      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78305      Bone imaging multiple areas    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78306      Bone imaging whole body        331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78315      Bone imaging 3 phase           331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
                                                                                                                                                                                            page 7 of 34
                                                                                                                                                       Line Level Payment Action
                                                                                                                                                                       Modifier U6 NOT coded on
                                                                                                                                       Modifier U6 coded on line     line (provider not responsible
                                                                                                                                        (performed in house or          for service. Lab/radiology
Procedure                                                                              On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description           Schedule?          APG Type          APG?       lab/radiology provider)                  directlly )
 78320      Bone imaging (3D)              331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78350      Bone mineral single photon     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78351      Bone mineral dual photon       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78399      Musculoskeletal nuclear exam   330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78414      Non-imaging heart function     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78428      Cardiac shunt imaging          330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78445      Vascular flow imaging          330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78451      Ht muscle image spect sing     331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78452      Ht muscle image spect mult     332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78453      Ht muscle image planar sing    331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78454      Ht musc image planar mult      332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78457      Venous thrombosis imaging      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78458      Ven thrombosis images bilat    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78459      Heart muscle imaging (PET)     290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78466      Heart infarct image            331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78468      Heart infarct image (ef)       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78469      Heart infarct image (3D)       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78472      Gated heart planar single      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78473      Gated heart multiple           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78481      Heart first pass single        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78483      Heart first pass multiple      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78491      Heart image (pet) single       290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78492      Heart image (pet) multiple     290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78494      Heart image spect              332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78496      Heart first pass add-on        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78499      Cardiovascular nuclear exam    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78580      Lung perfusion imaging         330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78584      Lung V/Q image single breath   330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78585      Lung V/Q imaging               330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78586      Aerosol lung image single      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78587      Aerosol lung image multiple    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78588      Perfusion lung image           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78591      Vent image 1 breath 1 proj     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78593      Vent image 1 proj gas          330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78594      Vent image mult proj gas       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78596      Lung differential function     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78599      Respiratory nuclear exam       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78600      Brain image < 4 views          330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78601      Brain image w/flow < 4 views   330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78605      Brain image 4+ views           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78606      Brain image w/flow 4 + views   330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78607      Brain imaging (3D)             331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78608      Brain imaging (PET)            290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78609      Brain imaging (PET)            290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78610      Brain flow imaging only        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78630      Cerebrospinal fluid scan       331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78635      CSF ventriculography           331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78645      CSF shunt evaluation           330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78647      Cerebrospinal fluid scan       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78650      CSF leakage imaging            330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78660      Nuclear exam of tear flow      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78699      Nervous system nuclear exam    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78700      Kidney imaging morphol         330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78701      Kidney imaging with flow       330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78707      K flow/funct image w/o drug    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
                                                                                                                                                                                            page 8 of 34
                                                                                                                                                       Line Level Payment Action
                                                                                                                                                                       Modifier U6 NOT coded on
                                                                                                                                       Modifier U6 coded on line     line (provider not responsible
                                                                                                                                        (performed in house or          for service. Lab/radiology
Procedure                                                                              On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description           Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 78708      K flow/funct image w/drug      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78709      K flow/funct image multiple    330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78710      Kidney imaging (3D)            330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78725      Kidney function study          330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78730      Urinary bladder retention      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78740      Ureteral reflux study          330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78761      Testicular imaging w/flow      330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78799      Genitourinary nuclear exam     330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78800      Tumor imaging limited area     331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78801      Tumor imaging mult areas       331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78802      Tumor imaging whole body       332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78803      Tumor imaging (3D)             332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78804      Tumor imaging whole body       332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78805      Abscess imaging ltd area       331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE        No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78806      Abscess imaging whole body     332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78807      Nuclear localization/abscess   332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 78811      Pet image ltd area             290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78812      Pet image skull-thigh          290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78813      Pet image full body            290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78814      Pet image w/ct lmtd            290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78815      Pet image w/ct skull-thigh     290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78816      Pet image w/ct full body       290 PET SCANS                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 78999      Nuclear diagnostic exam        330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE         No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                                                                                                                                  rate
 80047      Metabolic panel ionized ca     403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80048      Metabolic panel total ca       403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80050      General health panel           403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80051      Electrolyte panel              400 LEVEL I CHEMISTRY TESTS                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                          regional base rate
 80053      Comprehen metabolic panel      403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                base rate
 80055      Obstetric panel                403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80061      Lipid panel                    403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80069      Renal function panel           403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80074      Acute hepatitis panel          403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80076      Hepatic function panel         403 ORGAN OR DISEASE ORIENTED PANELS            No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80100      Drug screen qualitate/multi    404 TOXICOLOGY TESTS                            No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                          regional base rate
 80101      Drug screen single             404 TOXICOLOGY TESTS                            No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                          regional base rate
 80102      Drug confirmation              404 TOXICOLOGY TESTS                            No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                          regional base rate
 80103      Drug analysis tissue prep      404 TOXICOLOGY TESTS                            No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                          regional base rate
 80104      Drug scrn 1+ class nonchromo   405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                base rate
 80150      Assay of amikacin              405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80152      Assay of amitriptyline         405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80154      Assay of benzodiazepines       405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80156      Assay carbamazepine total      405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80157      Assay carbamazepine free       405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80158      Assay of cyclosporine          405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80160      Assay of desipramine           405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80162      Assay of digoxin               405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80164      Assay dipropylacetic acid      405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80166      Assay of doxepin               405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80168      Assay of ethosuximide          405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80170      Assay of gentamicin            405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80172      Assay of gold                  405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80173      Assay of haloperidol           405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80174      Assay of imipramine            405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80176      Assay of lidocaine             405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
 80178      Assay of lithium               405 THERAPEUTIC DRUG MONITORING                 No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                base rate
                                                                                                                                                                                            page 9 of 34
                                                                                                                                             Line Level Payment Action
                                                                                                                                                             Modifier U6 NOT coded on
                                                                                                                             Modifier U6 coded on line     line (provider not responsible
                                                                                                                              (performed in house or          for service. Lab/radiology
Procedure                                                                         On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description      Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 80182      Assay of nortriptyline         405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80184      Assay of phenobarbital         405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80185      Assay of phenytoin total       405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80186      Assay of phenytoin free        405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80188      Assay of primidone             405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80190      Assay of procainamide          405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80192      Assay of procainamide          405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80194      Assay of quinidine             405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80195      Assay of sirolimus             405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80196      Assay of salicylate            405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80197      Assay of tacrolimus            405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80198      Assay of theophylline          405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80200      Assay of tobramycin            405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80201      Assay of topiramate            405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80202      Assay of vancomycin            405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80299      Quantitative assay drug        405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80400      Acth stimulation panel         399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80402      Acth stimulation panel         399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80406      Acth stimulation panel         399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80408      Aldosterone suppression eval   399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80410      Calcitonin stimul panel        399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80412      CRH stimulation panel          399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80414      Testosterone response          399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80415      Estradiol response panel       399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80416      Renin stimulation panel        403 ORGAN OR DISEASE ORIENTED PANELS       No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80417      Renin stimulation panel        403 ORGAN OR DISEASE ORIENTED PANELS       No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80418      Pituitary evaluation panel     399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80420      Dexamethasone panel            399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80422      Glucagon tolerance panel       399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80424      Glucagon tolerance panel       399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80426      Gonadotropin hormone panel     399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80428      Growth hormone panel           399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80430      Growth hormone panel           399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80432      Insulin suppression panel      399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80434      Insulin tolerance panel        399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80435      Insulin tolerance panel        399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80436      Metyrapone panel               399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80438      TRH stimulation panel          399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80439      TRH stimulation panel          399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 80440      TRH stimulation panel          399 LEVEL II ENDOCRINOLOGY TESTS           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                      base rate
 81000      Urinalysis nonauto w/scope     410 URINALYSIS                             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81001      Urinalysis auto w/scope        410 URINALYSIS                             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81002      Urinalysis nonauto w/o scope   411 BLOOD AND URINE DIPSTICK TESTS         No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81003      Urinalysis auto w/o scope      411 BLOOD AND URINE DIPSTICK TESTS         No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81005      Urinalysis                     410 URINALYSIS                             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81007      Urine screen for bacteria      410 URINALYSIS                             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81015      Microscopic exam of urine      410 URINALYSIS                             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81020      Urinalysis glass test          410 URINALYSIS                             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81025      Urine pregnancy test           410 URINALYSIS                            Yes       Ancillary            Yes      pay as normal based on fee           zero payment
