101 CMR 320.00 — Rates for Clinical Laboratory Services

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Section

320.01: General Provisions 320.02: Definitions 320.03: Covered and Excluded Billing Situations 320.04: General Rate Provisions and Maximum Fees 320.05: Allowable Fees 320.06: Filing and Reporting Requirements 320.07: Severability

101 CMR 320.00 Rates for Clinical Laboratory Services

320.01 General Provisions

320.01: General Provisions

(1) Scope and Purpose. 101 CMR 320.00 governs the payment rates for clinical laboratory services rendered to publicly aided individuals. The rates set forth in 101 CMR 320.00 do not apply to individuals covered by M.G.L. c. 152 (the Workers’ Compensation Act). Rates for services rendered to such individuals are set forth in 114.3 CMR 40.00: Rates for Services under M.G.L. c. 152, Workers’ Compensation Act.

(2) Applicable Dates of Service. Rates contained in 101 CMR 320.00 apply for dates of service provided on or after September 1, 2024.

(3) Coverage. The payment rates in 101 CMR 320.00 are full compensation for clinical laboratory services rendered to publicly aided individuals.

(4) Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. Updates may reference coding systems including, but not limited to, the American Medical Association’s Current Procedural Terminology (CPT). The publication of such updates and corrections lists (a) codes for which only the code numbers changed, with the corresponding cross-references between existing and new codes; (b) deleted codes for which there are no corresponding new codes; and (c) codes for entirely new services that require pricing. EOHHS may list and price these codes according to the rate methodology used in setting clinical laboratory rates when Medicare fees are available (including, for codes relating to Coronavirus Disease 2019 (COVID-19), at 100% of Medicare fees). When Medicare fees are not available, EOHHS may apply individual consideration (IC) in reimbursing for these codes until appropriate rates can be developed.

(5) Administrative Bulletins. EOHHS may issue administrative bulletins to: (a) clarify its policy on and understanding of substantive provisions of 101 CMR 320.00; (b) specify any clinical laboratory services subject to selective, volume purchase, preferred supplier, or preferred provider contract(s) between a vendor or provider and governmental unit(s), the governmental unit(s) and eligible vendor(s) or provider(s) subject to the contract; the duration of the contract, the prices at which such clinical laboratory services will be available to eligible providers (as defined by the contract, if applicable), the rates which

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

eligible providers (as defined by the contract) will be paid by the relevant governmental unit(s) for such clinical laboratory services, and any other information deemed necessary by EOHHS; (c) specify any clinical laboratory services subject to rebate agreement(s) between a manufacturer and governmental unit(s), the governmental unit(s) and eligible providers subject to the agreement, the duration of the rebate agreement, the rates which will be paid to eligible providers (as defined by the applicable rebate agreement) by the relevant governmental unit(s) for the specified clinical laboratory services, and any other information deemed necessary by EOHHS.

(6) Disclaimer of Authorization of Services. 101 CMR 320.00 is neither authorization for nor approval of the substantive services for which rates are determined pursuant to 101 CMR 320.00. governmental units that purchase care are responsible for the definition, authorization, and approval of care and services extended to publicly aided individuals.

320.02 Definitions

320.02: Definitions

As used in 101 CMR 320.00, terms have the meanings ascribed in 101 CMR 320.02.

Allowable Fee. The amount of reimbursement that is paid by all governmental units for a laboratory service, as set forth in 101 CMR 320.04 and 101 CMR 320.05.

Bulk Purchase. A single purchase of a laboratory service (one or more tests) to be uniformly and concurrently performed on a minimum of 40 specimens of the same type. A single purchase of various, non-uniform laboratory services, such as by a physician, is not considered a bulk purchase, regardless of the number of specimens presented by such a purchaser to the laboratory.

Charge. The price of a laboratory service as determined by the clinical laboratory performing the service.

Clinical Laboratory. A laboratory where microbiological, chemical, hematological, biophysical, cytological, immuno-hematological, or pathological examinations are performed on materials derived from the human body to provide information for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition.

Center. The Center for Health Information and Analysis established under M.G.L. c. 12C.

Eligible Provider of Laboratory Services. A person licensed by an appropriate Board of Registration to perform clinical laboratory services, such registration being in accordance with the provisions of M.G.L. c. 112; or an independent laboratory. Such persons and laboratories must meet all conditions of participation that have been or may be adopted by a governmental unit that purchases laboratory services. For purposes of 101 CMR 320.00, eligible providers of laboratory services do not include hospital laboratories.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Fee Schedule. (Description of Service and HCPCS/CPT Procedure Code). The Healthcare Common Procedure Coding System (HCPCS), which is based upon the American Medical Association (AMA) Current Procedural Terminology (CPT), is the basis by which all procedures are performed. The CPT handbook is updated by the AMA annually. All non-physician codes and terminology is defined by the Centers for Medicare & Medicaid Services (CMS) and set forth in the HCPCS file.

Governmental Unit. The Commonwealth, any department, division, agency, board, or commission of the Commonwealth and any political subdivision of the Commonwealth.

Independent Clinical Laboratory. A clinical laboratory that is operated independently from a hospital or from an attending or consulting physician's office. If the laboratory is operated or directed by one or more licensed physicians, it must offer its services to other physicians to qualify as an independent clinical laboratory. In cases where two or more distinct, physically separated laboratory facilities operate under the same name and the same director, each facility that performs clinical laboratory services is treated as a separate independent clinical laboratory.

Profile (or Panel) Tests. Any group of tests, whether performed manually, automated, or semi- automated, that is ordered for a specific patient on a specified day, and has at least one of the following characteristics. (a) The group of tests is designated as a profile or panel by the clinical laboratory performing the tests. (b) The group of tests is performed by the clinical laboratory and the customary charge is less than the sum of that clinical laboratory's usual and customary charges for the individual tests in that group.

Publicly Aided Individual. A person who receives medical care and services for which a governmental unit is liable, in whole or in part, under a statutory program of public assistance.

Rate. The lesser of the charge or the allowable fee, as defined in 101 CMR 320.02.

Usual and Customary Charge. The lowest fee charged by an independent clinical laboratory for any laboratory service (including individual and profile tests) specified by 101 CMR 320.00 or by such independent clinical laboratory, which fee is in effect at the time such laboratory service is performed, other than a fee offered for a bulk purchase, as defined in 101 CMR 320.02.

320.03 Covered and Excluded Billing Situations

320.03: Covered and Excluded Billing Situations

(1) Covered Billing Situations. Except as provided in 101 CMR 320.03(2), the method of determining rates of payment contained in 101 CMR 320.00 apply to clinical laboratory services provided to publicly aided individuals, with the following conditions. (a) If clinical laboratory services are performed by an independent clinical laboratory, then the independent clinical laboratory must bill the governmental unit directly. The independent clinical laboratory may not bill indirectly by having a physician or dentist bill either the payer or the patient for services performed by the independent clinical laboratory.

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

(b) If clinical laboratory services are performed by a registered physician or dentist, or by an agent under his or her direct supervision, in his or her private medical office or clinic, then the registered physician or dentist must bill the governmental unit directly.

(2) Excluded Billing Situations. 101 CMR 320.00 and the rates of payment contained in 101 CMR 320.00 do not govern the rates of payment for clinical laboratory services if (a) the service is provided in state institutions by a state-employed physician, dentist, or dentist consultant; (b) the service is provided by a physician or dentist whose salary from a hospital or affiliated medical school includes compensation for professional services rendered to patients; or (c) the physician, dentist, or independent laboratory does not customarily bill private patients without health insurance under comparable circumstances.

(3) Professional and Technical Component Services. Some laboratory services have both professional and technical components. The professional component is set forth in 101 CMR 316.00: Rates for Surgery and Anesthesia Services, while the technical component is set forth in 101 CMR 320.00. (a) The relevant codes for laboratory services containing both professional and technical components are 83020, 84165, 84166, 84181, 84182, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, 87207, and 89060. (b) Surgical pathology services are excluded from 101 CMR 320.00 and instead included in 101 CMR 316.00: Rates for Surgery and Anesthesia Services. Surgical pathology services include codes 80503, 80504, 80505, 80506, 85060, 85097, 85396, 86077, 86078, 86079, 86153, 86486, 86490, 86510, 86580, 88104, 88106, 88108, 88112, 88120, 88121, 88125, 88141, 88160, 88161, 88162, 88172, 88173, 88177, 88182, 88184, 88185, 88187, 88188, 88189, 88199, 88291, 88299, 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88333, 88334, 88341, 88344, 88346, 88348, 88350, 88355, 88356, 88358, 88360, 88361, 88362, 88363, 88365, 88366, 88367, 88368, 88369, 88374, 88375, 88377, 88380, 88381, 88387, 88388, 88399, 89049, 89060, 89220, 89230, and 89240.

320.04 General Rate Provisions and Maximum Fees

320.04: General Rate Provisions and Maximum Fees

(1) Rate Determination. Payment rates are the lowest of (a) the eligible provider's usual and customary charge to patients other than publicly aided individuals or industrial accident patients; (b) the applicable listing from the schedule of allowable fees listed in 101 CMR 320.05; or (c) the amount that is allowable under 42 U.S.C. § 1396b(i)(7).

(2) Individual Consideration (IC). Unlisted procedures and laboratory tests designated IC are individually considered items. The eligible provider's bill for such a test must be accompanied by a brief report of the procedure or test performed and the eligible provider's usual and customary charge for that procedure or test. Determination of appropriate payments for procedures and tests designated IC are in accordance with the following standards and criteria: (a) time required to perform the procedure; (b) degree of skill required in the procedure performed;

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

(c) severity or complexity of the patient's disease, disorder, or disability; (d) policies, procedures, and practices of other third-party purchasers of care; (e) prevailing medical-laboratory ethics and accepted custom of the medical-laboratory community; and (f) such other standards and criteria as may be adopted by EOHHS. In no event may an eligible provider bill or be paid in excess of the usual and customary charge for the service.

(3) Administrative and Supervisory Duties. The rates of payment under 101 CMR 320.00 are full compensation for clinical laboratory services rendered to publicly aided individuals, as well as any related administrative or supervisory duties in connection with clinical laboratory services, without regard to where the service is rendered.

(4) Profile (or Panel) Tests. In no event may an eligible provider bill or be paid separately for each of the tests included within a profile test when a profile test has either been performed by the provider or requested by an authorized person.

(5) Limitations on Payment for Panel Tests. (a) Any combination of the following tests when performed on a single patient on a single date of service is regarded as a single panel test: 80047 Basic Metabolic Panel -calcium, ionized (Consists of 82330, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests 80048 Basic Metabolic Panel -calcium, total (Consists of 82310, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests 80051 Electrolyte Panel (Consists of 82374, 82435, 84132, 84295): four individual tests 80053 Comprehensive Metabolic Panel (Consists of 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84460, 84450, 84520): 14 individual tests 80061 Lipid Panel (Consists of 82465, 83718, 84478): three individual tests 80069 Renal Function Panel (Consists of 82040, 82310, 82374, 82435, 82565, 82947, 84100, 84132, 84295, 84520): ten individual tests 80076 Hepatic Function Panel (Consists of 82040, 82247, 82248, 84075, 84155, 84460, 84450): seven individual tests 82040 Albumin; serum 82247 Bilirubin; total 82248 Bilirubin; direct 82310 Calcium; total 82374 Carbon dioxide (bicarbonate) 82435 Chloride; blood 82465 Cholesterol, serum or whole blood, total 82550 Creatine kinase (CK), (CPK); total 82565 Creatinine; blood 82947 Glucose; quantitative 82977 Glutamyltransferase, gamma (GGT) 83615 Lactate dehydrogenase (LD), (LDH) 84075 Phosphatase, alkaline 84100 Phosphorus, inorganic (phosphate)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

84132 Potassium; serum, plasma or whole blood 84155 Protein, total, except refractometry 84295 Sodium; serum, plasma or whole blood 84450 Transferase; aspatrate amino (AST) (SGOT) 84460 Transferase; alanine amino (ALT) (SGPT) 84478 Triglycerides 84520 Urea nitrogen; quantitative 84550 Uric acid; blood (b) Panel tests are reimbursed according to the following schedule. Code Rate Description ATP02 $5.60 Auto Test Panel Pricing Code, 1-2 Tests ATP03 $7.14 Auto Test Panel Pricing Code, 3 Tests ATP04 $7.54 Auto Test Panel Pricing Code, 4 Tests ATP05 $8.39 Auto Test Panel Pricing Code, 5 Tests ATP06 $8.41 Auto Test Panel Pricing Code, 6 Tests ATP07 $8.78 Auto Test Panel Pricing Code, 7 Tests ATP08 $9.09 Auto Test Panel Pricing Code, 8 Tests ATP09 $9.34 Auto Test Panel Pricing Code, 9 Tests ATP10 $9.34 Auto Test Panel Pricing Code, 10 Tests ATP11 $9.49 Auto Test Panel Pricing Code, 11 Tests ATP12 $9.69 Auto Test Panel Pricing Code, 12 Tests ATP13 $11.34 Auto Test Panel Pricing Code, 13 Tests ATP14 $11.34 Auto Test Panel Pricing Code, 14 Tests ATP15 $11.34 Auto Test Panel Pricing Code, 15 Tests ATP16 $11.34 Auto Test Panel Pricing Code, 16 Tests ATP17 $11.42 Auto Test Panel Pricing Code, 17 Tests ATP18 $11.42 Auto Test Panel Pricing Code, 18 Tests ATP19 $11.89 Auto Test Panel Pricing Code, 19 Tests ATP20 $12.28 Auto Test Panel Pricing Code, 20 Tests ATP21 $12.66 Auto Test Panel Pricing Code, 21 Tests ATP22 $13.04 Auto Test Panel Pricing Code, 22 Tests ATP23 $13.04 Auto Test Panel Pricing Code, 23 or more Tests

