WIXLIB

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee 1718117281173811748117581176MODIFIERQWQWSHORT DESCRIPTIONTestosterone responseEstradiol response panelRenin stimulation panelRenin stimulation panelPituitary evaluation panelDexamethasone panelGlucagon tolerance panelGlucagon tolerance panelGonadotropin hormone panelGrowth hormone panelGrowth hormone panelInsulin suppression panelInsulin tolerance panelInsulin tolerance panelMetyrapone panelTrh stimulation panelTrh stimulation panelUrinalysis nonauto w/scopeUrinalysis auto w/scopeUrinalysis nonauto w/o scopeUrinalysis auto w/o scopeUrinalysis auto w/o scopeUrinalysisUrine screen for bacteriaUrine screen for bacteriaMicroscopic exam of urineUrinalysis glass testUrine pregnancy testUrinalysis volume measureHpa-1 genotypingHpa-2 genotypingHpa-3 genotypingHpa-4 genotypingHpa-5 genotypingHpa-6 genotypingHpa-9 genotypingHpa-15 genotypingIdh1 common variantsIdh2 common variantsDmd dup/delet analysisBrca1&2 gen full seq dup/delBrca1&2 gene full seq alysBrca1&2 gen ful dup/del alysBrca1 gene full seq alysBrca1 gene full dup/del alysBrca2 gene full dup/del alysAbl1 geneAff2 gene detc abnor allelesAff2 gene charac allelesAr gene full gene sequenceAr gene known famil variantAsxl1 full gene sequenceAsxl1 gene target seq alysRATE 300.00137.00274.83301.35185.20676.50241.908 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee 2368123781238812398124081241MODIFIERSHORT DESCRIPTIONAtn1 gene detc abnor allelesAtxn1 gene detc abnor alleleAtxn2 gene detc abnor alleleAtxn3 gene detc abnor alleleAtxn7 gene detc abnor alleleAtxn8os gen detc abnor allelAtxn10 gene detc abnor allelCacna1a gen detc abnor allelCacna1a gene full gene seqCacna1a gen known famil vrntCnbp gene detc abnor alleleCstb gene detc abnor alleleCstb gene full gene sequenceCstb gene known famil vrntAspa geneApc gene full sequenceApc gene known fam variantsApc gene dup/delet variantsAr gene charac allelesBckdhb geneBcr/abl1 gene major bpBcr/abl1 gene minor bpBcr/abl1 gene other bpBlm geneBraf geneBrca1&2 185&5385&6174 vrntBrca1 gene known famil vrntBrca2 gene full seq alysBrca2 gene known famil vrntCebpa gene full sequenceCalr gene com variantsCftr gene com variantsCftr gene known fam variantsCftr gene dup/delet variantsCftr gene full sequenceCftr gene intron poly tCyp2c19 gene com variantsCyp2d6 gene com variantsCyp2c9 gene com variantsCytogen micrarray copy nmbrCytogen m array copy no&snpCyp3a4 gene common variantsCyp3a5 gene common variantsDpyd gene common variantsBtk gene common variantsDmpk gene detc abnor alleleEgfr gene com variantsEzh2 gene full gene sequenceEzh2 gene common variantsF9 full gene sequenceDmpk gene charac allelesF2 geneF5 geneRATE 0274.8365.6973.379 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee 2948129581296812978129881299MODIFIERSHORT DESCRIPTIONFancc geneFmr1 gene detectionFmr1 gene charac allelesFlt3 geneFlt3 gene analysisG6pd gene alys cmn variantG6pd known familial variantG6pd full gene sequenceG6pc geneGba geneGjb2 gene full sequenceGjb2 gene known fam variantsGjb6 gene com variantsHexa geneHfe geneHba1/hba2 geneHba1/hba2 gene fam vrntHba1/hba2 full gene sequenceIkbkap geneIgh gene rearrange amp methIgh gene rearrang dir probeIgh vari regional mutationIgk rearrangeabn clonal popStr markers specimen analStr markers spec anal addlChimerism anal no cell selecChimerism anal w/cell selectHba1/hba2 gene dup/del vrntsJak2 geneHtt gene detc abnor allelesKit gene targeted seq analysKit gene analys d816 variantHtt gene charac allelesKras gene variants exon 2Kras gene addl variantsCytogenomic neo microra alysIfnl3 geneFxn gene detc abnor allelesFxn gene