Ch. 1, § 6. Fee Schedule for Services

The following fees shall apply for each test request submitted: Chemistry Fee Test Description $14.00 Oral fluid collection kit and 4 drug screen w/confirmation $9.00 Urine analysis kit and 8 drug screen w/confirmation $9.50 Blood alcohol collection kit w/confirmation and 10 drug screen $90.00 20 drug blood screening panel w/alcohol screen and confirmation $9.00 Ethyl Glucuronide (ETG) $9.00 Methadone $9.00 Propoxyphene $8.00 Cotinine $23.00 Synthetic marijuana $23.00 Inhalants $23.00 Emerging drugs $9.00 Toxicology screen $9.00 Toxicology confirmation Microbiology Fee Test Description CPT code $8.00 Drinking water total coliform N/A $8.00 Drinking water E. coli screen N/A $4.00 Occult blood feces 82270 $20.00 Immunoassay for blood fecal 82274 $15.00 Chemiluminescent assay 82397 $45.00 Electrophoretic test 82664 $10.00 Assay IgA/IgD/IgG/IgM each 82784 $6.00 IgG 1 2 3 or 4 each 82787 $15.00 Immunoassay nonAntibody 83516 $10.00 Immunoassay dipstick 83518 $15.00 Immunoassay quant nos nonab 83520 $20.00 Western blot test 84181 $20.00 Protein western blot test 84182 $4.00 Bl smear w/o diff wbc count 85008 $5.00 Chromogenic substrate assay 85130 $15.00 Immunoglobulin assay 86023 $5.00 Complement fixation each 86171 $15.00 Fluorescent Antibody screen 86255 $15.00 Fluorescent Antibody titer 86256 $5.00 Heterophile Antibody screen 86308 $5.00 Heterophile Antibody titer 86309 $10.00 Heterophile Antibody absrbj 86310 $15.00 Immunoassay infectious agent 86318 $10.00 Particle agglut antbdy scrn 86403 $10.00 Particle agglut antbdy titr 86406 $40.00 Quantiferon Gold (Tb immun measure) 86480 $3.00 Syphilis test non-trep qual 86592 $5.00 Syphilis test non-trep quant 86593 $6.00 Bacterium Antibody 86609 $15.00 Borrelia Antibody 86619 $15.00 CMV Antibody 86644 $15.00 CMV Antibody IgM 86645 $20.00 Diphtheria Antibody 86648 $15.00 Encephalitis californ antbdy 86651 $15.00 Encephaltis east eqne anbdy 86652 $15.00 Encephaltis st louis antbody 86653 $15.00 Encephaltis west eqne antbdy 86654 $15.00 Epstein-barr Antibody 86663 $15.00 Epstein-barr nuclear antigen 86664 $15.00 Epstein-barr capsid vca 86665 $10.00 Francisella tularensis 86668 $6.00 Fungus nes Antibody 86671 $15.00 Helicobacter pylori Antibody 86677 $15.00 Helminth Antibody 86682 $15.00 Herpes simplex nes antbdy 86694 $15.00 HIV-1/hIV-2 1 result screen 86703 $15.00 Hepatitis B Core Antibody total 86704 $15.00 Hepatitis B Core Antibody IgM 86705 $15.00 Hepatitis B Surface Antibody 86706 $15.00 Hepatitis A Antibody total 86708 $15.00 Hepatitis A Antibody IgM 86709 $15.00 Legionella Antibody 86713 $15.00 Leishmania Antibody 86717 $15.00 Leptospira Antibody 86720 $6.00 Mumps Antibody 86735 $15.00 Mycoplasma Antibody 86738 $15.00 Neisseria meningitidis 86741 $15.00 Parvovirus Antibody 86747 $14.00 Protozoa Antibody nos 86753 $20.00 Rickettsia Antibody 86757 $6.00 Rubella Antibody 86762 $6.00 Rubeola Antibody 86765 $15.00 Toxoplasma Antibody 86777 $15.00 Toxoplasma Antibody IgM 86778 $15.00 Treponema pallidum 86780 $5.00 Trichinella Antibody 86784 $6.00 Varicella-zoster Antibody 86787 $20.00 West Nile virus ab IgM 86788 $20.00 West Nile virus Antibody 86789 $15.00 Virus Antibody nos 86790 $20.00 Hepatitis C Antibody 86803 $5.00 Specimen infect agnt concntj 87015 $5.00 Feces culture aerobic bact 87045 $5.00 Stool cultr aerobic bact ea 87046 $5.00 Culture othr specimn aerobic 87070 $5.00 Culture aerobic quant other 87071 $5.00 Culture bacteria anaerobic 87073 $5.00 Cultr bacteria except blood 87075 $10.00 Culture anaerobe ident each 87076 $10.00 Culture aerobic identify 87077 $5.00 Culture screen only 87081 $10.00 Culture of specimen by kit 87084 $5.00 Urine culture/colony count 87086 $5.00 Skin fungi culture 87101 $5.00 Fungus isolation culture 87102 $5.00 Fungi identification yeast 87106 $5.00 Fungi identification mold 87107 $5.00 Mycoplasma 87109 $10.00 Mycobacteria culture 