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

320.05 Allowable Fees

320.05: Allowable Fees

Code Rate Description Organ and Disease Oriented Panels 80047 $12.11 Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) 80048 $7.46 Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) 80050 $17.65 General health panel This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443) 80051 $6.18 Electrolyte panel This panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295) 80053 $9.31 Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 80055 $42.16 Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) Antibody, rubella (86762) Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901) 80061 $11.81 Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) 80069 $7.65 Renal function panel This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) 80074 $42.00 Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803) 80076 $7.20 Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) 80081 $66.02 Obstetric panel (includes HIV testing) Drug Testing and Therapeutic Assays 80143 $16.44 Acetaminophen 80145 $34.01 Adalimumab 80150 $13.30 Amikacin 80151 $16.44 Amiodarone 80155 $34.01 Caffeine 80156 $12.85 Carbamazepine; total 80157 $11.68 Carbamazepine; free 80158 $15.92 Cyclosporine 80159 $17.77 Clozapine

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 80161 $16.44 Carbamazepine; -10,11-epoxide 80162 $11.71 Digoxin; total 80163 $11.71 Digoxin; free 80164 $11.94 Valproic acid (dipropylacetic acid); total 80165 $11.94 Valproic acid (dipropylacetic acid); free 80167 $16.44 Felbamate 80168 $14.41 Ethosuximide 80169 $12.11 Everolimus 80170 $14.45 Gentamicin 80171 $19.11 Gabapentin, whole blood, serum, or plasma 80173 $13.92 Haloperidol 80175 $11.68 Lamotrigine 80176 $12.95 Lidocaine 80177 $11.68 Levetiracetam 80178 $5.83 Lithium 80179 $16.44 Salicylate 80180 $15.92 Mycophenolate (mycophenolic acid) 80181 $16.44 Flecainide 80183 $11.68 Oxcarbazepine 80184 $13.49 Phenobarbital 80185 $11.68 Phenytoin; total 80186 $12.13 Phenytoin; free 80187 $23.91 Posaconazole 80188 $14.63 Primidone 80189 $23.91 Itraconazole 80190 $52.91 Procainamide; 80192 $14.77 Procainamide; with metabolites (eg, n-acetyl procainamide) 80193 $34.01 Leflunomide 80194 $12.88 Quinidine 80195 $12.11 Sirolimus 80197 $12.11 Tacrolimus 80198 $12.47 Theophylline 80199 $23.91 Tiagabine 80200 $14.22 Tobramycin 80201 $10.51 Topiramate 80202 $11.94 Vancomycin 80203 $11.68 Zonisamide 80204 $34.01 Methotrexate 80210 $23.91 Rufinamide

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 80220 $16.44 Hydroxychloroquine 80230 $34.01 Infliximab 80235 $23.91 Lacosamide 80280 $34.01 Vedolizumab 80285 $23.91 Voriconazole Evocative Suppression Testing 80299 $16.44 Quantitation of therapeutic drug, not elsewhere specified 80305 $8.92 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80306 $11.89 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80307 $47.55 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 80400 $28.77 ACTH stimulation panel; for adrenal insufficiency This panel must include the following: Cortisol (82533 x 2) 80402 $76.69 ACTH stimulation panel; for 21 hydroxylase deficiency This panel must include the following: Cortisol (82533 x 2) 17 hydroxyprogesterone (83498 x 2) 80406 $69.02 ACTH stimulation panel; for 3 beta-hydroxydehydrogenase deficiency This panel must include the following: Cortisol (82533 x 2) 17 hydroxypregnenolone (84143 x 2) 80408 $110.68 Aldosterone suppression evaluation panel (eg, saline infusion) This panel must include the following: Aldosterone (82088 x 2) Renin (84244 x 2) 80410 $70.88 Calcitonin stimulation panel (eg, calcium, pentagastrin) This panel must include the following: Calcitonin (82308 x 3)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 80412 $706.93 Corticotropic releasing hormone (CRH) stimulation panel This panel must include the following: Cortisol (82533 x 6) Adrenocorticotropic hormone (ACTH) (82024 x 6) 80414 $45.54 Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on 3 pooled blood samples) 80415 $49.29 Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol, total (82670 x 2 on 3 pooled blood samples) 80416 $184.59 Renal vein renin stimulation panel (eg, captopril) This panel must include the following: Renin (84244 x 6) 80417 $38.79 Peripheral vein renin stimulation panel (eg, captopril) This panel must include the following: Renin (84244 x 2) 80418 $511.03 Combined rapid anterior pituitary evaluation panel This panel must include the following: Adrenocorticotropic hormone (ACTH) (82024 x 4) Luteinizing hormone (LH) (83002 x 4) Follicle stimulating hormone (FSH) (83001 x 4) Prolactin (84146 x 4) Human growth hormone (HGH) (83003 x 4) Cortisol (82533 x 4) Thyroid stimulating hormone (TSH) (84443 x 4) 80420 $142.76 Dexamethasone suppression panel, 48 hour This panel must include the following: Free cortisol, urine (82530 x 2) Cortisol (82533 x 2) Volume measurement for timed collection (81050 x 2) 80422 $40.63 Glucagon tolerance panel; for insulinoma This panel must include the following: Glucose (82947 x 3) Insulin (83525 x 3) 80424 $44.53 Glucagon tolerance panel; for pheochromocytoma This panel must include the following: Catecholamines, fractionated (82384 x 2) 80426 $130.88 Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4) 80428 $58.82 Growth hormone stimulation panel (eg, arginine infusion, l- dopa administration) This panel must include the following: Human growth hormone (HGH) (83003 x 4) 80430 $114.05 Growth hormone suppression panel (glucose administration) This panel must include the following: Glucose (82947 x 3) Human growth hormone (HGH) (83003 x 4)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 80432 $146.05 Insulin-induced C-peptide suppression panel This panel must include the following: Insulin (83525) C-peptide (84681 x 5) Glucose (82947 x 5) 80434 $251.36 Insulin tolerance panel; for ACTH insufficiency This panel must include the following: Cortisol (82533 x 5) Glucose (82947 x 5) 80435 $90.83 Insulin tolerance panel; for growth hormone deficiency This panel must include the following: Glucose (82947 x 5) Human growth hormone (HGH) (83003 x 5) 80436 $80.39 Metyrapone panel This panel must include the following: Cortisol (82533 x 2) 11 deoxycortisol (82634 x 2) 80438 $44.46 Thyrotropin releasing hormone (TRH) stimulation panel; 1 hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3) 80439 $59.27 Thyrotropin releasing hormone (TRH) stimulation panel; 2 hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 4) Urinalysis 81000 $3.55 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non- automated, with microscopy 81001 $2.80 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy 81002 $3.07 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non- automated, without microscopy 81003 $1.98 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 81005 $1.91 Urinalysis; qualitative or semiquantitative, except immunoassays 81007 $26.44 Urinalysis; bacteriuria screen, except by culture or dipstick 81015 $2.69 Urinalysis; microscopic only 81020 $4.14 Urinalysis; 2 or 3 glass test 81025 $7.59 Urine pregnancy test, by visual color comparison methods

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81050 $3.21 Volume measurement for timed collection, each 81099 IC Unlisted urinalysis procedure Chemistry 82009 $3.99 Ketone body(s) (eg, acetone, acetoacetic acid, beta- hydroxybutyrate); qualitative 82010 $7.20 Ketone body(s) (eg, acetone, acetoacetic acid, beta- hydroxybutyrate); quantitative 82013 $10.84 Acetylcholinesterase 82016 $14.54 Acylcarnitines; qualitative, each specimen 82017 $14.88 Acylcarnitines; quantitative, each specimen 82024 $34.06 Adrenocorticotropic hormone (ACTH) 82030 $22.75 Adenosine, 5-monophosphate, cyclic (cyclic AMP) 82040 $4.37 Albumin; serum, plasma or whole blood 82042 $6.86 Albumin; other source, quantitative, each specimen 82043 $5.10 Albumin; urine (eg, microalbumin), quantitative 82044 $5.49 Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) 82045 $29.93 Albumin; ischemia modified 82075 $26.46 Alcohol (ethanol); breath 82077 $15.23 Alcohol (ethanol); any specimen except urine and breath, immunoassay (eg, IA, EIA, ELISA, RIA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase) 82085 $8.56 Aldolase 82088 $35.94 Aldosterone 82103 $11.85 Alpha-1-antitrypsin; total 82104 $12.75 Alpha-1-antitrypsin; phenotype 82105 $14.79 Alpha-fetoprotein (AFP); serum 82106 $14.99 Alpha-fetoprotein (AFP); amniotic fluid 82107 $56.80 Alpha-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP (including ratio) 82108 $22.47 Aluminum 82120 $5.28 Amines, vaginal fluid, qualitative 82127 $12.50 Amino acids; single, qualitative, each specimen 82128 $12.23 Amino acids; multiple, qualitative, each specimen 82131 $20.27 Amino acids; single, quantitative, each specimen 82135 $14.51 Aminolevulinic acid, delta (ALA) 82136 $17.29 Amino acids, 2 to 5 amino acids, quantitative, each specimen 82139 $14.88 Amino acids, 6 or more amino acids, quantitative, each specimen

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 82140 $12.85 Ammonia 82143 $8.25 Amniotic fluid scan (spectrophotometric) 82150 $5.71 Amylase 82154 $25.42 Androstanediol glucuronide 82157 $25.82 Androstenedione 82160 $22.53 Androsterone 82163 $18.10 Angiotensin II 82164 $12.88 Angiotensin I - converting enzyme (ACE) 82166 $34.06 Anti-mullerian hormone (AMH) 82172 $18.60 Apolipoprotein, each 82175 $16.73 Arsenic 82180 $8.72 Ascorbic acid (Vitamin C), blood 82190 $14.02 Atomic absorption spectroscopy, each analyte 82232 $14.27 Beta-2 microglobulin 82239 $15.10 Bile acids; total 82240 $23.44 Bile acids; cholylglycine 82247 $4.43 Bilirubin; total 82248 $4.43 Bilirubin; direct 82252 $4.02 Bilirubin; feces, qualitative 82261 $14.88 Biotinidase, each specimen 82270 $3.86 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) 82271 $4.69 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources 82272 $3.73 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82274 $14.04 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations 82286 $4.55 Bradykinin 82300 $20.85 Cadmium 82306 $26.10 Vitamin D; 25 hydroxy, includes fraction(s), if performed 82308 $23.63 Calcitonin 82310 $4.55 Calcium; total 82330 $12.06 Calcium; ionized

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 82331 $11.76 Calcium; after calcium infusion test 82340 $5.32 Calcium; urine quantitative, timed specimen 82355 $10.21 Calculus; qualitative analysis 82360 $11.35 Calculus; quantitative analysis, chemical 82365 $11.38 Calculus; infrared spectroscopy 82370 $11.04 Calculus; X-ray diffraction 82373 $15.93 Carbohydrate deficient transferrin 82374 $4.30 Carbon dioxide (bicarbonate) 82375 $10.86 Carboxyhemoglobin; quantitative 82376 $12.41 Carboxyhemoglobin; qualitative 82378 $16.72 Carcinoembryonic antigen (CEA) 82379 $14.88 Carnitine (total and free), quantitative, each specimen 82380 $8.13 Carotene 82382 $24.08 Catecholamines; total urine 82383 $25.64 Catecholamines; blood 82384 $22.27 Catecholamines; fractionated 82387 $15.93 Cathepsin-D 82390 $9.47 Ceruloplasmin 82397 $12.45 Chemiluminescent assay 82415 $11.17 Chloramphenicol 82435 $4.06 Chloride; blood 82436 $5.07 Chloride; urine 82438 $4.41 Chloride; other source 82441 $5.30 Chlorinated hydrocarbons, screen 82465 $3.84 Cholesterol, serum or whole blood, total 82480 $6.94 Cholinesterase; serum 82482 $8.65 Cholinesterase; RBC 82485 $18.21 Chondroitin B sulfate, quantitative 82495 $17.88 Chromium 82507 $24.52 Citrate 82523 $16.47 Collagen cross links, any method 82525 $10.94 Copper 82528 $19.86 Corticosterone 82530 $14.74 Cortisol; free 82533 $14.37 Cortisol; total 82540 $4.09 Creatine