                                                                                                                                 schedule payment
 81050      Urinalysis volume measure      410 URINALYSIS                             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 81099      Urinalysis test procedure      400 LEVEL I CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 82000      Assay of blood acetaldehyde    400 LEVEL I CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 82003      Assay of acetaminophen         405 THERAPEUTIC DRUG MONITORING            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                      base rate
 82009      Test for acetone/ketones       400 LEVEL I CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
 82010      Acetone assay                  400 LEVEL I CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                                regional base rate
                                                                                                                                                                                page 10 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 82013      Acetylcholinesterase assay     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82016      Acylcarnitines qual            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82017      Acylcarnitines quant           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82024      Assay of acth                  399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82030      Assay of adp & amp             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82040      Assay of serum albumin         402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82042      Assay of urine albumin         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82043      Microalbumin quantitative      410 URINALYSIS                           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82044      Microalbumin semiquant         410 URINALYSIS                           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82045      Albumin ischemia modified      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82055      Assay of ethanol               400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82075      Assay of breath ethanol        400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82085      Assay of aldolase              400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82088      Assay of aldosterone           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82101      Assay of urine alkaloids       404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82103      Alpha-1-antitrypsin total      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82104      Alpha-1-antitrypsin pheno      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82105      Alpha-fetoprotein serum        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82106      Alpha-fetoprotein amniotic     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82107      Alpha-fetoprotein l3           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82108      Assay of aluminum              404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82120      Amines vaginal fluid qual      391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82127      Amino acid single qual         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82128      Amino acids mult qual          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82131      Amino acids single quant       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82135      Assay aminolevulinic acid      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82136      Amino acids quant 2-5          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82139      Amino acids quan 6 or more     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82140      Assay of ammonia               400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82143      Amniotic fluid scan            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82145      Assay of amphetamines          405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82150      Assay of amylase               400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82154      Androstanediol glucuronide     399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82157      Assay of androstenedione       399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82160      Assay of androsterone          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82163      Assay of angiotensin II        399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82164      Angiotensin I enzyme test      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82172      Assay of apolipoprotein        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82175      Assay of arsenic               404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82180      Assay of ascorbic acid         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82190      Atomic absorption              401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82205      Assay of barbiturates          404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82232      Assay of beta-2 protein        399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82239      Bile acids total               401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82240      Bile acids cholylglycine       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82247      Bilirubin total                400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82248      Bilirubin direct               400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82252      Fecal bilirubin test           402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82261      Assay of biotinidase           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82270      Occult blood feces             400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82271      Occult blood other sources     402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82272      Occult bld feces 1-3 tests     402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82274      Assay test for blood fecal     402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82286      Assay of bradykinin            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82300      Assay of cadmium               404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 11 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 82306      Vitamin d 25 hydroxy           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82308      Assay of calcitonin            399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82310      Assay of calcium               402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82330      Assay of calcium               402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82331      Calcium infusion test          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82340      Assay of calcium in urine      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82355      Calculus analysis qual         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82360      Calculus assay quant           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82365      Calculus spectroscopy          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82370      X-ray assay calculus           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82373      Assay c-d transfer measure     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82374      Assay blood carbon dioxide     402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82375      Assay carboxyhb quant          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82376      Assay carboxyhb qual           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82378      Carcinoembryonic antigen       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82379      Assay of carnitine             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82380      Assay of carotene              400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82382      Assay urine catecholamines     399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82383      Assay blood catecholamines     399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82384      Assay three catecholamines     399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82387      Assay of cathepsin-d           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82390      Assay of ceruloplasmin         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82397      Chemiluminescent assay         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82415      Assay of chloramphenicol       405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82435      Assay of blood chloride        402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82436      Assay of urine chloride        402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82438      Assay other fluid chlorides    400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82441      Test for chlorohydrocarbons    404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82465      Assay bld/serum cholesterol    402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82480      Assay serum cholinesterase     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82482      Assay rbc cholinesterase       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82485      Assay chondroitin sulfate      399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82486      Gas/liquid chromatography      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82487      Paper chromatography           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82488      Paper chromatography           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82489      Thin layer chromatography      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82491      Chromotography quant sing      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82492      Chromotography quant mult      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82495      Assay of chromium              404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82507      Assay of citrate               401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82520      Assay of cocaine               404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82523      Collagen crosslinks            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82525      Assay of copper                404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82528      Assay of corticosterone        399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82530      Cortisol free                  400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82533      Total cortisol                 399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82540      Assay of creatine              402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82541      Column chromotography qual     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82542      Column chromotography quant    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82543      Column chromotograph/isotope   401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82544      Column chromotograph/isotope   401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82550      Assay of ck (cpk)              400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82552      Assay of cpk in blood          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82553      Creatine mb fraction           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82554      Creatine isoforms              401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 12 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 82565      Assay of creatinine            400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82570      Assay of urine creatinine      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82575      Creatinine clearance test      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82585      Assay of cryofibrinogen        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82595      Assay of cryoglobulin          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82600      Assay of cyanide               404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82607      Vitamin B-12                   398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82608      B-12 binding capacity          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82610      Cystatin c                     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82615      Test for urine cystines        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82626      Dehydroepiandrosterone         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82627      Dehydroepiandrosterone         399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82633      Desoxycorticosterone           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82634      Deoxycortisol                  399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82638      Assay of dibucaine number      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82646      Assay of dihydrocodeinone      404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82649      Assay of dihydromorphinone     404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82651      Assay of dihydrotestosterone   399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82652      Vit d 1 25-dihydroxy           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82654      Assay of dimethadione          405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82656      Pancreatic elastase fecal      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82657      Enzyme cell activity           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82658      Enzyme cell activity ra        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82664      Electrophoretic test           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82666      Assay of epiandrosterone       399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82668      Assay of erythropoietin        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82670      Assay of estradiol             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82671      Assay of estrogens             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82672      Assay of estrogen              399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82677      Assay of estriol               399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82679      Assay of estrone               399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82690      Assay of ethchlorvynol         404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82693      Assay of ethylene glycol       404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82696      Assay of etiocholanolone       399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82705      Fats/lipids feces qual         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82710      Fats/lipids feces quant        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82715      Assay of fecal fat             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82725      Assay of blood fatty acids     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82726      Long chain fatty acids         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82728      Assay of ferritin              400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82731      Assay of fetal fibronectin     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82735      Assay of fluoride              404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82742      Assay of flurazepam            405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82746      Blood folic acid serum         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82747      Assay of folic acid rbc        408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82757      Assay of semen fructose        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82759      Assay of rbc galactokinase     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82760      Assay of galactose             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82775      Assay galactose transferase    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82776      Galactose transferase test     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82784      Assay iga/igd/igg/igm each     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82785      Assay of ige                   401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82787      Igg 1 2 3 or 4 each            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82800      Blood pH                       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82803      Blood gases any combination    400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 13 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 82805      Blood gases w/o2 saturation    400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82810      Blood gases o2 sat only        400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82820      Hemoglobin-oxygen affinity     408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82930      Gastric analy w/ph ea spec     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82938      Gastrin test                   399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82941      Assay of gastrin               399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82943      Assay of glucagon              399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82945      Glucose other fluid            400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82946      Glucagon tolerance test        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82947      Assay glucose blood quant      402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82948      Reagent strip/blood glucose    411 BLOOD AND URINE DIPSTICK TESTS       No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82950      Glucose test                   402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82951      Glucose tolerance test (GTT)   400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82952      GTT-added samples              402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82953      Glucose-tolbutamide test       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82955      Assay of g6pd enzyme           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82960      Test for G6PD enzyme           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82962      Glucose blood test             402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82963      Assay of glucosidase           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82965      Assay of gdh enzyme            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82975      Assay of glutamine             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82977      Assay of GGT                   402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 82978      Assay of glutathione           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 82979      Assay rbc glutathione          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82980      Assay of glutethimide          405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 82985      Glycated protein               