87116 $10.00 Mycobacteric identification 87118 $25.00 DNA/RNA direct probe 87149 $40.00 DNA/RNA amplified probe 87150 $50.00 Culture type pulse field gel (PFGE) 87152 $50.00 DNA/RNA sequencing 87153 $4.00 Macroscopic exam arthropod 87168 $4.00 Macroscopic exam parasite 87169 $4.00 Pinworm exam 87172 $5.00 Tissue homogenization cultr 87176 $8.00 Ova and parasites smears 87177 $5.00 Microbe susceptible diffuse 87181 $5.00 Microbe susceptible disk 87184 $10.00 Microbe susceptible mic 87186 $10.00 Microbe susceptible mlc 87187 $3.00 Smear fluorescent/acid stai 87206 $5.00 Smear special stain 87207 $15.00 Smear complex stain 87209 $3.00 Smear wet mount saline/ink 87210 $25.00 Assay toxin or antitoxin 87230 $15.00 Cryptosporidium ag if 87272 $15.00 Legionella micdadei ag if 87277 $15.00 Legion pneumophilia ag if 87278 $15.00 Pneumocystis carinii ag if 87281 $16.32 Antibody detection nos if 87299 $15.00 Adenovirus ag eia 87301 $15.00 Aspergillus ag eia 87305 $15.00 Chylmd trach ag eia 87320 $15.00 Cryptococcus neoform ag eia 87327 $15.00 Cryptosporidium ag eia 87328 $15.00 Giardia ag eia 87329 $15.00 Cytomegalovirus ag eia 87332 $15.00 E. coli 0157 ag eia 87335 $15.00 H. pylori stool eia 87338 $15.00 H. pylori ag eia 87339 $15.00 Hepatitis B Surface Antigen 87340 $15.00 Histoplasma capsul ag eia 87385 $15.00 Influenza A/B ag eia 87400 $15.00 Resp syncytial ag eia 87420 $15.00 Rotavirus ag eia 87425 $15.00 Shiga-like toxin ag eia 87427 $15.00 Ag detect nos eia mult 87449 $13.00 Ag detect nos eia single 87450 $13.00 Ag detect polyval eia mult 87451 $40.00 Bartonella DNA amp probe 87471 $40.00 Lyme dis DNA amp probe 87476 $40.00 Candida DNA amp probe 87481 $40.00 Chylmd pneum DNA amp probe 87486 $12.00 Chylmd trach DNA amp probe 87491 $14.00 Chylmd trach and N. gono DNA amp probe 87491 $40.00 C. diff amplified probe 87493 $40.00 Cytomeg DNA amp probe 87496 $40.00 Enterovirus probe&revrs trns 87498 $20.00 Influenza DNA amp prob 1+ 87501 $20.00 Influenza DNA amp probe 87502 $100.00 Nfct agent detection gi 87505 $150.00 IaDNA-DNA/RNA probe tq 6-11 87506 $250.00 IaDNA-DNA/RNA probe tq 12-25 87507 $40.00 Hepatitis B DNA amp probe 87516 $50.00 Hepatitis B DNA quant 87517 $25.00 Hepatitis C RNA dir probe 87520 $40.00 Hepatitis C probe&rvrs trnsc 87521 $55.00 Hepatitis C revrs trnscrp 87522 $45.00 Hsv DNA amp probe 87529 $45.00 HIV-1 probe&reverse trnscrpj 87535 $115.00 HIV-1 quant&revrse trnscrpj 87536 $25.00 Legion pneumo DNA dir prob 87540 $40.00 Legion pneumo DNA amp prob 87541 $56.82 Legion pneumo DNA quant 87542 $20.00 Mycobacteria DNA dir probe 87550 $40.00 Mycobacteria DNA amp probe 87551 $20.00 M.tuberculo DNA dir probe 87555 $40.00 M.tuberculo DNA amp probe 87556 $20.00 M.avium-intra DNA dir prob 87560 $40.00 M.avium-intra DNA amp prob 87561 $40.00 M.pneumon DNA amp probe 87581 $12.00 N.gonorrhoeae DNA amp prob 87591 $45.00 HPV low-risk types 87623 $45.00 HPV high-risk types 87624 $45.00 HPV types 16 & 18 only 87625 $100.00 Resp virus 3-11 targets 87631 $150.00 Resp virus 6-11 targets 87632 $200.00 Resp virus 12-25 targets 87633 $47.76 Staph a DNA amp probe 87640 $47.76 Mr-Staph DNA amp probe 87641 $27.29 Strep A DNA dir probe 87650 $47.76 Strep A DNA amp probe 87651 $47.76 Strep B DNA amp probe 87653 $45.00 Trichomonas vaginalis amplif 87661 $25.00 Detect agent nos DNA dir 87797 $35.00 Pertussis (PCR) 87798 $40.00 Norovirus molecular 87798 $40.00 Detect agent nos DNA amp 87798 $55.00 Detect agent nos DNA quant 87799 $50.00 Detect agnt mult DNA direc 87800 $95.00 Detect agnt mult DNA ampli 87801 $16.32 Strep B assay w/optic 87802 $30.00 HIV antigen w/HIV antibodies 87806 $15.00 RSV assay w/optic 87807 $15.00 Adenovirus assay w/optic 87809 $6.00 Group A Strep assay 87880 $16.32 Agent nos assay w/optic 87899 $300.00 Genotype DNA/RNA Hep C 87902 $250.00 Genotype DNA Hepatitis B 87912 $26.88 Protein analysis w/probe 88372 $15.00 HIV-1/HIV-2 confirm 86703-92