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 82542 $21.24 Column chromatography, includes mass spectrometry, if performed (eg, HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS- MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen 82550 $5.74 Creatine kinase (CK), (CPK); total 82552 $11.81 Creatine kinase (CK), (CPK); isoenzymes 82553 $10.19 Creatine kinase (CK), (CPK); MB fraction only 82554 $10.47 Creatine kinase (CK), (CPK); isoforms 82565 $4.52 Creatinine; blood 82570 $4.57 Creatinine; other source 82575 $8.34 Creatinine; clearance 82585 $12.47 Cryofibrinogen 82595 $5.71 Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) 82600 $17.11 Cyanide 82607 $13.30 Cyanocobalamin (Vitamin B-12); 82608 $12.63 Cyanocobalamin (Vitamin B-12); unsaturated binding capacity 82610 $16.33 Cystatin C 82615 $8.42 Cystine and homocystine, urine, qualitative 82626 $22.28 Dehydroepiandrosterone (DHEA) 82627 $19.60 Dehydroepiandrosterone-sulfate (DHEA-S) 82633 $27.32 Desoxycorticosterone, 11- 82634 $25.82 Deoxycortisol, 11- 82638 $10.80 Dibucaine number 82642 $25.82 Dihydrotestosterone (DHT) 82652 $33.95 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed 82653 $20.26 Elastase, pancreatic (EL-1), fecal; quantitative 82656 $10.17 Elastase, pancreatic (EL-1), fecal; qualitative or semi- quantitative 82657 $19.55 Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; nonradioactive substrate, each specimen 82658 $38.83 Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; radioactive substrate, each specimen 82664 $54.24 Electrophoretic technique, not elsewhere specified 82668 $16.57 Erythropoietin 82670 $24.64 Estradiol; total 82671 $28.48 Estrogens; fractionated 82672 $19.14 Estrogens; total 82677 $21.32 Estriol 82679 $22.00 Estrone

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 82681 $24.64 Estradiol; free, direct measurement (eg, equilibrium dialysis) 82693 $13.14 Ethylene glycol 82696 $23.14 Etiocholanolone 82705 $4.50 Fat or lipids, feces; qualitative 82710 $14.82 Fat or lipids, feces; quantitative 82715 $20.26 Fat differential, feces, quantitative 82725 $16.55 Fatty acids, nonesterified 82726 $17.42 Very long chain fatty acids 82728 $12.02 Ferritin 82731 $56.80 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82735 $16.35 Fluoride 82746 $12.96 Folic acid; serum 82747 $15.57 Folic acid; RBC 82757 $15.29 Fructose, semen 82759 $18.94 Galactokinase, RBC 82760 $9.88 Galactose 82775 $18.58 Galactose-1-phosphate uridyl transferase; quantitative 82776 $10.35 Galactose-1-phosphate uridyl transferase; screen 82777 $39.02 Galectin-3 82784 $8.20 Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each 82785 $14.52 Gammaglobulin (immunoglobulin); IgE 82787 $7.07 Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each 82800 $9.70 Gases, blood, pH only 82803 $22.99 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); 82805 $69.47 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); with O2 saturation, by direct measurement, except pulse oximetry 82810 $8.62 Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry 82820 $11.76 Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen) 82930 $5.92 Gastric acid analysis, includes pH if performed, each specimen 82938 $15.60 Gastrin after secretin stimulation 82941 $15.55 Gastrin 82943 $12.60 Glucagon 82945 $3.47 Glucose, body fluid, other than blood 82946 $15.67 Glucagon tolerance test

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 82947 $3.47 Glucose; quantitative, blood (except reagent strip) 82948 $4.44 Glucose; blood, reagent strip 82950 $4.19 Glucose; post glucose dose (includes glucose) 82951 $11.35 Glucose; tolerance test (GTT), 3 specimens (includes glucose) 82952 $3.46 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) 82955 $8.55 Glucose-6-phosphate dehydrogenase (G6PD); quantitative 82960 $5.34 Glucose-6-phosphate dehydrogenase (G6PD); screen 82962 $2.89 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use 82963 $18.94 Glucosidase, beta 82965 $11.60 Glutamate dehydrogenase 82977 $6.35 Glutamyltransferase, gamma (GGT) 82978 $13.62 Glutathione 82979 $8.32 Glutathione reductase, RBC 82985 $14.78 Glycated protein 83001 $16.39 Gonadotropin; follicle stimulating hormone (FSH) 83002 $16.33 Gonadotropin; luteinizing hormone (LH) 83003 $14.70 Growth hormone, human (HGH) (somatotropin) 83006 $66.67 Growth stimulation expressed gene 2 (ST2, Interleukin 1 receptor like-1) 83009 $59.40 Helicobacter pylori, blood test analysis for urease activity, non- radioactive isotope (eg, C-13) 83010 $11.09 Haptoglobin; quantitative 83012 $23.71 Haptoglobin; phenotypes 83013 $59.40 Helicobacter pylori; breath test analysis for urease activity, non- radioactive isotope (eg, C-13) 83014 $6.93 Helicobacter pylori; drug administration 83015 $18.47 Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); qualitative, any number of analytes 83018 $19.37 Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each, not elsewhere specified 83020 $11.35 Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) 83021 $15.93 Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) 83026 $3.54 Hemoglobin; by copper sulfate method, non-automated 83030 $9.47 Hemoglobin; F (fetal), chemical 83033 $7.06 Hemoglobin; F (fetal), qualitative

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 83036 $8.56 Hemoglobin; glycosylated (A1C) 83037 $8.56 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use 83045 $5.72 Hemoglobin; methemoglobin, qualitative 83050 $7.23 Hemoglobin; methemoglobin, quantitative 83051 $6.45 Hemoglobin; plasma 83060 $7.76 Hemoglobin; sulfhemoglobin, quantitative 83065 $7.94 Hemoglobin; thermolabile 83068 $8.35 Hemoglobin; unstable, screen 83069 $3.48 Hemoglobin; urine 83070 $4.19 Hemosiderin, qualitative 83080 $14.88 b-Hexosaminidase, each assay 83088 $26.04 Histamine 83090 $15.80 Homocysteine 83150 $19.76 Homovanillic acid (HVA) 83491 $15.79 Hydroxycorticosteroids, 17- (17-OHCS) 83497 $11.38 Hydroxyindolacetic acid, 5-(HIAA) 83498 $23.96 Hydroxyprogesterone, 17-d 83500 $19.97 Hydroxyproline; free 83505 $21.43 Hydroxyproline; total 83516 $10.17 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method 83518 $8.50 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, single step method (eg, reagent strip) 83519 $16.23 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, by radioimmunoassay (eg, RIA) 83520 $15.23 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified 83521 $15.23 Immunoglobulin light chains (ie, kappa, lambda), free, each 83525 $10.08 Insulin; total 83527 $11.42 Insulin; free 83528 $17.48 Intrinsic factor 83529 $15.23 Interleukin-6 (IL-6) 83540 $5.71 Iron 83550 $7.71 Iron binding capacity 83570 $7.80 Isocitric dehydrogenase (IDH)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 83582 $13.64 Ketogenic steroids, fractionation 83586 $11.29 Ketosteroids, 17- (17-KS); total 83593 $25.13 Ketosteroids, 17- (17-KS); fractionation 83605 $10.20 Lactate (lactic acid) 83615 $5.33 Lactate dehydrogenase (LD), (LDH); 83625 $11.28 Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation 83630 $17.37 Lactoferrin, fecal; qualitative 83631 $17.31 Lactoferrin, fecal; quantitative 83632 $17.83 Lactogen, human placental (HPL) human chorionic somatomammotropin 83633 $9.92 Lactose, urine, qualitative 83655 $10.68 Lead 83661 $19.39 Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio 83662 $16.68 Fetal lung maturity assessment; foam stability test 83663 $16.68 Fetal lung maturity assessment; fluorescence polarization 83664 $17.04 Fetal lung maturity assessment; lamellar body density 83670 $8.65 Leucine aminopeptidase (LAP) 83690 $6.08 Lipase 83695 $12.63 Lipoprotein (a) 83698 $40.84 Lipoprotein-associated phospholipase A2 (Lp-PLA2) 83700 $9.93 Lipoprotein, blood; electrophoretic separation and quantitation 83701 $29.86 Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) 83704 $30.15 Lipoprotein, blood; quantitation of lipoprotein particle number(s) (eg, by nuclear magnetic resonance spectroscopy), includes lipoprotein particle subclass(es), when performed 83718 $7.22 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 83719 $11.24 Lipoprotein, direct measurement; VLDL cholesterol 83721 $9.26 Lipoprotein, direct measurement; LDL cholesterol 83722 $30.15 Lipoprotein, direct measurement; small dense LDL cholesterol 83727 $15.16 Luteinizing releasing factor (LRH) 83735 $5.91 Magnesium 83775 $6.50 Malate dehydrogenase 83785 $23.50 Manganese

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 83789 $21.26 Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen 83825 $14.34 Mercury, quantitative 83835 $14.94 Metanephrines 83857 $9.47 Methemalbumin 83861 $19.82 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity 83864 $25.13 Mucopolysaccharides, acid, quantitative 83872 $5.17 Mucin, synovial fluid (Ropes test) 83873 $15.17 Myelin basic protein, cerebrospinal fluid 83874 $11.39 Myoglobin 83876 $44.85 Myeloperoxidase (MPO) 83880 $34.62 Natriuretic peptide 83883 $11.99 Nephelometry, each analyte not elsewhere specified 83885 $21.61 Nickel 83915 $9.83 Nucleotidase 5'- 83916 $24.15 Oligoclonal immune (oligoclonal bands) 83918 $20.81 Organic acids; total, quantitative, each specimen 83919 $14.51 Organic acids; qualitative, each specimen 83921 $18.70 Organic acid, single, quantitative 83930 $5.83 Osmolality; blood 83935 $6.01 Osmolality; urine 83937 $26.32 Osteocalcin (bone g1a protein) 83945 $12.74 Oxalate 83950 $56.80 Oncoprotein; HER-2/neu 83951 $56.80 Oncoprotein; des-gamma-carboxy-prothrombin (DCP) 83970 $36.40 Parathormone (parathyroid hormone) 83986 $3.16 pH; body fluid, not otherwise specified 83987 $3.16 pH; exhaled breath condensate 83992 $15.79 Phencyclidine (PCP) 83993 $17.31 Calprotectin, fecal 84030 $4.85 Phenylalanine (PKU), blood 84035 $3.51 Phenylketones, qualitative 84060 $6.74 Phosphatase, acid; total 84066 $8.52 Phosphatase, acid; prostatic 84075 $4.57 Phosphatase, alkaline; 84078 $7.28 Phosphatase, alkaline; heat stable (total not included) 84080 $13.03 Phosphatase, alkaline; isoenzymes

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 84081 $14.57 Phosphatidylglycerol 84085 $8.32 Phosphogluconate, 6-, dehydrogenase, RBC 84087 $9.46 Phosphohexose isomerase 84100 $4.18 Phosphorus inorganic (phosphate); 84105 $5.10 Phosphorus inorganic (phosphate); urine 84106 $5.13 Porphobilinogen, urine; qualitative 84110 $7.44 Porphobilinogen, urine; quantitative 84112 $86.52 Evaluation of cervicovaginal fluid for specific amniotic fluid protein(s) (eg, placental alpha microglobulin-1 [PAMG-1], placental protein 12 [PP12], alpha-fetoprotein), qualitative, each specimen 84119 $11.78 Porphyrins, urine; qualitative 84120 $12.97 Porphyrins, urine; quantitation and fractionation 84126 $34.49 Porphyrins, feces, quantitative 84132 $4.20 Potassium; serum, plasma or whole blood 84133 $4.17 Potassium; urine 84134 $12.87 Prealbumin 84135 $18.76 Pregnanediol 84138 $18.56 Pregnanetriol 84140 $18.23 Pregnenolone 84143 $20.12 17-hydroxypregnenolone 84144 $18.40 Progesterone 84145 $24.00 Procalcitonin (PCT) 84146 $17.09 Prolactin 84150 $36.84 Prostaglandin, each 84152 $16.22 Prostate specific antigen (PSA); complexed (direct measurement) 84153 $16.22 Prostate specific antigen (PSA); total 84154 $16.22 Prostate specific antigen (PSA); free 84155 $3.24 Protein, total, except by refractometry; serum, plasma or whole blood 84156 $3.24 Protein, total, except by refractometry; urine 84157 $3.53 Protein, total, except by refractometry; other source (eg, synovial fluid, cerebrospinal fluid) 84160 $4.95 Protein, total, by refractometry, any source 84163 $13.27 Pregnancy-associated plasma protein-A (PAPP-A) 84165 $9.47 Protein; electrophoretic fractionation and quantitation, serum 84166 $15.72 Protein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 84181 $15.02 Protein; Western Blot, with interpretation and report, blood or other body fluid 84182 $25.76 Protein; Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each 84202 $12.65 Protoporphyrin, RBC; quantitative 84203 $8.59 Protoporphyrin, RBC; screen 84206 $23.54 Proinsulin 84207 $24.78 Pyridoxal phosphate (Vitamin B-6) 84210 $12.77 Pyruvate 84220 $8.32 Pyruvate kinase 84228 $10.26 Quinine 84233 $77.50 Receptor assay; estrogen 84234 $57.22 Receptor assay; progesterone 84235 $62.82 Receptor assay; endocrine, other than estrogen or progesterone (specify hormone) 84238 $32.25 Receptor assay; non-endocrine (specify receptor) 84244 $19.39 Renin 84252 $17.85 Riboflavin (Vitamin B-2) 84255 $22.51 Selenium 84260 $27.32 Serotonin 84270 $19.16 Sex hormone binding globulin (SHBG) 84275 $11.85 Sialic acid 84285 $22.23 Silica 84295 $4.24 Sodium; serum, plasma or whole blood 84300 $4.46 Sodium; urine 84302 $4.29 Sodium; other source 84305 $18.75 Somatomedin 84307 $16.12 Somatostatin 84311 $7.14 Spectrophotometry, analyte not elsewhere specified 84315 $2.89 Specific gravity (except urine) 84375 $34.39 Sugars, chromatographic, TLC or paper chromatography 84376 $4.85 Sugars (mono-, di-, and oligosaccharides); single qualitative, each specimen 84377 $4.85 Sugars (mono-, di-, and oligosaccharides); multiple qualitative, each specimen 84378 $10.17 Sugars (mono-, di-, and oligosaccharides); single quantitative, each specimen