charac allelesFxn gene full gene sequenceMgmt gene prmtr mthyltn alysMlh1 geneFxn gene known famil variantMcoln1 geneMthfr geneMlh1 gene full seqMlh1 gene known variantsMlh1 gene dup/delete variantMsh2 gene full seqMsh2 gene known variantsMsh2 gene dup/delete variantMsh6 gene full seqMsh6 gene known variantsRATE 5308.0010 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee 3618136281363813648137081371MODIFIERSHORT DESCRIPTIONMsh6 gene dup/delete variantMicrosatellite instabilityMecp2 gene full seqMecp2 gene known variantMecp2 gene dup/delet variantMyd88 gene p.leu265pro vrntNudt15 gene common variantsPalb2 gene full gene seqPalb2 gene known famil vrntPik3ca gene trgt seq alysNpm1 geneNras gene variants exon 2&3Pabpn1 gene detc abnor allelPca3/klk3 antigenPdgfra genePml/raralpha com breakpointsPml/raralpha 1 breakpointPms2 gene full seq analysisPms2 known familial variantsPms2 gene dup/delet variantsPlcg2 gene common variantsPten gene full sequencePten gene known fam variantPten gene dup/delet variantPmp22 gene dup/deletPmp22 gene full sequencePmp22 gene known fam variantSept9 gen prmtr mthyltn alysSlco1b1 gene com variantsSmn1 gene dos/deletion alysSmpd1 gene common variantsSnrpn/ube3a geneSerpina1 geneTgfbi gene common variantsRunx1 gene targeted seq alysTpmt gene com variantsSmn1 gene full gene sequenceSmn1 gen nown famil seq vrntTrb@ gene rearrange amplifyTrb@ gene rearrange dirprobeTrg gene rearrangement analPpp2r2b gen detc abnor allelTbp gene detc abnor allelesTert gene targeted seq alysTyms gene com variantsUgt1a1 gene common variantsVkorc1 geneHbb gene com variantsHbb gene known fam variantHbb gene dup/del variantsHbb full gene sequenceHla i & ii typing lrHla i & ii type verify lrRATE .58402.12404.5211 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee 4458144881450814558146081465MODIFIERSHORT DESCRIPTIONHla i typing complete lrHla i typing 1 locus lrHla i typing 1 antigen lrHla ii typing ag equiv lrHla ii typing 1 locus lrHla ii type 1 ag equiv lrHla i & ii typing hrHla i typing complete hrHla i typing 1 locus hrHla i typing 1 allele hrHla ii typing 1 loc hrHla ii typing 1 allele hrMopath procedure level 1Mopath procedure level 2Mopath procedure level 3Mopath procedure level 4Mopath procedure level 5Mopath procedure level 6Mopath procedure level 7Mopath procedure level 8Mopath procedure level 9Aortic dysfunction/dilationAortic dysfunction/dilationAshkenazi jewish assoc disCar ion chnnlpath inc 10 gnsCar ion chnnlpath inc 2 gnsExome sequence analysisExome sequence analysisExome re-evaluationFetal chrmoml aneuploidyFetal chrmoml microdeltjGenome sequence analysisGenome sequence analysisGenome re-evaluationHearing loss sequence analysHearing loss dup/del analysHrdtry brst ca-rlatd dsordrsHrdtry brst ca-rlatd dsordrsHereditary retinal disordersHereditary colon ca dsordrsHereditary colon ca dsordrsHeredtry nurondcrn tum dsrdrHeredtry nurondcrn tum dsrdrHrdtry cardmypy gene panelMitochondrial geneNoonan spectrum disordersGenetic tstg severe inh condTargeted genomic seq analysHrdtry perph neurphy panelTargeted genomic seq analysTargeted genomic seq analysWhole mitochondrial genomeWhole mitochondrial genomeRATE 91584.90759.532919.601287.00936.0012 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee T DESCRIPTIONX-linked intellectual dbltX-linked intellectual dbltAutoimmune rheumatoid arthrCor artery disease mrnaOnco (ovar) two proteinsOnco (ovar) five proteinsOncology tissue of originEndo assay seven analFetal aneuploidy trisom riskFtl cgen abnor two proteinsFtl cgen abnor 3 proteinsFtl cgen abnor three analFtl cgen abnor four analFtl cgen abnor five analOnc brst mrna 11 