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REF: North Carolina Breast and Cervical Cancer Control Program Exhibit B <br /> North Carolina Breast and Cervical Cancer Control Program <br /> 2014-2015 Services Fee Schedule(1) <br /> For the Period 07/01/2014 through 06/30/2015 <br /> Revised: 04/10/2014 <br /> 14-15 Office Fee <br /> Breast Procedures Code Fee Allowed <br /> Screening <br /> Clinical Breast Examination N/A Yes <br /> Screening Mammogram 77057 $ 58.98 No <br /> 77057TC $ 33.05 <br /> 77057-26 $ 25.93 <br /> Follow-Up <br /> Diagnostic Mammogram-Unilateral 77055 $ 64.29 No <br /> 77055TC $ 38.36 <br /> 77055-26 $ 25.93 <br /> Diagnostic Mammogram-Bilateral 77056 $ 82.64 No <br /> 77056TC $ 50.49 <br /> 77056-26 $ 32.15 <br /> Radiological examination, surgical specimen 76098 $ 13.74 No <br /> 76098TC $ 7.78 <br /> 76098-26 $ 5.96 <br /> Screening Mammogram, Digital,Bilateral G0202 $ 95.87 No <br /> G0202TC $ 70.20 <br /> G0202-26 $ 25.68 <br /> Diagnostic Mammogram,Digital,Bilateral G0204 $ 117.01 No <br /> G0204TC $ 84.85 <br /> G0204-26 $ 32.15 <br /> Diagnostic Mammogram,Digital,Unilateral G0206 $ 92.08 No <br /> G0206TC $ 66.40 <br /> G0206-26 $ 25.68 <br /> Ultrasound 76645 $ 70.91 No <br /> 76645TC $ 50.74 <br /> 76645-26 $ 20.17 <br /> Surgical Evaluation/Consultation N/A (2) Yes <br /> Fine Needle Aspiration 10021 $ 106.60 Yes <br /> Fine Needle Aspiration(with imaging guidance) 10022 $ 100.45 Yes <br /> Ultrasonic guidance for needle placement,imaging 76942 $ 52.88 No <br /> supervision and interpretation(performed in 76942-TC $ 28.25 <br /> conjunction with 10022 76942-26 $ 24.63 <br /> Cytopathology,evaluation of tine needle aspirate 88172 $ 39.17 No <br /> 89172TC $ 12.83 <br /> 88172-26 $ 26.33 <br /> Cytopathology,evaluation of line needle aspirate 88173 $ 105.08 No <br /> >Interpretation and Report 88173TC $ 52.76 <br /> 88173-26 $ 52.32 <br />