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 84379 $10.17 Sugars (mono-, di-, and oligosaccharides); multiple quantitative, each specimen 84392 $4.84 Sulfate, urine 84402 $22.46 Testosterone; free 84403 $22.76 Testosterone; total 84410 $45.22 Testosterone; bioavailable, direct measurement (eg, differential precipitation) 84425 $18.72 Thiamine (Vitamin B-1) 84430 $10.26 Thiocyanate 84431 $30.96 Thromboxane metabolite(s), including thromboxane if performed, urine 84432 $14.16 Thyroglobulin 84433 $19.55 Thiopurine S-methyltransferase (TPMT) 84436 $6.06 Thyroxine; total 84437 $5.71 Thyroxine; requiring elution (eg, neonatal) 84439 $7.95 Thyroxine; free 84442 $13.03 Thyroxine binding globulin (TBG) 84443 $14.82 Thyroid stimulating hormone (TSH) 84445 $44.85 Thyroid stimulating immune globulins (TSI) 84446 $12.50 Tocopherol alpha (Vitamin E) 84449 $15.87 Transcortin (cortisol binding globulin) 84450 $4.57 Transferase; aspartate amino (AST) (SGOT) 84460 $4.67 Transferase; alanine amino (ALT) (SGPT) 84466 $11.25 Transferrin 84478 $5.06 Triglycerides 84479 $5.71 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) 84480 $12.50 Triiodothyronine T3; total (TT-3) 84481 $14.94 Triiodothyronine T3; free 84482 $13.90 Triiodothyronine T3; reverse 84484 $11.00 Troponin, quantitative 84485 $6.35 Trypsin; duodenal fluid 84488 $6.44 Trypsin; feces, qualitative 84490 $8.76 Trypsin; feces, quantitative, 24-hour collection 84510 $9.37 Tyrosine 84512 $8.90 Troponin, qualitative 84520 $3.48 Urea nitrogen; quantitative 84525 $4.52 Urea nitrogen; semiquantitative (eg, reagent strip test) 84540 $4.90 Urea nitrogen, urine

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 84545 $6.35 Urea nitrogen, clearance 84550 $3.99 Uric acid; blood 84560 $4.48 Uric acid; other source 84577 $14.82 Urobilinogen, feces, quantitative 84578 $3.94 Urobilinogen, urine; qualitative 84580 $8.42 Urobilinogen, urine; quantitative, timed specimen 84583 $5.34 Urobilinogen, urine; semiquantitative 84585 $13.67 Vanillylmandelic acid (VMA), urine 84586 $31.16 Vasoactive intestinal peptide (VIP) 84588 $29.93 Vasopressin (antidiuretic hormone, ADH) 84590 $10.24 Vitamin A 84591 $15.04 Vitamin, not otherwise specified 84597 $12.10 Vitamin K 84600 $15.09 Volatiles (eg, acetic anhydride, diethylether) 84620 $11.39 Xylose absorption test, blood and/or urine 84630 $10.04 Zinc 84681 $18.35 C-peptide 84702 $13.27 Gonadotropin, chorionic (hCG); quantitative 84703 $6.63 Gonadotropin, chorionic (hCG); qualitative 84704 $13.48 Gonadotropin, chorionic (hCG); free beta chain 84830 $11.20 Ovulation tests, by visual color comparison methods for human luteinizing hormone 84999 $4.46 Unlisted chemistry procedure Hematology and Coagulation 85002 $4.25 Bleeding time 85004 $5.71 Blood count; automated differential WBC count 85007 $3.35 Blood count; blood smear, microscopic examination with manual differential WBC count 85008 $3.02 Blood count; blood smear, microscopic examination without manual differential WBC count 85009 $4.47 Blood count; manual differential WBC count, buffy coat 85013 $6.17 Blood count; spun microhematocrit 85014 $2.09 Blood count; hematocrit (Hct) 85018 $2.09 Blood count; hemoglobin (Hgb) 85025 $6.85 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85027 $5.71 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 85032 $3.80 Blood count; manual cell count (erythrocyte, leukocyte, or platelet) each 85041 $2.66 Blood count; red blood cell (RBC), automated 85044 $3.80 Blood count; reticulocyte, manual 85045 $3.52 Blood count; reticulocyte, automated 85046 $4.91 Blood count; reticulocytes, automated, including 1 or more cellular parameters (eg, reticulocyte hemoglobin content [CHr], immature reticulocyte fraction [IRF], reticulocyte volume [MRV], RNA content), direct measurement 85048 $2.24 Blood count; leukocyte (WBC), automated 85049 $3.95 Blood count; platelet, automated 85055 $31.52 Reticulated platelet assay 85130 $10.49 Chromogenic substrate assay 85170 $14.37 Clot retraction 85175 $17.96 Clot lysis time, whole blood dilution 85210 $11.45 Clotting; factor II, prothrombin, specific 85220 $15.57 Clotting; factor V (AcG or proaccelerin), labile factor 85230 $15.79 Clotting; factor VII (proconvertin, stable factor) 85240 $15.79 Clotting; factor VIII (AHG), 1-stage 85244 $18.01 Clotting; factor VIII related antigen 85245 $20.23 Clotting; factor VIII, VW factor, ristocetin cofactor 85246 $20.23 Clotting; factor VIII, VW factor antigen 85247 $20.23 Clotting; factor VIII, von Willebrand factor, multimetric analysis 85250 $16.79 Clotting; factor IX (PTC or Christmas) 85260 $15.79 Clotting; factor X (Stuart-Prower) 85270 $15.79 Clotting; factor XI (PTA) 85280 $17.06 Clotting; factor XII (Hageman) 85290 $14.41 Clotting; factor XIII (fibrin stabilizing) 85291 $8.03 Clotting; factor XIII (fibrin stabilizing), screen solubility 85292 $16.69 Clotting; prekallikrein assay (Fletcher factor assay) 85293 $16.69 Clotting; high molecular weight kininogen assay (Fitzgerald factor assay) 85300 $10.45 Clotting inhibitors or anticoagulants; antithrombin III, activity 85301 $9.53 Clotting inhibitors or anticoagulants; antithrombin III, antigen assay 85302 $10.59 Clotting inhibitors or anticoagulants; protein C, antigen 85303 $12.21 Clotting inhibitors or anticoagulants; protein C, activity 85305 $10.24 Clotting inhibitors or anticoagulants; protein S, total

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 85306 $13.51 Clotting inhibitors or anticoagulants; protein S, free 85307 $13.51 Activated Protein C (APC) resistance assay 85335 $11.35 Factor inhibitor test 85337 $15.23 Thrombomodulin 85345 $4.14 Coagulation time; Lee and White 85347 $3.77 Coagulation time; activated 85348 $3.96 Coagulation time; other methods 85360 $7.42 Euglobulin lysis 85362 $6.08 Fibrin(ogen) degradation (split) products (FDP) (FSP); agglutination slide, semiquantitative 85366 $70.96 Fibrin(ogen) degradation (split) products (FDP) (FSP); paracoagulation 85370 $10.96 Fibrin(ogen) degradation (split) products (FDP) (FSP); quantitative 85378 $8.57 Fibrin degradation products, D-dimer; qualitative or semiquantitative 85379 $8.98 Fibrin degradation products, D-dimer; quantitative 85380 $8.98 Fibrin degradation products, D-dimer; ultrasensitive (eg, for evaluation for venous thromboembolism), qualitative or semiquantitative 85384 $8.57 Fibrinogen; activity 85385 $12.75 Fibrinogen; antigen 85390 $13.65 Fibrinolysins or coagulopathy screen, interpretation and report 85397 $27.21 Coagulation and fibrinolysis, functional activity, not otherwise specified (eg, ADAMTS-13), each analyte 85400 $6.80 Fibrinolytic factors and inhibitors; plasmin 85410 $6.80 Fibrinolytic factors and inhibitors; alpha-2 antiplasmin 85415 $15.16 Fibrinolytic factors and inhibitors; plasminogen activator 85420 $5.76 Fibrinolytic factors and inhibitors; plasminogen, except antigenic assay 85421 $8.98 Fibrinolytic factors and inhibitors; plasminogen, antigenic assay 85441 $3.70 Heinz bodies; direct 85445 $6.01 Heinz bodies; induced, acetyl phenylhydrazine 85460 $6.82 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) 85461 $8.25 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette 85475 $7.82 Hemolysin, acid 85520 $11.54 Heparin assay

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 85525 $10.44 Heparin neutralization 85530 $11.54 Heparin-protamine tolerance test 85536 $6.07 Iron stain, peripheral blood 85540 $7.58 Leukocyte alkaline phosphatase with count 85547 $7.58 Mechanical fragility, RBC 85549 $16.54 Muramidase 85555 $6.59 Osmotic fragility, RBC; unincubated 85557 $11.78 Osmotic fragility, RBC; incubated 85576 $21.97 Platelet, aggregation (in vitro), each agent 85597 $15.86 Phospholipid neutralization; platelet 85598 $15.86 Phospholipid neutralization; hexagonal phospholipid 85610 $3.78 Prothrombin time; 85611 $3.47 Prothrombin time; substitution, plasma fractions, each 85612 $15.42 Russell viper venom time (includes venom); undiluted 85613 $8.45 Russell viper venom time (includes venom); diluted 85635 $8.69 Reptilase test 85651 $3.77 Sedimentation rate, erythrocyte; non-automated 85652 $2.38 Sedimentation rate, erythrocyte; automated 85660 $4.86 Sickling of RBC, reduction 85670 $5.09 Thrombin time; plasma 85675 $6.04 Thrombin time; titer 85705 $8.49 Thromboplastin inhibition, tissue 85730 $5.30 Thromboplastin time, partial (PTT); plasma or whole blood 85732 $5.71 Thromboplastin time, partial (PTT); substitution, plasma fractions, each 85810 $10.29 Viscosity 85999 IC Unlisted hematology and coagulation procedure Immunology 86000 $6.16 Agglutinins, febrile (eg, Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus), each antigen 86001 $6.90 Allergen specific IgG quantitative or semiquantitative, each allergen 86003 $4.60 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each 86005 $7.03 Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card) 86008 $15.81 Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86015 $10.63 Actin (smooth muscle) antibody (ASMA), each 86021 $13.27 Antibody identification; leukocyte antibodies 86022 $16.20 Antibody identification; platelet antibodies 86023 $10.99 Antibody identification; platelet associated immunoglobulin assay 86036 $10.63 Antineutrophil cytoplasmic antibody (ANCA); screen, each antibody 86037 $10.63 Antineutrophil cytoplasmic antibody (ANCA); titer, each antibody 86038 $10.66 Antinuclear antibodies (ANA); 86039 $9.84 Antinuclear antibodies (ANA); titer 86041 $16.23 Acetylcholine receptor (AChR); binding antibody 86042 $16.23 Acetylcholine receptor (AChR); blocking antibody 86043 $10.63 Acetylcholine receptor (AChR); modulating antibody 86051 $10.17 Aquaporin-4 (neuromyelitis optica [NMO]) antibody; enzyme- linked immunosorbent immunoassay (ELISA) 86052 $10.63 Aquaporin-4 (neuromyelitis optica [NMO]) antibody; cell- based immunofluorescence assay (CBA), each 86053 $33.27 Aquaporin-4 (neuromyelitis optica [NMO]) antibody; flow cytometry (ie, fluorescence-activated cell sorting [FACS]), each 86060 $6.44 Antistreptolysin 0; titer 86063 $5.09 Antistreptolysin 0; screen 86140 $4.57 C-reactive protein; 86141 $11.42 C-reactive protein; high sensitivity (hsCRP) 86146 $22.44 Beta 2 Glycoprotein I antibody, each 86147 $22.44 Cardiolipin (phospholipid) antibody, each Ig class 86148 $14.17 Anti-phosphatidylserine (phospholipid) antibody 86152 $221.16 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); 86155 $14.10 Chemotaxis assay, specify method 86156 $7.12 Cold agglutinin; screen 86157 $7.11 Cold agglutinin; titer 86160 $10.58 Complement; antigen, each component 86161 $10.58 Complement; functional activity, each component 86162 $17.92 Complement; total hemolytic (CH50) 86171 $8.83 Complement fixation tests, each antigen 86200 $11.42 Cyclic citrullinated peptide (CCP), antibody