genesOncology breast mrnaOnc breast mrna 58 genesOnc breast mrna 70 genesOnc breast mrna 12 genesOncology colon mrnaOncology colorectal scrOncology gynecologicOncology gynecologicOncology lungOncology prostate prob scoreOncology tum unknown originOnc prostate mrna 46 genesOnc prostate mrna 22 cnt genOncology thyroidOnc prostate 3 genesCardiology hrt trnspl mrnaNfct ds chrnc hcv 6 assaysTest for acetone/ketonesAcetone assayAcetone assayAcetylcholinesterase assayAcylcarnitines qualAcylcarnitines quantAssay of acthAssay of adp & ampAssay of serum albuminAssay of serum albuminOther source albumin quan eaOther source albumin quan eaUr albumin quantitativeUr albumin quantitativeUr albumin semiquantitativeUr albumin semiquantitativeAlbumin ischemia modifiedAssay of breath ethanolAssay of aldolaseAssay of aldosteroneAlpha-1-antitrypsin totalRATE 3 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee SHORT DESCRIPTIONAlpha-1-antitrypsin phenoAlpha-fetoprotein serumAlpha-fetoprotein amnioticAlpha-fetoprotein l3Assay of aluminumAmines vaginal fluid qualAmines vaginal fluid qualAmino acid single qualAmino acids mult qualAmino acids single quantAssay aminolevulinic acidAmino acids quant 2-5Amino acids quan 6 or moreAssay of ammoniaAmniotic fluid scanAssay of amylaseAssay of amylaseAndrostanediol glucuronideAssay of androstenedioneAssay of androsteroneAssay of angiotensin iiAngiotensin i enzyme testAssay of apolipoproteinAssay of arsenicAssay of ascorbic acidAtomic absorptionAssay of beta-2 proteinBile acids totalBile acids cholylglycineBilirubin totalBilirubin totalBilirubin directFecal bilirubin testAssay of biotinidaseOccult blood fecesOccult blood other sourcesOccult blood other sourcesOccult bld feces 1-3 testsAssay test for blood fecalAssay test for blood fecalAssay of bradykininAssay of cadmiumVitamin d 25 hydroxyAssay of calcitoninAssay of calciumAssay of calciumAssay of calciumAssay of calciumCalcium infusion testAssay of calcium in urineCalculus analysis qualCalculus assay quantCalculus spectroscopyRATE 014 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee SHORT DESCRIPTIONX-ray assay calculusAssay c-d transfer measureAssay blood carbon dioxideAssay blood carbon dioxideAssay carboxyhb quantAssay carboxyhb qualCarcinoembryonic antigenAssay of carnitineAssay of caroteneAssay urine catecholaminesAssay blood catecholaminesAssay three catecholaminesAssay of cathepsin-dAssay of ceruloplasminChemiluminescent assayAssay of chloramphenicolAssay of blood chlorideAssay of blood chlorideAssay of urine chlorideAssay other fluid chloridesTest for chlorohydrocarbonsAssay bld/serum cholesterolAssay bld/serum cholesterolAssay serum cholinesteraseAssay rbc cholinesteraseAssay chondroitin sulfateAssay of chromiumAssay of citrateCollagen crosslinksCollagen crosslinksAssay of copperAssay of corticosteroneCortisol freeTotal cortisolAssay of creatineCol chromotography qual/quanAssay of ck (cpk)Assay of ck (cpk)Assay of cpk in bloodCreatine mb fractionCreatine isoformsAssay of creatinineAssay of creatinineAssay of urine creatinineAssay of urine creatinineCreatinine clearance testAssay of cryofibrinogenAssay of cryoglobulinAssay of cyanideVitamin b-12B-12 binding capacityCystatin cTest for urine cystinesRATE 125.185.189.4614.146.4719.4015.0814.3218.529.5515 of 35Effective/End Date

KY Medcaid 2021 Clinical Diagnostic Laboratory Fee 9438294582946829478294782948MODIFIERQWQWSHORT DESCRIPTIONDehydroepiandrosteroneDehydroep

SHORT DESCRIPTION RATE 2021: Effective/ End Date 80143 Drug assay acetaminophen 18.64 80145 Drug assay adalimumab 38.57 80151 Drug assay amiodarone 18.64 80161 Asy carbamazepin 10,11-epxid 18.64