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Exhibit B <br /> North Carolina Breast and Cervical Cancer Control Program <br /> 2017 Services Fee Schedule(1) <br /> For the Period 01/01/2017 through 12/31/2017 <br /> Revised: 01/11/2017 <br /> 2017 Office Fee <br /> Breast Procedures Code Fee Allowed <br /> Screening <br /> Clinical Breast Examination N/A Yes <br /> Screening Digital Breast Tomosynthesis(2) 77063 $ 53.72 No <br /> 77063TC $ 23.72 <br /> 77063-26 $ 30.01 <br /> Screening Mammogram,Digital,Bilateral G0202 $ 130.16 No <br /> G0202TC $ 93.48 <br /> G0202-26 $ 36.68 <br /> Follow-Up <br /> Radiological examination,surgical specimen 76098 $ 15.96 No <br /> 76098TC $ 7.95 <br /> 76098-26 $ 8.01 <br /> Diagnostic Mammogram,Digital,Bilateral G0204 $ 161.35 No <br /> G0204TC $ 113.20 <br /> G0204-26 $ 48.16 <br /> Diagnostic Mammogram,Digital,Unilateral G0206 $ 127.21 No <br /> G0206TC $ 88.47 <br /> G0206-26 $ 38.74 <br /> Diagnostic Digital Breast Tomosynthesis(3) G0279 $ 53.73 No <br /> G0279TC $ 23.72 <br /> G0279-26 $ 30.01 <br /> Ultrasound,complete examination of breast including axilla, 76641 $ 103.36 No <br /> unilateral 76641TC $ 67.09 <br /> 76641-26 $ 36.27 <br /> Ultrasound,complete examination of breast including axilla, 76641-50 $ 155.04 No <br /> bilateral 76641-TC-50 $ 100.64 <br /> 76641-26-50 $ 54.40 <br /> Ultrasound,limited examination of breast including axilla, 76642 $ 85.19 No <br /> unilateral 76642TC $ 51.38 <br /> 76642-26 $ 33.81 <br /> Ultrasound,limited examination of breast including axilla, 76642-50 $ 127.79 No <br /> bilateral 76642-TC-50 $ 77.07 <br /> 76642-26-50 $ 50.72 <br /> Surgical Evaluation/Consultation N/A (7) Yes <br /> Fine Needle Aspiration 10021 $ 117.87 Yes <br /> Fine Needle Aspiration(with imaging guidance) 10022 $ 135.87 Yes <br /> Ultrasonic guidance for needle placement,imaging 76942 $ 58.51 No <br /> supervision and interpretation 76942-TC $ 26.32 <br /> 76942-26 $ 32.18 <br /> N.C.Department of Health and Human Services,Division of Public Health, Page 1 <br /> Chronic Disease and Injury Section,Cancer Prevention and Control Branch 2/2017 <br />