401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83001      Gonadotropin (FSH)             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83002      Gonadotropin (LH)              399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83003      Assay growth hormone (hgh)     399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83008      Assay of guanosine             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83009      H pylori (c-13) blood          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83010      Assay of haptoglobin quant     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83012      Assay of haptoglobins          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83013      H pylori (c-13) breath         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83014      H pylori drug admin            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83015      Heavy metal screen             404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83018      Quantitative screen metals     404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83020      Hemoglobin electrophoresis     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83021      Hemoglobin chromotography      409 LEVEL II HEMATOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83026      Hemoglobin copper sulfate      408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83030      Fetal hemoglobin chemical      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83033      Fetal hemoglobin assay qual    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83036      Glycosylated hemoglobin test   400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83037      Glycosylated hb home device    400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83045      Blood methemoglobin test       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83050      Blood methemoglobin assay      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83051      Assay of plasma hemoglobin     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83055      Blood sulfhemoglobin test      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83060      Blood sulfhemoglobin assay     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83065      Assay of hemoglobin heat       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83068      Hemoglobin stability screen    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83069      Assay of urine hemoglobin      402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83070      Assay of hemosiderin qual      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83071      Assay of hemosiderin quant     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83080      Assay of b hexosaminidase      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 14 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 83088      Assay of histamine             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83090      Assay of homocystine           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83150      Assay of for hva               399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83491      Assay of corticosteroids       399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83497      Assay of 5-hiaa                398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83498      Assay of progesterone          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83499      Assay of progesterone          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83500      Assay free hydroxyproline      399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83505      Assay total hydroxyproline     399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83516      Immunoassay nonantibody        394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83518      Immunoassay dipstick           394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83519      Ria nonantibody                394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83520      Immunoassay quant nos nonab    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83525      Assay of insulin               398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83527      Assay of insulin               399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83528      Assay of intrinsic factor      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83540      Assay of iron                  400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83550      Iron binding test              400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83570      Assay of idh enzyme            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83582      Assay of ketogenic steroids    398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83586      Assay 17- ketosteroids         398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83593      Fractionation ketosteroids     398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83605      Assay of lactic acid           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83615      Lactate (LD) (LDH) enzyme      402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83625      Assay of ldh enzymes           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83630      Lactoferrin fecal (qual)       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83631      Lactoferrin fecal (quant)      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83632      Placental lactogen             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83633      Test urine for lactose         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83634      Assay of urine for lactose     400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83661      L/s ratio fetal lung           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83662      Foam stability fetal lung      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83663      Fluoro polarize fetal lung     391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83664      Lamellar bdy fetal lung        391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83670      Assay of lap enzyme            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83690      Assay of lipase                400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83695      Assay of lipoprotein(a)        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83698      Assay lipoprotein pla2         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83700      Lipopro bld electrophoretic    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83701      Lipoprotein bld hr fraction    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83704      Lipoprotein bld by nmr         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83718      Assay of lipoprotein           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83719      Assay of blood lipoprotein     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83721      Assay of blood lipoprotein     400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83727      Assay of lrh hormone           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83735      Assay of magnesium             400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83775      Assay of md enzyme             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83785      Assay of manganese             404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83788      Mass spectrometry qual         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83789      Mass spectrometry quant        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83805      Assay of meprobamate           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83825      Assay of mercury               404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83835      Assay of metanephrines         399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83840      Assay of methadone             404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83857      Assay of methemalbumin         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 15 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 83858      Assay of methsuximide          405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83861      Microfluid analy tears         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83864      Mucopolysaccharides            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83866      Mucopolysaccharides screen     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83872      Assay synovial fluid mucin     400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83873      Assay of csf protein           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83874      Assay of myoglobin             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83876      Assay myeloperoxidase          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83880      Natriuretic peptide            401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83883      Assay nephelometry not spec    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83885      Assay of nickel                404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83887      Assay of nicotine              404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83915      Assay of nucleotidase          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83916      Oligoclonal bands              401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83918      Organic acids total quant      404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83919      Organic acids qual each        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83921      Organic acid single quant      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83925      Assay of opiates               404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83930      Assay of blood osmolality      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83935      Assay of urine osmolality      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83937      Assay of osteocalcin           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 83945      Assay of oxalate               401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83950      Oncoprotein her-2/neu          391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83951      Oncoprotein dcp                391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83970      Assay of parathormone          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 83986      Assay ph body fluid nos        400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83987      Exhaled breath condensate      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83992      Assay for phencyclidine        404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 83993      Assay for calprotectin fecal   401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84022      Assay of phenothiazine         405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84030      Assay of blood pku             400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84035      Assay of phenylketones         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84060      Assay acid phosphatase         402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84061      Phosphatase forensic exam      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84066      Assay prostate phosphatase     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84075      Assay alkaline phosphatase     402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84078      Assay alkaline phosphatase     402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84080      Assay alkaline phosphatases    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84081      Amniotic fluid enzyme test     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84085      Assay of rbc pg6d enzyme       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84087      Assay phosphohexose enzymes    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84100      Assay of phosphorus            402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84105      Assay of urine phosphorus      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84106      Test for porphobilinogen       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84110      Assay of porphobilinogen       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84112      Placenta alpha micro ig c/v    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84119      Test urine for porphyrins      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84120      Assay of urine porphyrins      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84126      Assay of feces porphyrins      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84127      Assay of feces porphyrins      399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84132      Assay of serum potassium       402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84133      Assay of urine potassium       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84134      Assay of prealbumin            400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84135      Assay of pregnanediol          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84138      Assay of pregnanetriol         399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 16 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 84140      Assay of pregnenolone          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84143      Assay of 17-hydroxypregneno    399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84144      Assay of progesterone          398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84145      Procalcitonin (pct)            399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84146      Assay of prolactin             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84150      Assay of prostaglandin         399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84152      Assay of psa complexed         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84153      Assay of psa total             400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84154      Assay of psa free              400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84155      Assay of protein serum         402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84156      Assay of protein urine         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84157      Assay of protein other         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84160      Assay of protein any source    402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84163      Pappa serum                    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84165      Protein e-phoresis serum       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84166      Protein e-phoresis/urine/csf   401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84181      Western blot test              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84182      Protein western blot test      395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84202      Assay RBC protoporphyrin       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84203      Test RBC protoporphyrin        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84206      Assay of proinsulin            399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84207      Assay of vitamin b-6           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84210      Assay of pyruvate              401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84220      Assay of pyruvate kinase       401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84228      Assay of quinine               405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84233      Assay of estrogen              399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84234      Assay of progesterone          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84235      Assay of endocrine hormone     399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84238      Assay nonendocrine receptor    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84244      Assay of renin                 399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84252      Assay of vitamin b-2           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84255      Assay of selenium              401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84260      Assay of serotonin             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84270      Assay of sex hormone globul    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84275      Assay of sialic acid           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84285      Assay of silica                404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84295      Assay of serum sodium          402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84300      Assay of urine sodium          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84302      Assay of sweat sodium          402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84305      Assay of somatomedin           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84307      Assay of somatostatin          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84311      Spectrophotometry              400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84315      Body fluid specific gravity    400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84375      Chromatogram assay sugars      401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84376      Sugars single qual             400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84377      Sugars multiple qual           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84378      Sugars single quant            400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84379      Sugars multiple quant          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84392      Assay of urine sulfate         410 URINALYSIS                           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84402      Assay of testosterone          399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84403      Assay of total testosterone    399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84425      Assay of vitamin b-1           401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84430      Assay of thiocyanate           404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84431      Thromboxane urine              401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84432      Assay of thyroglobulin         399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 17 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 84436      Assay of total thyroxine       398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84437      Assay of neonatal thyroxine    398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84439      Assay of free thyroxine        398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84442      Assay of thyroid activity      398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84443      Assay thyroid stim hormone     398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84445      Assay of tsi                   399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84446      Assay of vitamin e             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84449      Assay of transcortin           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84450      Transferase (AST) (SGOT)       402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84460      Alanine amino (ALT) (SGPT)     402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84466      Assay of transferrin           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84478      Assay of triglycerides         402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84479      Assay of thyroid (t3 or t4)    398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84480      Assay triiodothyronine (t3)    398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84481      