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86215 $11.68 Deoxyribonuclease, antibody 86225 $12.12 Deoxyribonucleic acid (DNA) antibody; native or double stranded 86226 $10.68 Deoxyribonucleic acid (DNA) antibody; single stranded 86231 $10.66 Endomysial antibody (EMA), each immunoglobulin (Ig) class 86235 $15.81 Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody 86255 $10.63 Fluorescent noninfectious agent antibody; screen, each antibody 86256 $10.63 Fluorescent noninfectious agent antibody; titer, each antibody 86258 $10.63 Gliadin (deamidated) (DGP) antibody, each immunoglobulin (Ig) class 86277 $13.88 Growth hormone, human (HGH), antibody 86280 $7.22 Hemagglutination inhibition test (HAI) 86294 $22.55 Immunoassay for tumor antigen, qualitative or semiquantitative (eg, bladder tumor antigen) 86300 $18.35 Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) 86301 $18.35 Immunoassay for tumor antigen, quantitative; CA 19-9 86304 $18.35 Immunoassay for tumor antigen, quantitative; CA 125 86305 $18.35 Human epididymis protein 4 (HE4) 86308 $4.57 Heterophile antibodies; screening 86309 $5.71 Heterophile antibodies; titer 86310 $6.50 Heterophile antibodies; titers after absorption with beef cells and guinea pig kidney 86316 $18.35 Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each 86317 $13.22 Immunoassay for infectious agent antibody, quantitative, not otherwise specified 86318 $15.95 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); 86320 $26.39 Immunoelectrophoresis; serum 86325 $20.40 Immunoelectrophoresis; other fluids (eg, urine, cerebrospinal fluid) with concentration 86327 $26.39 Immunoelectrophoresis; crossed (2-dimensional assay) 86328 $45.28 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 86329 $12.39 Immunodiffusion; not elsewhere specified

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86331 $10.56 Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen or antibody 86332 $21.49 Immune complex assay 86334 $19.70 Immunofixation electrophoresis; serum 86335 $25.88 Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) 86336 $13.75 Inhibin A 86337 $18.88 Insulin antibodies 86340 $13.30 Intrinsic factor antibodies 86341 $20.79 Islet cell antibody 86343 $10.99 Leukocyte histamine release test (LHR) 86344 $9.16 Leukocyte phagocytosis 86352 $119.81 Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP) 86353 $43.24 Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis 86355 $33.27 B cells, total count 86356 $23.62 Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen 86357 $33.27 Natural killer (NK) cells, total count 86359 $33.27 T cells; total count 86360 $41.43 T cells; absolute CD4 and CD8 count, including ratio 86361 $23.62 T cells; absolute CD4 count 86362 $10.63 Myelin oligodendrocyte glycoprotein (MOG-IgG1) antibody; cell-based immunofluorescence assay (CBA), each 86363 $33.27 Myelin oligodendrocyte glycoprotein (MOG-IgG1) antibody; flow cytometry (ie, fluorescence-activated cell sorting [FACS]), each 86364 $10.17 Tissue transglutaminase, each immunoglobulin (Ig) class 86366 $16.23 Muscle-specific kinase (MuSK) antibody 86367 $68.59 Stem cells (ie, CD34), total count 86376 $12.83 Microsomal antibodies (eg, thyroid or liver-kidney), each 86381 $22.44 Mitochondrial antibody (eg, M2), each 86382 $14.91 Neutralization test, viral 86384 $12.00 Nitroblue tetrazolium dye test (NTD) 86386 $19.21 Nuclear Matrix Protein 22 (NMP22), qualitative 86403 $10.18 Particle agglutination; screen, each antibody 86406 $9.38 Particle agglutination; titer, each antibody

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86408 $42.13 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID- 19]); screen 86409 $105.33 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID- 19]); titer 86413 $51.43 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (coronavirus disease [COVID-19]) antibody, quantitative 86430 $5.41 Rheumatoid factor; qualitative 86431 $5.00 Rheumatoid factor; quantitative 86480 $54.66 Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon 86481 $88.19 Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T- cells in cell suspension 86485 $25.15 Skin test; candida 86590 $11.16 Streptokinase, antibody 86592 $3.77 Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) 86593 $3.88 Syphilis test, non-treponemal antibody; quantitative 86596 $10.63 Voltage-gated calcium channel antibody, each 86602 $8.98 Antibody; actinomyces 86603 $11.35 Antibody; adenovirus 86606 $13.27 Antibody; Aspergillus 86609 $11.36 Antibody; bacterium, not elsewhere specified 86611 $8.98 Antibody; Bartonella 86612 $11.38 Antibody; Blastomyces 86615 $11.63 Antibody; Bordetella 86617 $13.66 Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot) 86618 $15.02 Antibody; Borrelia burgdorferi (Lyme disease) 86619 $11.80 Antibody; Borrelia (relapsing fever) 86622 $7.88 Antibody; Brucella 86625 $11.57 Antibody; Campylobacter 86628 $10.59 Antibody; Candida 86631 $10.42 Antibody; Chlamydia 86632 $11.18 Antibody; Chlamydia, IgM 86635 $10.12 Antibody; Coccidioides 86638 $10.69 Antibody; Coxiella burnetii (Q fever)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86641 $12.71 Antibody; Cryptococcus 86644 $12.69 Antibody; cytomegalovirus (CMV) 86645 $14.86 Antibody; cytomegalovirus (CMV), IgM 86648 $13.41 Antibody; Diphtheria 86651 $11.63 Antibody; encephalitis, California (La Crosse) 86652 $11.63 Antibody; encephalitis, Eastern equine 86653 $11.63 Antibody; encephalitis, St. Louis 86654 $11.63 Antibody; encephalitis, Western equine 86658 $11.49 Antibody; enterovirus (eg, coxsackie, echo, polio) 86663 $11.57 Antibody; Epstein-Barr (EB) virus, early antigen (EA) 86664 $13.48 Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA) 86665 $16.00 Antibody; Epstein-Barr (EB) virus, viral capsid (VCA) 86666 $8.98 Antibody; Ehrlichia 86668 $12.49 Antibody; Francisella tularensis 86671 $10.80 Antibody; fungus, not elsewhere specified 86674 $12.98 Antibody; Giardia lamblia 86677 $14.86 Antibody; Helicobacter pylori 86682 $11.47 Antibody; helminth, not elsewhere specified 86684 $13.97 Antibody; Haemophilus influenza 86687 $8.02 Antibody; HTLV-I 86688 $12.35 Antibody; HTLV-II 86689 $17.06 Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) 86692 $15.13 Antibody; hepatitis, delta agent 86694 $12.69 Antibody; herpes simplex, non-specific type test 86695 $11.63 Antibody; herpes simplex, type 1 86696 $17.06 Antibody; herpes simplex, type 2 86698 $12.16 Antibody; histoplasma 86701 $7.84 Antibody; HIV-1 86702 $11.92 Antibody; HIV-2 86703 $12.09 Antibody; HIV-1 and HIV-2, single result 86704 $10.63 Hepatitis B core antibody (HBcAb); total 86705 $10.38 Hepatitis B core antibody (HBcAb); IgM antibody 86706 $9.47 Hepatitis B surface antibody (HBsAb) 86707 $10.20 Hepatitis Be antibody (HBeAb) 86708 $10.93 Hepatitis A antibody (HAAb) 86709 $9.93 Hepatitis A antibody (HAAb), IgM antibody 86710 $11.95 Antibody; influenza virus 86711 $14.89 Antibody; JC (John Cunningham) virus

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86713 $13.49 Antibody; Legionella 86717 $10.80 Antibody; Leishmania 86720 $14.29 Antibody; Leptospira 86723 $11.63 Antibody; Listeria monocytogenes 86727 $11.35 Antibody; lymphocytic choriomeningitis 86732 $13.23 Antibody; mucormycosis 86735 $11.51 Antibody; mumps 86738 $11.68 Antibody; mycoplasma 86741 $11.63 Antibody; Neisseria meningitidis 86744 $14.10 Antibody; Nocardia 86747 $13.25 Antibody; parvovirus 86750 $11.63 Antibody; Plasmodium (malaria) 86753 $10.93 Antibody; protozoa, not elsewhere specified 86756 $14.01 Antibody; respiratory syncytial virus 86757 $17.06 Antibody; Rickettsia 86759 $16.08 Antibody; rotavirus 86762 $12.69 Antibody; rubella 86765 $11.36 Antibody; rubeola 86768 $11.63 Antibody; Salmonella 86769 $42.13 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 86771 $21.59 Antibody; Shigella 86774 $13.05 Antibody; tetanus 86777 $12.69 Antibody; Toxoplasma 86778 $12.71 Antibody; Toxoplasma, IgM 86780 $11.68 Antibody; Treponema pallidum 86784 $11.08 Antibody; Trichinella 86787 $11.36 Antibody; varicella-zoster 86788 $14.86 Antibody; West Nile virus, IgM 86789 $12.69 Antibody; West Nile virus 86790 $11.36 Antibody; virus, not elsewhere specified 86793 $11.63 Antibody; Yersinia 86794 $14.86 Antibody; Zika virus, IgM 86800 $14.03 Thyroglobulin antibody 86803 $12.58 Hepatitis C antibody; 86804 $13.66 Hepatitis C antibody; confirmatory test (eg, immunoblot) 86805 $167.12 Lymphocytotoxicity assay, visual crossmatch; with titration 86806 $41.97 Lymphocytotoxicity assay, visual crossmatch; without titration

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86807 $69.36 Serum screening for cytotoxic percent reactive antibody (PRA); standard method 86808 $26.17 Serum screening for cytotoxic percent reactive antibody (PRA); quick method 86812 $22.76 HLA typing; A, B, or C (eg, A10, B7, B27), single antigen 86813 $51.15 HLA typing; A, B, or C, multiple antigens 86816 $26.61 HLA typing; DR/DQ, single antigen 86817 $93.60 HLA typing; DR/DQ, multiple antigens 86821 $32.24 HLA typing; lymphocyte culture, mixed (MLC) 86825 $96.56 Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); first serum sample or dilution 86826 $32.21 Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution (List separately in addition to primary procedure) 86828 $56.61 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, flow cytometry); qualitative assessment of the presence or absence of antibody(ies) to HLA Class I and Class II HLA antigens 86829 $56.61 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); qualitative assessment of the presence or absence of antibody(ies) to HLA Class I or Class II HLA antigens 86830 $84.24 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); antibody identification by qualitative panel using complete HLA phenotypes, HLA Class I 86831 $72.21 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); antibody identification by qualitative panel using complete HLA phenotypes, HLA Class II 86832 $285.51 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); high definition qualitative panel for identification of antibody specificities (eg, individual antigen per bead methodology), HLA Class I

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86833 $287.31 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); high definition qualitative panel for identification of antibody specificities (eg, individual antigen per bead methodology), HLA Class II 86834 $315.32 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); semi-quantitative panel (eg, titer), HLA Class I 86835 $284.81 Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); semi-quantitative panel (eg, titer), HLA Class II 86849 IC Unlisted immunology procedure Transformation 86850 $8.62 Antibody screen, RBC, each serum technique 86860 IC Antibody elution (RBC), each elution 86870 IC Antibody identification, RBC antibodies, each panel for each serum technique 86880 $4.75 Antihuman globulin test (Coombs test); direct, each antiserum 86885 $5.04 Antihuman globulin test (Coombs test); indirect, qualitative, each reagent red cell 86886 $4.57 Antihuman globulin test (Coombs test); indirect, each antibody titer 86890 IC Autologous blood or component, collection processing and storage; predeposited 86891 IC Autologous blood or component, collection processing and storage; intra- or postoperative salvage 86900 $2.64 Blood typing, serologic; ABO 86901 $2.64 Blood typing, serologic; Rh (D) 86902 $5.60 Blood typing, serologic; antigen testing of donor blood using reagent serum, each antigen test 86904 $14.41 Blood typing, serologic; antigen screening for compatible unit using patient serum, per unit screened 86905 $3.38 Blood typing, serologic; RBC antigens, other than ABO or Rh (D), each 86906 $6.83 Blood typing, serologic; Rh phenotyping, complete 86920 IC Compatibility test each unit; immediate spin technique 86921 IC Compatibility test each unit; incubation technique 86922 IC Compatibility test each unit; antiglobulin technique 86923 IC Compatibility test each unit; electronic

