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Exhibit B <br /> North Carolina Breast and Cervical Cancer Control Program <br /> 2015-2016 Services Fee Schedule(1) <br /> For the Period 07/01/2015 through 06/30/2016 <br /> Revised: 10/09/2015 <br /> CPT 15-16 Office Fee <br /> Breast Procedures(1) Code Fee Allowed <br /> Screening <br /> Clinical Breast Examination N/A Yes <br /> Screening Mammogram 77057 $ 78.38 No <br /> 77057-TC $ 43.56 <br /> 77057-26 $ 34.82 <br /> Follow-Up <br /> Diagnostic Mammogram-Unilateral 77055 $ 85.37 No <br /> 77055-TC $ 50.55 <br /> 77055-26 $ 34.82 <br /> Diagnostic Mammogram-Bilateral 77056 $ 109.71 No <br /> 77056-TC $ 66.53 <br /> 77056-26 $ 43.18 <br /> Radiological examination,surgical specimen 76098 $ 15.60 No <br /> 76098-TC $ 7.30 <br /> 76098-26 $ 8.00 <br /> Screening Mammogram,Digital,Bilateral G0202 $ 126.99 No <br /> G0202-TC $ 92.50 <br /> G0202-26 $ 34.48 <br /> Diagnostic Mammogram,Digital,Bilateral G0204 $ 154.99 No <br /> G0204-TC $ 111.81 <br /> G0204-26 $ 43.18 <br /> Diagnostic Mammogram,Digital,Unilateral G0206 $ 121.99 No <br /> G0206-TC $ 87.51 <br /> G0206-26 $ 34.48 <br /> Ultrasound,complete examination of breast including axilla,unitaleral 76641 $ 102.21 No <br /> 76641-TC $ 66.53 <br /> 76641-26 $ 35.67 <br /> bilateral 76641-50 $ 153.32 <br /> 76641-TC-50 $ 99.80 <br /> 76641-26-50 $ 53.51 <br /> Ultrasound,limited examination of breast including axilla,unitaleral 76642 $ 84.10 No <br /> 76642-TC $ 50.88 <br /> 76642-26 $ 33.22 <br /> bilateral 76642-50 $ 126.15 <br /> 76642-TC-50 $ 76.32 <br /> 76642-26-50 $ 49.83 <br /> Diagnostic Digital Mammogram,Tomosynthesis(3D)Unilateral 77061 No charge No <br /> 77061-TC No charge <br /> 77061-26 No charge <br /> Diagnostic Digital Mammogram,Tomosynthesis(3D)Bilateral 77062 No charge No <br /> 77062-TC No charge <br /> 77062-26 No charge <br />