Free assay (FT-3)              398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84482      T3 reverse                     398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84484      Assay of troponin quant        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84485      Assay duodenal fluid trypsin   401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84488      Test feces for trypsin         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84490      Assay of feces for trypsin     401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84510      Assay of tyrosine              401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84512      Assay of troponin qual         401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84520      Assay of urea nitrogen         402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84525      Urea nitrogen semi-quant       411 BLOOD AND URINE DIPSTICK TESTS       No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84540      Assay of urine/urea-n          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84545      Urea-N clearance test          400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84550      Assay of blood/uric acid       402 BASIC CHEMISTRY TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84560      Assay of urine/uric acid       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84577      Assay of feces/urobilinogen    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84578      Test urine urobilinogen        411 BLOOD AND URINE DIPSTICK TESTS       No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84580      Assay of urine urobilinogen    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84583      Assay of urine urobilinogen    400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84585      Assay of urine vma             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84586      Assay of vip                   399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84588      Assay of vasopressin           399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84590      Assay of vitamin a             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84591      Assay of nos vitamin           405 THERAPEUTIC DRUG MONITORING          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84597      Assay of vitamin k             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84600      Assay of volatiles             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84620      Xylose tolerance test          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84630      Assay of zinc                  404 TOXICOLOGY TESTS                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84681      Assay of c-peptide             401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84702      Chorionic gonadotropin test    398 LEVEL I ENDOCRINOLOGY TESTS          No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84703      Chorionic gonadotropin assay   400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 84704      Hcg free betachain test        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 84830      Ovulation tests                399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 84999      Clinical chemistry test        400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85002      Bleeding time test             406 LEVEL I CLOTTING TESTS               No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85007      Bl smear w/diff wbc count      408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85008      Bl smear w/o diff wbc count    408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85009      Manual diff wbc count b-coat   408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85013      Spun microhematocrit           408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85014      Hematocrit                     408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85018      Hemoglobin                     408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 85025      Complete cbc w/auto diff wbc   408 LEVEL I HEMATOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 18 of 34
                                                                                                                                            Line Level Payment Action
                                                                                                                                                            Modifier U6 NOT coded on
                                                                                                                            Modifier U6 coded on line     line (provider not responsible
                                                                                                                             (performed in house or          for service. Lab/radiology
Procedure                                                                        On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                 APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 85027      Complete cbc automated         408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85032      Manual cell count each         408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85041      Automated rbc count            408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85044      Manual reticulocyte count      408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85045      Automated reticulocyte count   408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85046      Reticyte/hgb concentrate       408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85048      Automated leukocyte count      408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85049      Automated platelet count       408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85055      Reticulated platelet assay     407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85097      Bone marrow interpretation     390 LEVEL I PATHOLOGY                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85130      Chromogenic substrate assay    409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85170      Blood clot retraction          406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85175      Blood clot lysis time          406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85210      Blood clot factor II test      406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85220      Blood clot factor V test       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85230      Blood clot factor VII test     407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85240      Blood clot factor VIII test    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85244      Blood clot factor VIII test    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85245      Blood clot factor VIII test    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85246      Blood clot factor VIII test    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85247      Blood clot factor VIII test    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85250      Blood clot factor IX test      407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85260      Blood clot factor X test       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85270      Blood clot factor XI test      407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85280      Blood clot factor XII test     407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85290      Blood clot factor XIII test    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85291      Blood clot factor XIII test    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85292      Blood clot factor assay        407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85293      Blood clot factor assay        407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85300      Antithrombin III test          407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85301      Antithrombin III test          407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85302      Blood clot inhibitor antigen   407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85303      Blood clot inhibitor test      407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85305      Blood clot inhibitor assay     407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85306      Blood clot inhibitor test      407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85307      Assay activated protein c      401 LEVEL II CHEMISTRY TESTS              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85335      Factor inhibitor test          407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85337      Thrombomodulin                 407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85345      Coagulation time               406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85347      Coagulation time               406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85348      Coagulation time               406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85360      Euglobulin lysis               409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85362      Fibrin degradation products    406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85366      Fibrinogen test                406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85370      Fibrinogen test                407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85378      Fibrin degrade semiquant       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85379      Fibrin degradation quant       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85380      Fibrin degradation vte         409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85384      Fibrinogen                     406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85385      Fibrinogen                     406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85390      Fibrinolysins screen           406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85396      Clotting assay whole blood     407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85397      Clotting funct activity        407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85400      Fibrinolytic plasmin           407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85410      Fibrinolytic antiplasmin       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
                                                                                                                                                                               page 19 of 34
                                                                                                                                            Line Level Payment Action
                                                                                                                                                            Modifier U6 NOT coded on
                                                                                                                            Modifier U6 coded on line     line (provider not responsible
                                                                                                                             (performed in house or          for service. Lab/radiology
Procedure                                                                        On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                 APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 85415      Fibrinolytic plasminogen       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85420      Fibrinolytic plasminogen       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85421      Fibrinolytic plasminogen       407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85441      Heinz bodies direct            408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85445      Heinz bodies induced           408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85460      Hemoglobin fetal               409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85461      Hemoglobin fetal               408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85475      Hemolysin                      407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85520      Heparin assay                  407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85525      Heparin neutralization         407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85530      Heparin-protamine tolerance    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85536      Iron stain peripheral blood    408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85540      Wbc alkaline phosphatase       408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85547      RBC mechanical fragility       408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85549      Muramidase                     401 LEVEL II CHEMISTRY TESTS              No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85555      RBC osmotic fragility          409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85557      RBC osmotic fragility          409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85576      Blood platelet aggregation     407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85597      Phospholipid pltlt neutraliz   407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85598      Hexagnal phosph pltlt neutrl   407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85611      Prothrombin test               406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85612      Viper venom prothrombin time   407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85613      Russell viper venom diluted    407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85635      Reptilase test                 409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 85651      Rbc sed rate nonautomated      408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85652      Rbc sed rate automated         408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85660      RBC sickle cell test           408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85670      Thrombin time plasma           406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85675      Thrombin time titer            406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85705      Thromboplastin inhibition      407 LEVEL II CLOTTING TESTS               No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85730      Thromboplastin time partial    406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85732      Thromboplastin time partial    406 LEVEL I CLOTTING TESTS                No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 85810      Blood viscosity examination    409 LEVEL II HEMATOLOGY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 85999      Hematology procedure           408 LEVEL I HEMATOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86000      Agglutinins febrile            394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86001      Allergen specific igg          394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86003      Allergen specific IgE          394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86005      Allergen specific IgE          394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86021      WBC antibody identification    394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86022      Platelet antibodies            394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86023      Immunoglobulin assay           394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86038      Antinuclear antibodies         400 LEVEL I CHEMISTRY TESTS               No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86039      Antinuclear antibodies (ANA)   400 LEVEL I CHEMISTRY TESTS               No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86060      Antistreptolysin o titer       394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86063      Antistreptolysin o screen      394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86077      Physician blood bank service   390 LEVEL I PATHOLOGY                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86078      Physician blood bank service   390 LEVEL I PATHOLOGY                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86079      Physician blood bank service   390 LEVEL I PATHOLOGY                     No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86140      C-reactive protein             394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86141      C-reactive protein hs          400 LEVEL I CHEMISTRY TESTS               No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
 86146      Glycoprotein antibody          401 LEVEL II CHEMISTRY TESTS              No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                     base rate
 86147      Cardiolipin antibody           395 LEVEL II IMMUNOLOGY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 86148      Phospholipid antibody          401 LEVEL II CHEMISTRY TESTS              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 86155      Chemotaxis assay               395 LEVEL II IMMUNOLOGY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                     base rate
 86156      Cold agglutinin screen         394 LEVEL I IMMUNOLOGY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                               regional base rate