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 86927 IC Fresh frozen plasma, thawing, each unit 86930 IC Frozen blood, each unit; freezing (includes preparation) 86931 IC Frozen blood, each unit; thawing 86932 IC Frozen blood, each unit; freezing (includes preparation) and thawing 86940 $7.73 Hemolysins and agglutinins; auto, screen, each 86941 $10.68 Hemolysins and agglutinins; incubated 86945 $24.12 Irradiation of blood product, each unit 86960 IC Volume reduction of blood or blood product (eg, red blood cells or platelets), each unit 86965 $24.12 Pooling of platelets or other blood products 86970 $19.27 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with chemical agents or drugs, each 86971 $19.27 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each 86976 $19.27 Pretreatment of serum for use in RBC antibody identification; by dilution 86977 $19.27 Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors, each 86978 $19.27 Pretreatment of serum for use in RBC antibody identification; by differential red cell absorption using patient RBCs or RBCs of known phenotype, each absorption 86985 IC Splitting of blood or blood products, each unit 86999 IC Unlisted transfusion medicine procedure Microbiology 87003 $14.85 Animal inoculation, small animal, with observation and dissection 87015 $5.89 Concentration (any type), for infectious agents 87040 $9.10 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) 87045 $8.32 Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species 87046 $8.32 Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87070 $7.60 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates 87071 $8.72 Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool 87073 $8.52 Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool 87075 $8.35 Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates 87076 $7.13 Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate 87077 $7.13 Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate 87081 $5.85 Culture, presumptive, pathogenic organisms, screening only; 87084 $23.87 Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart 87086 $7.12 Culture, bacterial; quantitative colony count, urine 87088 $7.13 Culture, bacterial; with isolation and presumptive identification of each isolate, urine 87101 $6.80 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail 87102 $7.42 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood) 87103 $18.04 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; blood 87106 $9.10 Culture, fungi, definitive identification, each organism; yeast 87107 $9.10 Culture, fungi, definitive identification, each organism; mold 87109 $13.57 Culture, mycoplasma, any source 87110 $17.28 Culture, chlamydia, any source 87116 $9.52 Culture, tubercle or other acid-fast bacilli (eg, TB, AFB, mycobacteria) any source, with isolation and presumptive identification of isolates 87118 $12.88 Culture, mycobacterial, definitive identification, each isolate 87140 $4.91 Culture, typing; immunofluorescent method, each antiserum 87143 $11.04 Culture, typing; gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87147 $4.57 Culture, typing; immunologic method, other than immunofluorescence (eg, agglutination grouping), per antiserum 87149 $17.68 Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed 87150 $30.94 Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed 87152 $6.83 Culture, typing; identification by pulse field gel typing 87153 $101.73 Culture, typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene) 87154 $192.30 Culture, typing; identification of blood pathogen and resistance typing, when performed, by nucleic acid (DNA or RNA) probe, multiplexed amplified probe technique including multiplex reverse transcription, when performed, per culture or isolate, 6 or more targets 87158 $6.83 Culture, typing; other methods 87164 $9.47 Dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection 87166 $9.97 Dark field examination, any source (eg, penile, vaginal, oral, skin); without collection 87168 $3.77 Macroscopic examination; arthropod 87169 $3.80 Macroscopic examination; parasite 87172 $3.77 Pinworm exam (eg, cellophane tape prep) 87176 $5.19 Homogenization, tissue, for culture 87177 $7.85 Ova and parasites, direct smears, concentration and identification 87181 $4.19 Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip) 87184 $6.60 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents) 87185 $4.19 Susceptibility studies, antimicrobial agent; enzyme detection (eg, beta lactamase), per enzyme 87186 $7.63 Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate 87187 $35.42 Susceptibility studies, antimicrobial agent; microdilution or agar dilution, minimum lethal concentration (MLC), each plate (List separately in addition to code for primary procedure)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87188 $5.86 Susceptibility studies, antimicrobial agent; macrobroth dilution method, each agent 87190 $6.45 Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent 87197 $13.25 Serum bactericidal titer (Schlichter test) 87205 $3.77 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87206 $4.75 Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types 87207 $5.28 Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses) 87209 $15.86 Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites 87210 $5.13 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 87220 $3.77 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) 87230 $17.41 Toxin or antitoxin assay, tissue culture (eg, Clostridium difficile toxin) 87250 $17.25 Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection 87252 $22.99 Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect 87253 $17.81 Virus isolation; tissue culture, additional studies or definitive identification (eg, hemabsorption, neutralization, immunofluorescence stain), each isolate 87254 $17.25 Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus 87255 $29.86 Virus isolation; including identification by non-immunologic method, other than by cytopathic effect (eg, virus specific enzymatic activity) 87260 $12.73 Infectious agent antigen detection by immunofluorescent technique; adenovirus 87265 $10.56 Infectious agent antigen detection by immunofluorescent technique; Bordetella pertussis/parapertussis 87267 $11.83 Infectious agent antigen detection by immunofluorescent technique; Enterovirus, direct fluorescent antibody (DFA)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87269 $12.00 Infectious agent antigen detection by immunofluorescent technique; giardia 87270 $10.56 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 87271 $11.83 Infectious agent antigen detection by immunofluorescent technique; Cytomegalovirus, direct fluorescent antibody (DFA) 87272 $10.56 Infectious agent antigen detection by immunofluorescent technique; cryptosporidium 87273 $10.56 Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 2 87274 $10.56 Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 1 87275 $10.80 Infectious agent antigen detection by immunofluorescent technique; influenza B virus 87276 $14.17 Infectious agent antigen detection by immunofluorescent technique; influenza A virus 87278 $13.76 Infectious agent antigen detection by immunofluorescent technique; Legionella pneumophila 87279 $14.49 Infectious agent antigen detection by immunofluorescent technique; Parainfluenza virus, each type 87280 $11.83 Infectious agent antigen detection by immunofluorescent technique; respiratory syncytial virus 87281 $10.56 Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii 87283 $53.62 Infectious agent antigen detection by immunofluorescent technique; Rubeola 87285 $10.74 Infectious agent antigen detection by immunofluorescent technique; Treponema pallidum 87290 $11.83 Infectious agent antigen detection by immunofluorescent technique; Varicella zoster virus 87299 $14.20 Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism 87300 $10.56 Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum 87301 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87305 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Aspergillus 87320 $13.23 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Chlamydia trachomatis 87324 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Clostridium difficile toxin(s) 87327 $11.83 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Cryptococcus neoformans 87328 $12.19 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; cryptosporidium 87329 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; giardia 87332 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; cytomegalovirus 87335 $11.16 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Escherichia coli 0157

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87336 $14.11 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Entamoeba histolytica dispar group 87337 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Entamoeba histolytica group 87338 $12.68 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Helicobacter pylori, stool 87339 $14.11 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Helicobacter pylori 87340 $9.11 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; hepatitis B surface antigen (HBsAg) 87341 $9.11 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; hepatitis B surface antigen (HBsAg) neutralization 87350 $10.17 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; hepatitis Be antigen (HBeAg)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87380 $16.19 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; hepatitis, delta agent 87385 $11.68 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Histoplasma capsulatum 87389 $21.24 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result 87390 $21.22 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; HIV-1 87391 $19.31 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; HIV-2 87400 $12.46 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each 87420 $12.27 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; respiratory syncytial virus

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87425 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; rotavirus 87426 $35.33 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) 87427 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Shiga-like toxin 87428 $63.59 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 87430 $14.82 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Streptococcus, group A 87449 $10.56 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; not otherwise specified, each organism 87451 $9.27 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; polyvalent for multiple organisms, each polyvalent antiserum

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87467 $13.27 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; hepatitis B surface antigen (HBsAg), quantitative 87468 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Anaplasma phagocytophilum, amplified probe technique 87469 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Babesia microti, amplified probe technique 87471 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique 87472 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, quantification 87475 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique 87476 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, amplified probe technique 87478 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia miyamotoi, amplified probe technique 87480 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique 87481 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 87482 $49.16 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification 87483 $367.55 Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen (eg, Neisseria meningitidis, Streptococcus pneumoniae, Listeria, Haemophilus influenzae, E. coli, Streptococcus agalactiae, enterovirus, human parechovirus, herpes simplex virus type 1 and 2, human herpesvirus 6, cytomegalovirus, varicella zoster virus, Cryptococcus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets 87484 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Ehrlichia chaffeensis, amplified probe technique 87485 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87486 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique 87487 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification 87490 $20.06 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87492 $47.15 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87493 $32.87 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique 87495 $26.48 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique 87496 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique 87497 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification 87498 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed 87500 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique 87501 $45.25 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 $84.48 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types 87503 $25.77 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87505 $113.14 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87506 $231.92 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87507 $367.55 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets 87510 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique 87511 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique 87512 $36.83 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification 87516 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, amplified probe technique 87517 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification 87520 $27.53 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique 87521 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 87522 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed 87523 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis D (delta), quantification, including reverse transcription, when performed 87525 $26.28 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, direct probe technique 87526 $34.62 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, amplified probe technique

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87527 $36.83 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification 87528 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique 87529 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique 87530 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification 87531 $51.15 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique 87532 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique 87533 $36.83 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, quantification 87534 $19.33 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique 87535 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique, includes reverse transcription when performed 87536 $75.05 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification, includes reverse transcription when performed 87537 $19.33 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique 87538 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique, includes reverse transcription when performed 87539 $51.70 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification, includes reverse transcription when performed 87540 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, direct probe technique 87541 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique 87542 $36.83 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification 87550 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, direct probe technique 87551 $42.54 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87552 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, quantification 87555 $23.70 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique 87556 $36.76 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique 87557 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, quantification 87560 $24.07 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, direct probe technique 87561 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique 87562 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, quantification 87563 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique 87580 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique 87581 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique 87582 $266.87 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, quantification 87590 $23.70 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique 87591 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 87592 $37.78 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification 87593 $30.95 Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus (eg, monkeypox virus, cowpox virus, vaccinia virus), amplified probe technique, each 87623 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) 87624 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) 87625 $35.76 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87631 $125.78 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87632 $192.30 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87633 $367.55 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets 87634 $61.91 Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique 87635 $51.31 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (coronavirus disease [COVID-19]), amplified probe technique 87636 $142.63 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique 87637 $142.63 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique 87640 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 87641 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique 87650 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87651 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique 87652 $36.83 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification 87653 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 87660 $17.68 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique 87661 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique 87662 $45.25 Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique 87797 $26.48 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism 87798 $30.94 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism 87799 $37.78 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism 87800 $38.51 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 $61.91 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique 87802 $11.23 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B 87803 $14.11 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Clostridium difficile toxin A 87804 $14.60 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza 87806 $28.90 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87807 $11.55 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus 87808 $13.48 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Trichomonas vaginalis 87809 $19.19 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; adenovirus 87810 $31.12 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Chlamydia trachomatis

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 87811 $41.38 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87850 $21.66 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Neisseria gonorrhoeae 87880 $14.58 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A 87899 $14.17 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; not otherwise specified 87900 $114.95 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 87901 $227.04 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions 87902 $227.04 Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus 87903 $430.94 Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through 10 drugs tested 87904 $22.99 Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; each additional drug tested (List separately in addition to code for primary procedure) 87905 $10.78 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) 87906 $113.52 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion) 87910 $227.04 Infectious agent genotype analysis by nucleic acid (DNA or RNA); cytomegalovirus 87912 $227.04 Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis B virus 87913 $257.45 Infectious agent genotype analysis by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), mutation identification in targeted region(s) 87999 IC Unlisted microbiology procedure Anatomic Pathology 88000 IC Necropsy (autopsy), gross examination only; without CNS 88005 IC Necropsy (autopsy), gross examination only; with brain

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 88007 IC Necropsy (autopsy), gross examination only; with brain and spinal cord 88012 IC Necropsy (autopsy), gross examination only; infant with brain 88014 IC Necropsy (autopsy), gross examination only; stillborn or newborn with brain 88016 IC Necropsy (autopsy), gross examination only; macerated stillborn 88020 IC Necropsy (autopsy), gross and microscopic; without CNS 88025 IC Necropsy (autopsy), gross and microscopic; with brain 88027 IC Necropsy (autopsy), gross and microscopic; with brain and spinal cord 88028 IC Necropsy (autopsy), gross and microscopic; infant with brain 88029 IC Necropsy (autopsy), gross and microscopic; stillborn or newborn with brain 88036 IC Necropsy (autopsy), limited, gross and/or microscopic; regional 88037 IC Necropsy (autopsy), limited, gross and/or microscopic; single organ 88040 IC Necropsy (autopsy); forensic examination 88045 IC Necropsy (autopsy); coroner's call 88099 IC Unlisted necropsy (autopsy) procedure Cytopathology 88130 $15.86 Sex chromatin identification; Barr bodies 88140 $7.05 Sex chromatin identification; peripheral blood smear, polymorphonuclear drumsticks 88142 $17.87 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision 88143 $20.32 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision 88147 $44.59 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision 88148 $15.27 Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision 88150 $15.27 Cytopathology, slides, cervical or vaginal; manual screening under physician supervision

