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North Carolina Breast and Cervical Cancer Control Program <br /> 2012-2013 Services Fee Schedule(1) <br /> For the Period 7/1/12 through 6/30/13 <br /> Revised 3/22/2012 <br /> 12-13 Office Fee <br /> Breast Procedures Code Fee Allowed <br /> Screening <br /> Clinical Breast Examination N/A Yes <br /> Screening Mammogram 77057 $ 76.76 No <br /> 77057TC $ 43.46 <br /> 77057-26 $ 33.29 <br /> Follow-Up <br /> Diagnostic Mammogram-Unilateral 77055 $ 82.75 No <br /> 77055TC $ 49.46 <br /> 77055-26 $ 33.29 <br /> Diagnostic Mammogram-Bilateral 77056 $ 105.81 No <br /> 77056TC $ 64.60 <br /> 77056-26 $ 41.21 <br /> Sterotactic,localization guidance for breast biopsy or 77031 $ 138.29 No <br /> needle placement,each lesion, 7703 ITC $ 62.40 <br /> 77031-26 $ 75.89 . <br /> Mammographic guidance for needle placement, 77032 $ 51.24 No <br /> breast,each lesion 77032TC $ 24.85 <br /> 77032-26 $ 26.40 <br /> Radiological examination,surgical specimen 76098 $ 17.59 No <br /> 76098TC $ 10.02 <br /> 76098-26 $ 7.58 <br /> Screening Mammogram,Digital,Bilateral G0202 $ 76.76 No <br /> 60202TC $ 43.46 <br /> G0202-26 $ 33.29 <br /> Diagnostic Mammogram,Digital,Bilateral 00204 $ 105.81 No <br /> G0204TC $ 64.60 <br /> G0204-26 $ 41.21 <br /> Diagnostic Mammogram,Digital,Unilateral G0206 $ 82.75 No <br /> G0206TC $ 49.46 <br /> 00206-26 $ 33.29 <br /> Ultrasound 76645 $ 83.93 No <br /> 76645TC $ 58.29 <br /> 76645-26 $ 25.64 <br /> Surgical Evaluation/Consultation N/A (2) Yes <br /> Fine Needle Aspiration 10021 $ 137.10 Yes <br /> Fine Needle Aspiration(with imaging guidance) 10022 $ 128.89 Yes <br /> Ultrasonic guidance for needle placement,imaging 76942 $ 192.80 No <br /> supervision and interpretation(performed in 76942-TC $ 160.84 <br /> conjunction with 10022 76942-26 $ 31.96 <br /> Cytopathology,evaluation of fine needle aspirate 88172 $ 50.46 No <br /> 88172TC $ 17.59 <br /> 88172-26 $ 32.87 <br /> Cytopathology,evaluation of fine needle aspirate 88173 $ 131.79 No <br /> >Interpretation and Report 88173TC $ 65.87 <br /> 88173-26 $ 65.93 <br /> Revised:3/22/12 <br />