                                                                                                                                                                               page 20 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 86157      Cold agglutinin titer          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86160      Complement antigen             394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86161      Complement/function activity   394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86162      Complement total (ch50)        394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86171      Complement fixation each       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86185      Counterimmunoelectrophoresis   394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86200      Ccp antibody                   394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86215      Deoxyribonuclease antibody     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86225      DNA antibody                   394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86226      Dna antibody single strand     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86235      Nuclear antigen antibody       395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86243      Fc receptor                    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86255      Fluorescent antibody screen    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86256      Fluorescent antibody titer     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86277      Growth hormone antibody        399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86280      Hemagglutination inhibition    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86294      Immunoassay tumor qual         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86300      Immunoassay tumor ca 15-3      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86301      Immunoassay tumor ca 19-9      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86304      Immunoassay tumor ca 125       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86305      Human epididymis protein 4     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86308      Heterophile antibodies         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86309      Heterophile antibodies         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86310      Heterophile antibodies         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86316      Immunoassay tumor other        401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86317      Immunoassay infectious agent   395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86318      Immunoassay infectious agent   395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86320      Serum immunoelectrophoresis    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86325      Other immunoelectrophoresis    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86327      Immunoelectrophoresis assay    401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86329      Immunodiffusion                395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86331      Immunodiffusion ouchterlony    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86332      Immune complex assay           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86334      Immunofix e-phoresis serum     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86335      Immunfix e-phorsis/urine/csf   395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86337      Insulin antibodies             399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86340      Intrinsic factor antibody      399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86341      Islet cell antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86343      Leukocyte histamine release    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86344      Leukocyte phagocytosis         395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86352      Cell function assay w/stim     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86353      Lymphocyte transformation      395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86355      B cells total count            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86356      Mononuclear cell antigen       395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86357      Nk cells total count           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86359      T cells total count            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86360      T cell absolute count/ratio    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86361      T cell absolute count          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86367      Stem cells total count         395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86376      Microsomal antibody            399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86378      Migration inhibitory factor    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86382      Neutralization test viral      395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86384      Nitroblue tetrazolium dye      396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86403      Particle agglutination test    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86406      Particle agglutination test    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 21 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 86430      Rheumatoid factor test         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86431      Rheumatoid factor quant        394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86480      Tb test cell immun measure     395 LEVEL II IMMUNOLOGY TESTS           Yes       Ancillary            No       pay as normal based on fee           zero payment
                                                                                                                               schedule payment
 86481      Tb ag response t-cell susp     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86485      Skin test candida              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86486      Skin test nos antigen          396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86490      Coccidioidomycosis skin test   394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86510      Histoplasmosis skin test       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86580      TB intradermal test            394 LEVEL I IMMUNOLOGY TESTS            Yes       Ancillary            Yes      pay as normal based on fee           zero payment
                                                                                                                               schedule payment
 86590      Streptokinase antibody         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86592      Syphilis test non-trep qual    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86593      Syphilis test non-trep quant   394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86602      Antinomyces antibody           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86603      Adenovirus antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86606      Aspergillus antibody           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86609      Bacterium antibody             397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86611      Bartonella antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86612      Blastomyces antibody           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86615      Bordetella antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86617      Lyme disease antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86618      Lyme disease antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86619      Borrelia antibody              395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86622      Brucella antibody              395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86625      Campylobacter antibody         395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86628      Candida antibody               396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86631      Chlamydia antibody             396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86632      Chlamydia igm antibody         396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86635      Coccidioides antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86638      Q fever antibody               395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86641      Cryptococcus antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86644      CMV antibody                   395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86645      Cmv antibody igm               395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86648      Diphtheria antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86651      Encephalitis antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86652      Encephalitis antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86653      Encephalitis antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86654      Encephalitis antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86658      Enterovirus antibody           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86663      Epstein-barr antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86664      Epstein-barr antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86665      Epstein-barr antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86666      Ehrlichia antibody             395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86668      Francisella tularensis         395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86671      Fungus antibody                394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86674      Giardia lamblia antibody       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86677      Helicobacter pylori            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86682      Helminth antibody              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86684      Hemophilus influenza           394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86687      Htlv-i antibody                394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86688      Htlv-ii antibody               394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86689      HTLV/HIV confirmatory test     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86692      Hepatitis delta agent          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86694      Herpes simplex test            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86695      Herpes simplex test            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86696      Herpes simplex type 2          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 22 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 86698      Histoplasma                    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86701      HIV-1                          394 LEVEL I IMMUNOLOGY TESTS            Yes       Ancillary            Yes      pay as normal based on fee            zero payment
                                                                                                                               schedule payment
 86702      HIV-2                          394 LEVEL I IMMUNOLOGY TESTS            Yes       Ancillary            Yes      pay as normal based on fee            zero payment
                                                                                                                               schedule payment
 86703      Hiv-1/hiv-2 single assay       394 LEVEL I IMMUNOLOGY TESTS            Yes       Ancillary            Yes      pay as normal based on fee            zero payment
                                                                                                                               schedule payment
 86704      Hep b core antibody total      400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86705      Hep b core antibody igm        400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86706      Hep b surface antibody         400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86707      Hep be antibody                400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86708      Hep a antibody total           400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86709      Hep a antibody igm             400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86710      Influenza virus antibody       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86713      Legionella antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86717      Leishmania antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86720      Leptospira antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86723      Listeria monocytogenes ab      395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86727      Lymph choriomeningitis ab      395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86729      Lympho venereum antibody       395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86732      Mucormycosis antibody          395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86735      Mumps antibody                 394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86738      Mycoplasma antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86741      Neisseria meningitidis         395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86744      Nocardia antibody              395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86747      Parvovirus antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86750      Malaria antibody               395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86753      Protozoa antibody nos          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86756      Respiratory virus antibody     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86757      Rickettsia antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86759      Rotavirus antibody             395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86762      Rubella antibody               394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86765      Rubeola antibody               394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86768      Salmonella antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86771      Shigella antibody              395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86774      Tetanus antibody               395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86777      Toxoplasma antibody            395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86778      Toxoplasma antibody igm        395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86780      Treponema pallidum             395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86784      Trichinella antibody           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86787      Varicella-zoster antibody      394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86788      West nile virus ab igm         395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86789      West nile virus antibody       395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86790      Virus antibody nos             394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86793      Yersinia antibody              395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86800      Thyroglobulin antibody         399 LEVEL II ENDOCRINOLOGY TESTS         No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86803      Hepatitis c ab test            400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86804      Hep c ab test confirm          401 LEVEL II CHEMISTRY TESTS             No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86805      Lymphocytotoxicity assay       393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86806      Lymphocytotoxicity assay       393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86807      Cytotoxic antibody screening   393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86808      Cytotoxic antibody screening   393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86812      Hla typing a b or c            393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86813      Hla typing a b or c            393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86816      Hla typing dr/dq               393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86817      Hla typing dr/dq               393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86821      Lymphocyte culture mixed       393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86822      Lymphocyte culture primed      393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 23 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 86825      Hla x-math non-cytotoxic       393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86826      Hla x-match noncytotoxc addl   393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86849      Immunology procedure           394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86850      RBC antibody screen            394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86860      RBC antibody elution           394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86870      RBC antibody identification    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86880      Coombs test direct             394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86885      Coombs test indirect qual      394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86886      Coombs test indirect titer     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 86890      Autologous blood process       393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 86891      Autologous blood op salvage    393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86900      Blood typing abo               393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86901      Blood typing rh (d)            393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86902      Blood type antigen donor ea    393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86904      Blood typing patient serum     393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86905      Blood typing rbc antigens      393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86906      Blood typing rh phenotype      393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86910      Blood typing paternity test    393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86911      Blood typing antigen system    393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86920      Compatibility test spin        393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86921      Compatibility test incubate    393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86922      Compatibility test antiglob    393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86923      Compatibility test electric    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86927      Plasma fresh frozen            393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86930      Frozen blood prep              393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86931      Frozen blood thaw              393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86932      Frozen blood freeze/thaw       393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86940      Hemolysins/agglutinins auto    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86941      Hemolysins/agglutinins         395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86945      Blood product/irradiation      393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86950      Leukacyte transfusion          393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86960      Vol reduction of blood/prod    393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86965      Pooling blood platelets        393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86970      RBC pretreatment               393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86971      RBC pretreatment               393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86972      RBC pretreatment               393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86975      Rbc pretreatment serum         393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86976      Rbc pretreatment serum         393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86977      Rbc pretreatment serum         393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86978      Rbc pretreatment serum         393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86985      Split blood or products        393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 86999      Transfusion procedure          393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87001      Small animal inoculation       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87003      Small animal inoculation       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87015      Specimen concentration         396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87040      Blood culture for bacteria     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87045      Feces culture bacteria         396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87046      Stool cultr bacteria each      396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87070      Culture bacteria other         396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87071      Culture bacteri aerobic othr   396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87073      Culture bacteria anaerobic     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87075      Cultr bacteria except blood    396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87076      Culture anaerobe ident each    396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87077      Culture aerobic identify       396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87081      Culture screen only            396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 24 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 87084      Culture of specimen by kit     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87086      Urine culture/colony count     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87088      Urine bacteria culture         396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87101      Skin fungi culture             396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87102      