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 88152 $24.38 Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision 88153 $21.19 Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision 88155 $12.92 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code[s] for other technical and interpretation services) 88164 $15.27 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision 88165 $37.23 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision 88166 $15.27 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision 88167 $15.27 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 88174 $22.37 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision 88175 $23.47 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision Cytogenic Studies 88230 $102.73 Tissue culture for non-neoplastic disorders; lymphocyte 88233 $124.11 Tissue culture for non-neoplastic disorders; skin or other solid tissue biopsy 88235 $132.55 Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells 88237 $126.77 Tissue culture for neoplastic disorders; bone marrow, blood cells 88239 $130.09 Tissue culture for neoplastic disorders; solid tumor 88240 $11.53 Cryopreservation, freezing and storage of cells, each cell line

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 88241 $10.66 Thawing and expansion of frozen cells, each aliquot 88245 $152.71 Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells 88248 $152.71 Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X) 88249 $152.71 Chromosome analysis for breakage syndromes; score 100 cells, clastogen stress (eg, diepoxybutane, mitomycin C, ionizing radiation, UV radiation) 88261 $233.11 Chromosome analysis; count 5 cells, 1 karyotype, with banding 88262 $110.67 Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding 88263 $132.54 Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding 88264 $127.53 Chromosome analysis; analyze 20-25 cells 88267 $166.30 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding 88269 $153.15 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding 88271 $18.89 Molecular cytogenetics; DNA probe, each (eg, FISH) 88272 $35.89 Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells (eg, for derivatives and markers) 88273 $30.70 Molecular cytogenetics; chromosomal in situ hybridization, analyze 10-30 cells (eg, for microdeletions) 88274 $37.37 Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells 88275 $45.14 Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells 88280 $29.52 Chromosome analysis; additional karyotypes, each study 88283 $60.50 Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) 88285 $23.73 Chromosome analysis; additional cells counted, each study 88289 $30.36 Chromosome analysis; additional high resolution study 88371 $19.60 Protein analysis of tissue by Western Blot, with interpretation and report; 88372 $23.12 Protein analysis of tissue by Western Blot, with interpretation and report; immunological probe for band identification, each In vivo, (e.g., Transcutaneous) Laboratory Procedures 88720 $4.43 Bilirubin, total, transcutaneous

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 88738 $4.43 Hemoglobin (Hgb), quantitative, transcutaneous 88740 $8.26 Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin 88741 $8.26 Hemoglobin, quantitative, transcutaneous, per day; methemoglobin Other Procedures 89050 $4.16 Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; 89051 $4.94 Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count 89055 $3.77 Leukocyte assessment, fecal, qualitative or semiquantitative 89060 $6.46 Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) 89125 $5.19 Fat stain, feces, urine, or respiratory secretions 89160 $4.28 Meat fibers, feces 89190 $5.11 Nasal smear for eosinophils Reproductive Medicine Procedures 89250 IC Culture of oocyte(s)/embryo(s), less than 4 days; 89251 IC Culture of oocyte(s)/embryo(s), less than 4 days; with co- culture of oocyte(s)/embryos 89253 IC Assisted embryo hatching, microtechniques (any method) 89254 IC Oocyte identification from follicular fluid 89255 IC Preparation of embryo for transfer (any method) 89257 IC Sperm identification from aspiration (other than seminal fluid) 89258 IC Cryopreservation; embryo(s) 89259 IC Cryopreservation; sperm 89264 IC Sperm identification from testis tissue, fresh or cryopreserved 89268 IC Insemination of oocytes 89272 IC Extended culture of oocyte(s)/embryo(s), 4-7 days 89280 IC Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes 89281 IC Assisted oocyte fertilization, microtechnique; greater than 10 oocytes 89290 IC Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos 89291 IC Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 89300 $8.68 Semen analysis; presence and/or motility of sperm including Huhner test (post coital) 89310 $7.59 Semen analysis; motility and count (not including Huhner test) 89320 $10.86 Semen analysis; volume, count, motility, and differential 89321 $10.63 Semen analysis; sperm presence and motility of sperm, if performed 89322 $13.67 Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger) 89325 $9.41 Sperm antibodies 89329 $17.28 Sperm evaluation; hamster penetration test 89330 $9.15 Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test 89331 $17.28 Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) 89335 IC Cryopreservation, reproductive tissue, testicular 89342 IC Storage (per year); embryo(s) 89343 IC Storage (per year); sperm/semen 89344 IC Storage (per year); reproductive tissue, testicular/ovarian 89346 IC Storage (per year); oocyte(s) 89352 IC Thawing of cryopreserved; embryo(s) 89353 IC Thawing of cryopreserved; sperm/semen, each aliquot 89354 IC Thawing of cryopreserved; reproductive tissue, testicular/ovarian 89356 IC Thawing of cryopreserved; oocytes, each aliquot 89398 IC Unlisted reproductive medicine laboratory procedure Other Pathology and Laboratory 36415 $7.56 Collection of venous blood by venipuncture 78267 $9.75 Urea breath test, C-14 (isotopic); acquisition for analysis 78268 $83.26 Urea breath test, C-14 (isotopic); analysis 81105 $107.78 Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3 [platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-1a/b (L33P) 81106 $107.78 Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib [platelet], alpha polypeptide [GPIba]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post- transfusion purpura), gene analysis, common variant, HPA-2a/b (T145M)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81107 $107.78 Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B (integrin, alpha 2b [platelet glycoprotein IIb of IIb/IIIa complex], antigen CD41 [GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S) 81108 $107.78 Human Platelet Antigen 4 genotyping (HPA-4), ITGB3 (integrin, beta 3 [platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) 81109 $107.78 Human Platelet Antigen 5 genotyping (HPA-5), ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] [GPIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505E)) 81110 $107.78 Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin, beta 3 [platelet glycoprotein IIIa, antigen CD61] [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-6a/b (R489Q) 81111 $107.78 Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alpha 2b [platelet glycoprotein IIb of IIb/IIIa complex, antigen CD41] [GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M) 81112 $107.78 Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 molecule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) 81120 $170.42 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C) 81121 $260.85 IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M) 81161 $246.04 DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed 81162 $1,609.32 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81163 $412.72 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis 81164 $515.22 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) 81165 $249.46 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis 81166 $265.75 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) 81167 $249.46 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) 81168 $182.82 CCND1/IGH (t(11;14)) (eg, mantle cell lymphoma) translocation analysis, major breakpoint, qualitative and quantitative, if performed 81170 $264.56 ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain 81171 $120.82 AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81172 $242.37 AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) 81173 $265.75 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence 81174 $163.32 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant 81175 $596.59 ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81176 $213.33 ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) 81177 $120.82 ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81178 $120.82 ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81179 $120.82 ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81180 $120.82 ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81181 $120.82 ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81182 $120.82 ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81183 $120.82 ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81184 $120.82 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81185 $746.30 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence 81186 $163.32 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant 81187 $120.82 CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81188 $120.82 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81189 $242.37 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence 81190 $163.32 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) 81191 $182.82 NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81192 $182.82 NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis 81193 $182.82 NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis 81194 $457.06 NTRK (neurotrophic receptor tyrosine kinase 1, 2, and 3) (eg, solid tumors) translocation analysis 81200 $41.67 ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common variants (eg, E285A, Y231X) 81201 $687.86 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence 81202 $246.93 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants 81203 $176.38 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants 81204 $120.82 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) 81205 $83.77 BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (eg, maple syrup urine disease) gene analysis, common variants (eg, R183P, G278S, E422X) 81206 $144.59 BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative 81207 $127.73 BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative 81208 $189.27 BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or quantitative 81209 $34.67 BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom syndrome) gene analysis, 2281del6ins7 variant 81210 $154.68 BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s) 81212 $388.03 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81215 $330.92 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant 81216 $163.25 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis 81217 $330.92 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant 81218 $213.33 CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence 81219 $107.26 CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9 81220 $490.85 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) 81221 $85.74 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants 81222 $383.68 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants 81223 $440.06 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence 81224 $148.82 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) 81225 $256.94 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) 81226 $397.65 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) 81227 $154.16 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) 81228 $793.69 Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization [CGH] microarray analysis