Fungus isolation culture       396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87103      Blood fungus culture           397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87106      Fungi identification yeast     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87107      Fungi identification mold      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87109      Mycoplasma                     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87110      Chlamydia culture              396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87116      Mycobacteria culture           397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87118      Mycobacteric identification    397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87140      Culture type immunofluoresc    397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87143      Culture typing glc/hplc        397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87147      Culture type immunologic       396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87149      Dna/rna direct probe           396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87150      Dna/rna amplified probe        396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87152      Culture type pulse field gel   397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87153      Dna/rna sequencing             397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87158      Culture typing added method    397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87164      Dark field examination         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87166      Dark field examination         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87168      Macroscopic exam arthropod     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87169      Macroscopic exam parasite      396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87172      Pinworm exam                   396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87176      Tissue homogenization cultr    396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87177      Ova and parasites smears       396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87181      Microbe susceptible diffuse    396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87184      Microbe susceptible disk       396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87185      Microbe susceptible enzyme     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87186      Microbe susceptible mic        396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87187      Microbe susceptible mlc        396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87188      Microbe suscept macrobroth     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87190      Microbe suscept mycobacteri    396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87197      Bactericidal level serum       396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87205      Smear gram stain               396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87206      Smear fluorescent/acid stai    396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87207      Smear special stain            396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87209      Smear complex stain            400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87210      Smear wet mount saline/ink     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87220      Tissue exam for fungi          396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87230      Assay toxin or antitoxin       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87250      Virus inoculate eggs/animal    397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87252      Virus inoculation tissue       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87253      Virus inoculate tissue addl    397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87254      Virus inoculation shell via    397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87255      Genet virus isolate hsv        397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87260      Adenovirus ag if               394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87265      Pertussis ag if                394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87267      Enterovirus antibody dfa       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87269      Giardia ag if                  394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87270      Chlamydia trachomatis ag if    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87271      Cytomegalovirus dfa            394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87272      Cryptosporidium ag if          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87273      Herpes simplex 2 ag if         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 25 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 87274      Herpes simplex 1 ag if         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87275      Influenza b ag if              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87276      Influenza a ag if              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87277      Legionella micdadei ag if      394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87278      Legion pneumophilia ag if      394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87279      Parainfluenza ag if            394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87280      Respiratory syncytial ag if    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87281      Pneumocystis carinii ag if     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87283      Rubeola ag if                  394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87285      Treponema pallidum ag if       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87290      Varicella zoster ag if         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87299      Antibody detection nos if      394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87300      Ag detection polyval if        394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87301      Adenovirus ag eia              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87305      Aspergillus ag eia             396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87320      Chylmd trach ag eia            394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87324      Clostridium ag eia             394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87327      Cryptococcus neoform ag eia    394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87328      Cryptosporidium ag eia         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87329      Giardia ag eia                 394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87332      Cytomegalovirus ag eia         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87335      E coli 0157 ag eia             394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87336      Entamoeb hist dispr ag eia     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87337      Entamoeb hist group ag eia     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87338      Hpylori stool eia              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87339      H pylori ag eia                394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87340      Hepatitis b surface ag eia     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87341      Hepatitis b surface ag eia     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87350      Hepatitis be ag eia            394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87380      Hepatitis delta ag eia         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87385      Histoplasma capsul ag eia      394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87390      Hiv-1 ag eia                   394 LEVEL I IMMUNOLOGY TESTS            Yes       Ancillary            Yes      pay as normal based on fee           zero payment
                                                                                                                               schedule payment
 87391      Hiv-2 ag eia                   394 LEVEL I IMMUNOLOGY TESTS            Yes       Ancillary            Yes      pay as normal based on fee            zero payment
                                                                                                                               schedule payment
 87400      Influenza a/b ag eia           395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87420      Resp syncytial ag eia          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87425      Rotavirus ag eia               394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87427      Shiga-like toxin ag eia        394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87430      Strep a ag eia                 394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87449      Ag detect nos eia mult         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87450      Ag detect nos eia single       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87451      Ag detect polyval eia mult     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87470      Bartonella dna dir probe       394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87471      Bartonella dna amp probe       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87472      Bartonella dna quant           397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87475      Lyme dis dna dir probe         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87476      Lyme dis dna amp probe         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87477      Lyme dis dna quant             397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87480      Candida dna dir probe          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87481      Candida dna amp probe          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87482      Candida dna quant              394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87485      Chylmd pneum dna dir probe     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87486      Chylmd pneum dna amp probe     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87487      Chylmd pneum dna quant         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87490      Chylmd trach dna dir probe     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87491      Chylmd trach dna amp probe     394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 26 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 87492      Chylmd trach dna quant         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87493      C diff amplified probe         394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87495      Cytomeg dna dir probe          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87496      Cytomeg dna amp probe          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87497      Cytomeg dna quant              397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87498      Enterovirus dna amp probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87500      Vanomycin dna amp probe        395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87501      Influenza dna amp prob 1+      395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87502      Influenza dna amp probe        395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87503      Influenza dna amp prob addl    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87510      Gardner vag dna dir probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87511      Gardner vag dna amp probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87512      Gardner vag dna quant          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87515      Hepatitis b dna dir probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87516      Hepatitis b dna amp probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87517      Hepatitis b dna quant          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87520      Hepatitis c rna dir probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87521      Hepatitis c rna amp probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87522      Hepatitis c rna quant          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87525      Hepatitis g dna dir probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87526      Hepatitis g dna amp probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87527      Hepatitis g dna quant          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87528      Hsv dna dir probe              397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87529      Hsv dna amp probe              397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87530      Hsv dna quant                  397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87531      Hhv-6 dna dir probe            397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87532      Hhv-6 dna amp probe            397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87533      Hhv-6 dna quant                397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87534      Hiv-1 dna dir probe            397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87535      Hiv-1 dna amp probe            397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87537      Hiv-2 dna dir probe            397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87538      Hiv-2 dna amp probe            397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87540      Legion pneumo dna dir prob     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87541      Legion pneumo dna amp prob     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87542      Legion pneumo dna quant        397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87550      Mycobacteria dna dir probe     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87551      Mycobacteria dna amp probe     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87552      Mycobacteria dna quant         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87555      M.tuberculo dna dir probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87556      M.tuberculo dna amp probe      397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87557      M.tuberculo dna quant          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87560      M.avium-intra dna dir prob     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87561      M.avium-intra dna amp prob     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87562      M.avium-intra dna quant        397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87580      M.pneumon dna dir probe        397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87581      M.pneumon dna amp probe        397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87582      M.pneumon dna quant            397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87590      N.gonorrhoeae dna dir prob     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87591      N.gonorrhoeae dna amp prob     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87592      N.gonorrhoeae dna quant        397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87620      Hpv dna dir probe              397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87621      Hpv dna amp probe              397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87622      Hpv dna quant                  397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87640      Staph a dna amp probe          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87641      Mr-staph dna amp probe         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 27 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 87650      Strep a dna dir probe          394 LEVEL I IMMUNOLOGY TESTS             No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87651      Strep a dna amp probe          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87652      Strep a dna quant              397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87653      Strep b dna amp probe          397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87660      Trichomonas vagin dir probe    397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87797      Detect agent nos dna dir       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87798      Detect agent nos dna amp       397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87799      Detect agent nos dna quant     397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87800      Detect agnt mult dna direc     393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87801      Detect agnt mult dna ampli     393 BLOOD AND TISSUE TYPING              No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 87802      Strep b assay w/optic          396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87803      Clostridium toxin a w/optic    396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87804      Influenza assay w/optic        396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87807      Rsv assay w/optic              396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87808      Trichomonas assay w/optic      396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87809      Adenovirus assay w/optic       396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87810      Chylmd trach assay w/optic     396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87850      N. gonorrhoeae assay w/optic   396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87880      Strep a assay w/optic          396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87899      Agent nos assay w/optic        396 LEVEL I MICROBIOLOGY TESTS           No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 87905      Sialidase enzyme assay         397 LEVEL II MICROBIOLOGY TESTS          No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 87906      Genotype dna hiv reverse t     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88104      Cytopath fl nongyn smears      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88106      Cytopath fl nongyn filter      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88107      Cytopath fl nongyn sm/fltr     390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88108      Cytopath concentrate tech      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88112      Cytopath cell enhance tech     390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88120      Cytp urne 3-5 probes ea spec   391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88121      Cytp urine 3-5 probes cmptr    391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88125      Forensic cytopathology         390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88130      Sex chromatin identification   390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88140      Sex chromatin identification   390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88141      Cytopath c/v interpret         392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88142      Cytopath c/v thin layer        392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88143      Cytopath c/v thin layer redo   392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88147      Cytopath c/v automated         392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88148      Cytopath c/v auto rescreen     392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88150      Cytopath c/v manual            392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88152      Cytopath c/v auto redo         392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88153      Cytopath c/v redo              392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88154      Cytopath c/v select            392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88155      Cytopath c/v index add-on      392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88160      Cytopath smear other source    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88161      Cytopath smear other source    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88162      Cytopath smear other source    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88164      Cytopath tbs c/v manual        392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88165      Cytopath tbs c/v redo          392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88166      Cytopath tbs c/v auto redo     392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88167      Cytopath tbs c/v select        392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88172      Cytp dx eval fna 1st ea site   390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88173      Cytopath eval fna report       390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88174      Cytopath c/v auto in fluid     392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88175      Cytopath c/v auto fluid redo   392 PAP SMEARS                           No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88177      Cytp fna eval ea addl          390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88182      Cell marker study              391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
                                                                                                                                                                              page 28 of 34
                                                                                                                                           Line Level Payment Action
                                                                                                                                                           Modifier U6 NOT coded on
                                                                                                                           Modifier U6 coded on line     line (provider not responsible
                                                                                                                            (performed in house or          for service. Lab/radiology
Procedure                                                                       On APG Fee                      Packaged    provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description    Schedule?           APG Type     APG?      lab/radiology provider)                  directlly )
 88184      Flowcytometry/ tc 1 marker     390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88185      Flowcytometry/tc add-on        391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88187      Flowcytometry/read 2-8         390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88188      Flowcytometry/read 9-15        390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88189      Flowcytometry/read 16 & >      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88199      Cytopathology procedure        390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88299      Cytogenetic study              391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88300      Surgical path gross            390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88302      Tissue exam by pathologist     390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88304      Tissue exam by pathologist     390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88305      Tissue exam by pathologist     390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88307      Tissue exam by pathologist     391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88309      Tissue exam by pathologist     391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88311      Decalcify tissue               390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88312      Special stains group 1         390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88313      Special stains group 2         390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88314      Histochemical stains add-on    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88318      Chemical histochemistry        390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88319      Enzyme histochemistry          390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88321      Microslide consultation        390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88323      Microslide consultation        390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88325      Comprehensive review of data   390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88329      Path consult introp            390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88331      Path consult intraop 1 bloc    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88332      Path consult intraop addl      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88333      Intraop cyto path consult 1    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88334      Intraop cyto path consult 2    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88342      Immunohistochemistry           390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88346      Immunofluorescent study        390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88347      Immunofluorescent study        390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88348      Electron microscopy            391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88349      Scanning electron microscopy   391 LEVEL II PATHOLOGY                   No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88355      Analysis skeletal muscle       390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88356      Analysis nerve                 390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88358      Analysis tumor                 390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88360      Tumor                          390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
            immunohistochem/manual                                                                                                                            regional base rate
 88361      Tumor                          390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
            immunohistochem/comput                                                                                                                            regional base rate
 88362      Nerve teasing preparations     390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88363      Xm archive tissue molec anal   390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88365      Insitu hybridization (fish)    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88367      Insitu hybridization auto      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88368      Insitu hybridization manual    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88371      Protein western blot tissue    390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88372      Protein analysis w/probe       390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88380      Microdissection laser          390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88381      Microdissection manual         390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88384      Eval molecular probes 11-50    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide           zero payment
                                                                                                                                    base rate
 88385      Eval molecul probes 51-250     395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88386      Eval molecul probes 251-500    395 LEVEL II IMMUNOLOGY TESTS            No       Ancillary            No       pay as normal on statewide            zero payment
                                                                                                                                    base rate
 88387      Tiss exam molecular study      390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88388      Tiss ex molecul study add-on   390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88399      Surgical pathology procedure   390 LEVEL I PATHOLOGY                    No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88720      Bilirubin total transcut       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88738      Hgb quant transcutaneous       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
 88740      Transcutaneous carboxyhb       400 LEVEL I CHEMISTRY TESTS              No       Ancillary            Yes          package as normal           payment reduced based on
                                                                                                                                                              regional base rate
                                                                                                                                                                              page 29 of 34
                                                                                                                                                          Line Level Payment Action
                                                                                                                                                                          Modifier U6 NOT coded on
                                                                                                                                          Modifier U6 coded on line     line (provider not responsible
                                                                                                                                           (performed in house or          for service. Lab/radiology
Procedure                                                                                 On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description              Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 88741      Transcutaneous methb           400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89050      Body fluid cell count          390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89051      Body fluid cell count          390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89055      Leukocyte assessment fecal     408 LEVEL I HEMATOLOGY TESTS                       No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89060      Exam synovial fluid crystals   390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89125      Specimen fat stain             390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89160      Exam feces for meat fibers     390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89190      Nasal smear for eosinophils    390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89220      Sputum specimen collection     396 LEVEL I MICROBIOLOGY TESTS                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89230      Collect sweat for test         390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89240      Pathology lab procedure        390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89250      Cultr oocyte/embryo <4 days    391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 89251      Cultr oocyte/embryo <4 days    391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 89253      Embryo hatching                391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 89254      Oocyte identification          391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 89255      Prepare embryo for transfer    390 LEVEL I PATHOLOGY                              No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 89257      Sperm identification           390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89258      Cryopreservation embryo(s)     390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89259      Cryopreservation sperm         390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89260      Sperm isolation simple         390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89261      Sperm isolation complex        390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89264      Identify sperm tissue          390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89268      Insemination of oocytes        390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89272      Extended culture of oocytes    390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89280      Assist oocyte fertilization    391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 89281      Assist oocyte fertilization    391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 89290      Biopsy oocyte polar body       391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 89291      Biopsy oocyte polar body       391 LEVEL II PATHOLOGY                             No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 89300      Semen analysis w/huhner        390 LEVEL I PATHOLOGY                              No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 89310      Semen analysis w/count         390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89320      Semen anal vol/count/mot       390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89321      Semen anal sperm detection     390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89322      Semen anal strict criteria     400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89325      Sperm antibody test            390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89329      Sperm evaluation test          390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89330      Evaluation cervical mucus      390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89331      Retrograde ejaculation anal    400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89335      Cryopreserve testicular tiss   390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89342      Storage/year embryo(s)         390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89343      Storage/year sperm/semen       390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89344      Storage/year reprod tissue     390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89346      Storage/year oocyte(s)         390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89352      Thawing cryopresrved embryo    390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89353      Thawing cryopresrved sperm     390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89354      Thaw cryoprsvrd reprod tiss    390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 89356      Thawing cryopresrved oocyte    390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 91065      Breath hydrogen test           401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 92611      Motion fluoroscopy/swallow     471 PLAIN FILM                                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 93880      Extracranial study             288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base        zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93882      Extracranial study             288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93886      Intracranial study             288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93888      Intracranial study             288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate




                                                                                                                                                                                             page 30 of 34
                                                                                                                                                          Line Level Payment Action
                                                                                                                                                                          Modifier U6 NOT coded on
                                                                                                                                          Modifier U6 coded on line     line (provider not responsible
                                                                                                                                           (performed in house or          for service. Lab/radiology
Procedure                                                                                 On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description              Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 93890      Tcd vasoreactivity study       288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93892      Tcd emboli detect w/o inj      288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93893      Tcd emboli detect w/inj        288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93925      Lower extremity study          288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93926      Lower extremity study          288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93930      Upper extremity study          288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93931      Upper extremity study          288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93970      Extremity study                288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93971      Extremity study                288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93975      Vascular study                 288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93976      Vascular study                 288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93978      Vascular study                 288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93979      Vascular study                 288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93980      Penile vascular study          288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93981      Penile vascular study          288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 93990      Doppler flow testing           288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 94010      Breathing capacity test        412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94011      Spirometry up to 2 yrs old     412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94012      Spirmtry w/brnchdil inf-2 yr   412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94014      Patient recorded spirometry    412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94015      Patient recorded spirometry    412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94060      Evaluation of wheezing         412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94150      Vital capacity test            412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94200      Lung function test (MBC/MVV)   412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94240      Residual lung capacity         412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94370      Breath airway closing volume   412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94375      Respiratory flow volume loop   412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94400      CO2 breathing response curve   412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94450      Hypoxia response curve         412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94452      Hast w/report                  412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94453      Hast w/oxygen titrate          412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94644      Cbt 1st hour                   412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94645      Cbt each addl hour             412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94680      Exhaled air analysis o2        412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94690      Exhaled air analysis           412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94720      Monoxide diffusing capacity    412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94725      Membrane diffusion capacity    412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94750      Pulmonary compliance study     412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94774      Ped home apnea rec compl       412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94775      Ped home apnea rec hk-up       412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94776      Ped home apnea rec downld      412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94777      Ped home apnea rec report      412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 94799      Pulmonary service/procedure    412 SIMPLE PULMONARY FUNCTION TESTS                No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 95250      Glucose monitoring cont        401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 95251      Gluc monitor cont phys i&r     401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 96902      Trichogram                     390 LEVEL I PATHOLOGY                              No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 0030T      Antiprothrombin antibody       395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