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81229 $1,022.98 Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants, comparative genomic hybridization (CGH) microarray analysis 81230 $154.16 CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) 81231 $154.16 CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) 81232 $154.16 DPYD (dihydropyrimidine dehydrogenase) (eg, 5- fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) 81233 $154.68 BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) 81234 $120.82 DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles 81235 $286.24 EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) 81236 $249.46 EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence 81237 $154.68 EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) 81238 $529.13 F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence 81239 $242.37 DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) 81240 $57.93 F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant 81241 $64.70 F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant 81242 $32.29 FANCC (Fanconi anemia, complementation group C) (eg, Fanconi anemia, type C) gene analysis, common variant (eg, IVS4+4A>T)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81243 $50.30 FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81244 $39.59 FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; characterization of alleles (eg, expanded size and promoter methylation status) 81245 $145.96 FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15) 81246 $73.20 FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) 81247 $154.16 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) 81248 $330.92 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) 81249 $529.13 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence 81250 $51.58 G6PC (glucose-6-phosphatase, catalytic subunit) (eg, Glycogen storage disease, type 1a, von Gierke disease) gene analysis, common variants (eg, R83C, Q347X) 81251 $41.67 GBA (glucosidase, beta, acid) (eg, Gaucher disease) gene analysis, common variants (eg, N370S, 84GG, L444P, IVS2+1G>A) 81252 $89.18 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence 81253 $54.25 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants 81254 $30.87 GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6- D13S1854)]) 81255 $45.37 HEXA (hexosaminidase A [alpha polypeptide]) (eg, Tay-Sachs disease) gene analysis, common variants (eg, 1278insTATC, 1421+1G>C, G269S) 81256 $57.64 HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81257 $90.18 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring) 81258 $330.92 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant 81259 $529.13 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence 81260 $34.67 IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase complex-associated protein) (eg, familial dysautonomia) gene analysis, common variants (eg, 2507+6T>C, R696P) 81261 $174.60 IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (eg, polymerase chain reaction) 81262 $60.45 IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (eg, Southern blot) 81263 $259.73 IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B-cell), variable region somatic mutation analysis 81264 $152.33 IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) 81265 $205.54 Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (eg, pre-transplant recipient and donor germline testing, post-transplant non- hematopoietic recipient germline [eg, buccal swab or other germline tissue sample] and donor testing, twin zygosity testing, or maternal cell contamination of fetal cells) 81266 $268.80 Comparative analysis using Short Tandem Repeat (STR) markers; each additional specimen (eg, additional cord blood donor, additional fetal samples from different cultures, or additional zygosity in multiple birth pregnancies) (List separately in addition to code for primary procedure)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81267 $182.95 Chimerism (engraftment) analysis, post transplantation specimen (eg, hematopoietic stem cell), includes comparison to previously performed baseline analyses; without cell selection 81268 $229.98 Chimerism (engraftment) analysis, post transplantation specimen (eg, hematopoietic stem cell), includes comparison to previously performed baseline analyses; with cell selection (eg, CD3, CD33), each cell type 81269 $178.49 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants 81270 $80.83 JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant 81271 $120.82 HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81272 $290.59 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11, 13, 17, 18) 81273 $110.12 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) 81274 $242.37 HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) 81275 $170.42 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) 81276 $170.42 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) 81277 $1,022.98 Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of- heterozygosity variants for chromosomal abnormalities 81278 $182.82 IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative 81279 $163.32 JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) 81283 $64.70 IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant 81284 $120.82 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81285 $242.37 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) 81286 $242.37 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence 81287 $109.92 MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis 81288 $169.60 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis 81289 $163.32 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) 81290 $34.67 MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type IV) gene analysis, common variants (eg, IVS3-2A>G, del6.4kb) 81291 $57.62 MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) 81292 $595.62 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81293 $291.90 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81294 $178.49 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 81295 $336.61 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81296 $297.84 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81297 $188.10 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 81298 $566.03 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81299 $271.62 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81300 $209.89 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 81301 $307.39 Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed 81302 $465.52 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis 81303 $105.83 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant 81304 $132.28 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants 81305 $154.68 MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81306 $256.94 NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) 81307 $596.59 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence 81308 $265.75 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant 81309 $242.37 PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene analysis, targeted sequence analysis (eg, exons 7, 9, 20) 81310 $217.40 NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, exon 12 variants 81311 $260.85 NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) 81312 $120.82 PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81313 $224.92 PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) 81314 $290.59 PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81315 $182.82 PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; common breakpoints (eg, intron 3 and intron 6), qualitative or quantitative 81316 $182.82 PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative or quantitative 81317 $596.59 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis 81318 $291.90 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants 81319 $179.46 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 81320 $256.94 PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) 81321 $529.13 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis 81322 $41.10 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant 81323 $264.56 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant 81324 $668.78 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie- Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis 81325 $678.67 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie- Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis 81326 $41.10 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie- Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant 81327 $169.32 SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81328 $154.16 SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) 81329 $120.82 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed 81330 $41.45 SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (eg, Niemann-Pick disease, Type A) gene analysis, common variants (eg, R496L, L302P, fsP330) 81331 $45.04 SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (eg, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis 81332 $38.49 SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (eg, alpha-1-antitrypsin deficiency), gene analysis, common variants (eg, *S and *Z) 81333 $120.82 TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) 81334 $290.59 RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) 81335 $154.16 TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) 81336 $265.75 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence 81337 $163.32 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) 81338 $132.57 MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) 81339 $163.32 MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 81340 $184.24 TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81341 $43.73 TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot) 81342 $177.70 TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) 81343 $120.82 PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81344 $120.82 TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles 81345 $163.32 TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) 81346 $154.16 TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) 81347 $170.42 SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) 81348 $154.68 SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) 81349 $1,022.98 Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low-pass sequencing analysis 81350 $206.36 UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugated hyperbilirubinemia [Gilbert syndrome]) gene analysis, common variants (eg, *28, *36, *37) 81351 $566.03 TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence 81352 $290.59 TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) 81353 $271.62 TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81355 $77.78 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variant(s) (eg, -1639G>A, c.173+1000C>T) 81357 $170.42 U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, S34F, S34Y, Q157R, Q157P) 81360 $170.42 ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs, E122fs, R448fs) 81361 $154.16 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) 81362 $330.92 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) 81363 $178.49 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) 81364 $286.24 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence 81370 $354.62 HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-A, -B, -C, -DRB1/3/4/5, and -DQB1 81371 $356.74 HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-A, -B, and -DRB1 (eg, verification typing) 81372 $355.92 HLA Class I typing, low resolution (eg, antigen equivalents); complete (ie, HLA-A, -B, and -C) 81373 $112.38 HLA Class I typing, low resolution (eg, antigen equivalents); one locus (eg, HLA-A, -B, or -C), each 81374 $65.55 HLA Class I typing, low resolution (eg, antigen equivalents); one antigen equivalent (eg, B*27), each 81375 $194.67 HLA Class II typing, low resolution (eg, antigen equivalents); HLA-DRB1/3/4/5 and -DQB1 81376 $107.78 HLA Class II typing, low resolution (eg, antigen equivalents); one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, - DPB1, or -DPA1), each 81377 $83.55 HLA Class II typing, low resolution (eg, antigen equivalents); one antigen equivalent, each 81378 $304.75 HLA Class I and II typing, high resolution (ie, alleles or allele groups), HLA-A, -B, -C, and -DRB1 81379 $295.76 HLA Class I typing, high resolution (ie, alleles or allele groups); complete (ie, HLA-A, -B, and -C)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81380 $156.31 HLA Class I typing, high resolution (ie, alleles or allele groups); one locus (eg, HLA-A, -B, or -C), each 81381 $149.83 HLA Class I typing, high resolution (ie, alleles or allele groups); one allele or allele group (eg, B57:01P), each 81382 $109.07 HLA Class II typing, high resolution (ie, alleles or allele groups); one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, - DQA1, -DPB1, or -DPA1), each 81383 $96.24 HLA Class II typing, high resolution (ie, alleles or allele groups); one allele or allele group (eg, HLA-DQB106:02P), each 81400 $56.40 Molecular pathology procedure, Level 1 (eg, identification of single germline variant [eg, SNP] by techniques such as restriction enzyme digestion or melt curve analysis) 81401 $120.82 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) 81402 $132.57 Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T- cell receptor gene rearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity [LOH], uniparental disomy [UPD]) 81403 $163.32 Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) 81404 $242.37 Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) 81405 $265.75 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis) 81406 $249.46 Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81407 $746.30 Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) 81408 $1,763.75 Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) 81410 $444.47 Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK 81411 $1,190.70 Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 81412 $2,159.32 Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1 81413 $515.81 Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A 81414 $515.81 Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 81415 $4,215.36 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis 81416 $10,582.50 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code for primary procedure)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81417 $282.20 Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syndrome) 81418 $0.00 Drug metabolism (eg, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis 81419 $2,159.32 Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, and ZEB2 81420 $669.39 Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21 81422 $669.39 Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood 81425 $4,436.89 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis 81426 $2,389.84 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to code for primary procedure) 81427 $2,061.52 Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/syndrome) 81430 $1,433.05 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81431 $599.30 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes 81432 $598.84 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 81433 $387.08 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 81434 $527.28 Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A 81435 $515.81 Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11 81436 $515.81 Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11 81437 $387.08 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81438 $387.08 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL 81439 $515.81 Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes (eg, DSG2, MYBPC3, MYH7, PKP2, TTN) 81440 $2,931.35 Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP 81441 $2,159.32 Inherited bone marrow failure syndromes (IBMFS) (eg, Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, congenital amegakaryocytic thrombocytopenia) sequence analysis panel, must include sequencing of at least 30 genes, including BRCA2, BRIP1, DKC1, FANCA, FANCB, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCI, FANCL, GATA1, GATA2, MPL, NHP2, NOP10, PALB2, RAD51C, RPL11, RPL35A, RPL5, RPS10, RPS19, RPS24, RPS26, RPS7, SBDS, TERT, and TINF2 81442 $1,890.39 Noonan spectrum disorders (eg, Noonan syndrome, cardio- facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81443 $2,159.32 Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish-associated disorders [eg, Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, must include sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH) 81445 $527.28 Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA analysis 81448 $515.81 Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) 81449 $527.28 Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis 81450 $669.81 Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis 81451 $669.81 Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis 81455 $2,574.72 Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis 81456 $2,574.72 Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis 81457 $0.00 Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability 81458 $0.00 Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability 81459 $0.00 Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements 81460 $1,134.97 Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke- like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection 81462 $0.00 Solid organ neoplasm, genomic sequence analysis panel, cell- free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements 81463 $0.00 Solid organ neoplasm, genomic sequence analysis panel, cell- free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability 81464 $0.00 Solid organ neoplasm, genomic sequence analysis panel, cell- free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements 81465 $825.44 Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81470 $806.03 X-linked intellectual disability (XLID) (eg, syndromic and non- syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 81471 $806.03 X-linked intellectual disability (XLID) (eg, syndromic and non- syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 81479 IC Unlisted molecular pathology procedure 81490 $741.35 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score 81493 $925.97 Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score 81500 $229.73 Oncology (ovarian), biochemical assays of two proteins (CA- 125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score 81503 $791.04 Oncology (ovarian), biochemical assays of five proteins (CA- 125, apolipoprotein A1, beta-2 microglobulin, transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score 81504 $458.58 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as tissue similarity scores 81506 $60.78 Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, HbA1c, insulin, hs-CRP, adiponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm reporting a risk score 81507 $701.09 Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy 81508 $47.89 Fetal congenital abnormalities, biochemical assays of two proteins (PAPP-A, hCG [any form]), utilizing maternal serum, algorithm reported as a risk score 81509 $1,311.67 Fetal congenital abnormalities, biochemical assays of three proteins (PAPP-A, hCG [any form], DIA), utilizing maternal serum, algorithm reported as a risk score

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81510 $48.98 Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG [any form]), utilizing maternal serum, algorithm reported as a risk score 81511 $135.37 Fetal congenital abnormalities, biochemical assays of four analytes (AFP, uE3, hCG [any form], DIA) utilizing maternal serum, algorithm reported as a risk score (may include additional results from previous biochemical testing) 81512 $61.31 Fetal congenital abnormalities, biochemical assays of five analytes (AFP, uE3, total hCG, hyperglycosylated hCG, DIA) utilizing maternal serum, algorithm reported as a risk score 81513 $125.78 Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, utilizing vaginal-fluid specimens, algorithm reported as a positive or negative result for bacterial vaginosis 81514 $231.92 Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species (L. crispatus and L. jensenii), utilizing vaginal-fluid specimens, algorithm reported as a positive or negative for high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and/or Candida species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata, Candida krusei, when reported 81517 $155.38 Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years 81518 $3,415.50 Oncology (breast), mRNA, gene expression profiling by real- time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy 81519 $3,415.50 Oncology (breast), mRNA, gene expression profiling by real- time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81520 $2,213.69 Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score 81521 $3,415.50 Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis 81522 $3,415.50 Oncology (breast), mRNA, gene expression profiling by RT- PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score 81523 $3,415.50 Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis 81525 $2,747.92 Oncology (colon), mRNA, gene expression profiling by real- time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score 81528 $262.58 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result 81529 $6,343.33 Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis 81535 $511.01 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination 81536 $156.59 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug combination (List separately in addition to code for primary procedure)

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description 81538 $2,531.86 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival 81539 $670.23 Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score 81540 $3,307.03 Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype 81541 $3,415.50 Oncology (prostate), mRNA gene expression profiling by real- time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score 81542 $3,415.50 Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as metastasis risk score 81546 $3,174.75 Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) 81551 $1,790.21 Oncology (prostate), promoter methylation profiling by real- time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy 81552 $6,857.46 Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis 81554 $4,867.95 Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP]) 81560 $565.04 Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party-induced

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score 81595 $2,857.28 Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score 81596 $63.66 Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liver 81599 IC Unlisted multianalyte assay with algorithmic analysis G0027 $5.73 Semen analysis; presence and/or motility of sperm excluding Huhner G0327 $0.00 ESRD related services for home dialysis (less than full month), per day; for patients twenty years of age and over G0103 $17.03 Prostate cancer screening; prostate specific antigen test (PSA) G0123 $17.87 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision G0143 $23.85 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision G0144 $38.78 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision G0145 $23.36 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision G0147 $15.27 Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision G0148 $28.17 Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening G0306 $6.85 Complete CBC, automated (HgB, HCT, RBC, WBC, without platelet count) and automated WBC differential count

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description G0307 $5.71 Complete CBC, automated (HgB, HCT, RBC, WBC; without platelet count) G0328 $15.92 Colorectal cancer screening; fecal occult blood test, immunoassay, one to three simultaneous determinations G0432 $17.26 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening G0433 $16.13 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening G0435 $10.56 Infectious agent antibody detection by rapid antibody test, HIV- 1 and/or HIV-2, screening G0471 $9.32 Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA) G0472 $40.87 Hepatitis C antibody screening for individual at high risk and other covered indication(s) G0475 $21.24 HIV antigen/antibody, combination assay, screening G0476 $30.94 Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test G0480 $59.69 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description G0481 $91.84 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0482 $123.97 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description G0483 $160.71 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed G0499 $24.93 Hepatitis B screening in nonpregnant, high-risk individual includes hepatitis B surface antigen (HBSAG), antibodies to HBSAG (anti-HBS) and antibodies to hepatitis B core antigen (anti-HBC), and is followed by a neutralizing confirmatory test, when performed, only for an initially reactive HBSAG result G0659 $54.80 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes G2023 $23.46 Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID- 19]), any specimen source G2023 CG $44.27 Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID- 19]), any specimen source

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description G2024 $25.46 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID- 19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source G2024 CG $46.27 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID- 19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source G9143 $106.46 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) P2028 $4.37 Cephalin flocculation, blood P2029 $4.37 Congo red, blood P2031 $4.37 Hair analysis (excluding arsenic) P2033 $4.37 Thymol turbidity, blood P2038 $4.37 Mucoprotein, blood (seromucoid) (medical necessity procedure) P3000 $15.27 Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision P9604 $4.78 Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated trip charge P9612 $7.56 Catheterization for collection of specimen, single patient, all places of service P9615 $7.56 Catheterization for collection of specimen(s) (multiple patients) Q0111 $15.27 Wet mounts, including preparations of vaginal, cervical or skin specimens Q0112 $5.14 All potassium hydroxide (KOH) preparations Q0113 $3.77 Pinworm examinations Q0114 $8.59 Fern test Q0115 $22.05 Postcoital direct, qualitative examinations of vaginal or cervical mucous U0001 $35.92 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT- PCR Diagnostic Panel U0002 $51.31 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID- 19), any technique, multiple types or subtypes (includes all targets), non-CDC

Final Adoption Date published in the Mass. Register: August 30, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 320.00: RATES FOR CLINICAL LABORATORY SERVICES

Code Rate Description U0003 $75.00 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R U0004 $75.00 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID- 19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R U0005 $25.00 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (coronavirus disease [COVID-19]), amplified probe technique, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either HCPCS code U0003 or U0004) as described by CMS-2020-01-R2

320.06 Filing and Reporting Requirements

320.06: Filing and Reporting Requirements

(1) Required Reports. Reporting requirements are governed by 957 CMR 6.00: Cost Reporting Requirements.

(2) Penalty for Noncompliance. The purchasing governmental unit may impose a penalty in the amount of up to 15% of its payments to any provider that fails to submit required information. The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under 101 CMR 320.06(2).

320.07 Severability

320.07: Severability

The provisions of 101 CMR 323.00 are severable. If any provision of 101 CMR 323.00 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 323.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 320.00: M.G.L. c. 118E.

101 CMR 320.00 — Rates for Clinical Laboratory Services

101 CMR 320.00 Rates for Clinical Laboratory Services

320.01 General Provisions

320.02 Definitions

320.03 Covered and Excluded Billing Situations

320.04 General Rate Provisions and Maximum Fees

320.05 Allowable Fees

320.06 Filing and Reporting Requirements

320.07 Severability

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