                                                                                                                                                                                             page 31 of 34
                                                                                                                                                          Line Level Payment Action
                                                                                                                                                                          Modifier U6 NOT coded on
                                                                                                                                          Modifier U6 coded on line     line (provider not responsible
                                                                                                                                           (performed in house or          for service. Lab/radiology
Procedure                                                                                 On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description              Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 0042T      Ct perfusion w/contrast cbf    299 CAT SCAN - BRAIN                               No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 0058T      Cryopreservation ovary tiss    390 LEVEL I PATHOLOGY                              No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 0059T      Cryopreservation oocyte        390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 0103T      Holotranscobalamin             401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 0111T      Rbc membranes fatty acids      399 LEVEL II ENDOCRINOLOGY TESTS                   No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 0126T      Chd risk imt study             288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 0233T      Skin glycation spectroscopy    401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  3111F     Ct/mri brain done w/in 24hrs   296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  3112F     Ct/mri brain done >24 hrs      296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  3155F     Cytogen test marrow b/4 tx     390 LEVEL I PATHOLOGY                              No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 C8900      MRA w/cont, abd                283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide           zero payment
                                               SITES                                                                                               base rate
 C8901      MRA w/o cont, abd              283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8902      MRA w/o fol w/cont, abd        283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8903      MRI w/cont, breast, uni        296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8904      MRI w/o cont, breast, uni      296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8905      MRI w/o fol w/cont, brst, un   296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8906      MRI w/cont, breast, bi         296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8907      MRI w/o cont, breast, bi       296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8908      MRI w/o fol w/cont, breast,    296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8909      MRA w/cont, chest              282 MAGNETIC RESONANCE ANGIOGRAPHY - CHEST         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8910      MRA w/o cont, chest            282 MAGNETIC RESONANCE ANGIOGRAPHY - CHEST         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8911      MRA w/o fol w/cont, chest      282 MAGNETIC RESONANCE ANGIOGRAPHY - CHEST         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 C8912      MRA w/cont, lwr ext            283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8913      MRA w/o cont, lwr ext          283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8914      MRA w/o fol w/cont, lwr ext    283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8918      MRA w/cont, pelvis             283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8919      MRA w/o cont, pelvis           283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8920      MRA w/o fol w/cont, pelvis     283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8931      MRA, w/dye, spinal canal       283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8932      MRA, w/o dye, spinal canal     283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8933      MRA, w/o&w/dye, spinal canal   283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8934      MRA, w/dye, upper extremity    283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8935      MRA, w/o dye, upper extr       283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 C8936      MRA, w/o&w/dye, upper extr     283 MAGNETIC RESONANCE ANGIOGRAPHY - OTHER         No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                               SITES                                                                                               base rate
 D0360      Cone beam ct                   301 CAT SCAN - OTHER                               No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 D0418      Analysis of saliva sample      390 LEVEL I PATHOLOGY                              No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 G0027      Semen analysis                 390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0101      CA screen;pelvic/breast exam   392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 G0103      PSA screening                  400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 G0122      Colon ca scrn; barium enema    287 DIGESTIVE RADIOLOGY                            No       Radiologic Procedure     No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 G0123      Screen cerv/vag thin layer     392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0124      Screen c/v thin layer by MD    392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0130      Single energy x-ray study      291 BONE DENSITOMETRY                              No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0141      Scr c/v cyto,autosys and md    392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0143      Scr c/v cyto,thinlayer,rescr   392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0144      Scr c/v cyto,thinlayer,rescr   392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0145      Scr c/v cyto,thinlayer,rescr   392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0147      Scr c/v cyto, automated sys    392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0148      Scr c/v cyto, autosys, rescr   392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0202      Screeningmammographydigital    286 MAMMOGRAPHY                                    No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0204      Diagnosticmammographydigital   286 MAMMOGRAPHY                                    No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0206      Diagnosticmammographydigital   286 MAMMOGRAPHY                                    No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0219      PET img wholbod melano nonco   290 PET SCANS                                      No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0235      PET not otherwise specified    290 PET SCANS                                      No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate


                                                                                                                                                                                             page 32 of 34
                                                                                                                                                          Line Level Payment Action
                                                                                                                                                                          Modifier U6 NOT coded on
                                                                                                                                          Modifier U6 coded on line     line (provider not responsible
                                                                                                                                           (performed in house or          for service. Lab/radiology
Procedure                                                                                 On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description              Schedule?           APG Type         APG?       lab/radiology provider)                  directlly )
 G0252      PET imaging initial dx         290 PET SCANS                                      No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 G0306      CBC/diffwbc w/o platelet       408 LEVEL I HEMATOLOGY TESTS                       No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 G0307      CBC without platelet           408 LEVEL I HEMATOLOGY TESTS                       No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0328      Fecal blood scrn immunoassay   398 LEVEL I ENDOCRINOLOGY TESTS                    No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0365      Vessel mapping hemo access     288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base        zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 G0389      Ultrasound exam AAA screen     288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate

 G0416      Sat biopsy prostate 1-20 spc   390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0417      Sat biopsy prostate 21-40      390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0418      Sat biopsy prostate 41-60      390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0419      Sat biopsy prostate: >60       390 LEVEL I PATHOLOGY                              No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0431      Drug screen multip class       400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
 G0432      EIA HIV-1/HIV-2 screen         396 LEVEL I MICROBIOLOGY TESTS                    Yes       Ancillary                Yes       pay as normal based on fee           zero payment
                                                                                                                                              schedule payment
 G0433      ELISA HIV-1/HIV-2 screen       396 LEVEL I MICROBIOLOGY TESTS                    Yes       Ancillary                Yes       pay as normal based on fee            zero payment
                                                                                                                                              schedule payment
 G0434      Drug screen multi drug class   400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 G0435      Oral HIV-1/HIV-2 screen        396 LEVEL I MICROBIOLOGY TESTS                    Yes       Ancillary                Yes       pay as normal based on fee           zero payment
                                                                                                                                              schedule payment
 G9143      Warfarin respon genetic test   395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 H0003      Alcohol and/or drug screenin   400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 P2028      Cephalin floculation test      397 LEVEL II MICROBIOLOGY TESTS                    No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 P2029      Congo red blood test           397 LEVEL II MICROBIOLOGY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 P2031      Hair analysis                  397 LEVEL II MICROBIOLOGY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 P2033      Blood thymol turbidity         397 LEVEL II MICROBIOLOGY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 P2038      Blood mucoprotein              400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 P3000      Screen pap by tech w md supv   392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 P3001      Screening pap smear by phys    392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 P7001      Culture bacterial urine        396 LEVEL I MICROBIOLOGY TESTS                     No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
 Q0091      Obtaining screen pap smear     392 PAP SMEARS                                     No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
 Q0111      Wet mounts/ w preparations     397 LEVEL II MICROBIOLOGY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 Q0112      Potassium hydroxide preps      397 LEVEL II MICROBIOLOGY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 Q0113      Pinworm examinations           397 LEVEL II MICROBIOLOGY TESTS                    No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 Q0114      Fern test                      401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
 Q0115      Post-coital mucous exam        401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3620     Newborn metabolic screening    401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3625     Maternal triple screen test    401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3626     Maternal serum quad screen     401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3628     PAMG-1 rapid assay for ROM     401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3630     Eosinophil blood count         408 LEVEL I HEMATOLOGY TESTS                       No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
  S3645     HIV-1 antibody testing of or   396 LEVEL I MICROBIOLOGY TESTS                     No       Ancillary                Yes            package as normal          payment reduced based on
                                                                                                                                                                             regional base rate
  S3650     Saliva test, hormone level;    401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
  S3652     Saliva test, hormone level;    401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3655     Antisperm antibodies test      395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3708     Gastrointestinal fat absorpt   400 LEVEL I CHEMISTRY TESTS                        No       Ancillary                Yes           package as normal           payment reduced based on
                                                                                                                                                                             regional base rate
  S3711     Circulating tumor cell test    401 LEVEL II CHEMISTRY TESTS                       No       Ancillary                No        pay as normal on statewide           zero payment
                                                                                                                                                   base rate
  S3713     KRAS mutation analysis         395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3837     Gene test hemochromato         395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3841     Gene test retinoblastoma       395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3854     Gene profile panel breast      395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3860     Genet test cardiac ion-comp    395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3861     Genetic test brugada           395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3862     Genet test cardiac ion-spec    395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3865     Comp genet test hyp cardiomy   395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3866     Spec gene test hyp cardiomy    395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3870     CGH test developmental delay   395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S3890     Fecal DNA analysis             395 LEVEL II IMMUNOLOGY TESTS                      No       Ancillary                No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S8035     Magnetic source imaging        296 MRI- OTHER                                     No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
                                                                                                                                                                                             page 33 of 34
                                                                                                                                                          Line Level Payment Action
                                                                                                                                                                          Modifier U6 NOT coded on
                                                                                                                                          Modifier U6 coded on line     line (provider not responsible
                                                                                                                                           (performed in house or          for service. Lab/radiology
Procedure                                                                                 On APG Fee                          Packaged     provider will pay out to       provider will bill Medicaid
  Code        Procedure Code Description   APG                APG Description              Schedule?          APG Type          APG?       lab/radiology provider)                  directlly )
  S8037     mrcp                           292 MRI- ABDOMEN                                   No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S8080     Scintimammography              286 MAMMOGRAPHY                                    No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S8092     Electron beam computed tomog   301 CAT SCAN - OTHER                               No       Radiologic Procedure     No        pay as normal on statewide            zero payment
                                                                                                                                                   base rate
  S9024     Paranasal sinus ultrasound     288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL       No       Radiologic Procedure     No       pay as normal on regional base         zero payment
                                               AND VASCULAR OF LOWER EXTREMITIES                                                                     rate




                                                                                                                                                                                             page 34 of 34

				
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