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Procedures CPT Code Fee <br />Automated Lipid Panel *80061 13.39$ <br />Lipid Panel (CLIA waived)1 80061QW 13.39$ <br />Cholesterol, Total Serum 82465 4.35$ <br />Cholesterol, Total Serum (CLIA waived) 82465QW 4.35$ <br />Lipoprotein (HDL)83718 8.19$ <br />Lipoprotein (HDL) (CLIA waived) 83718QW 8.19$ <br />Glucose, blood, quantitative 82947 3.93$ <br />Glucose, blood, quantitative (CLIA waived) 82947QW 3.93$ <br />Glucose, blood, reagent strip 82948 5.04$ <br />Glucose, tolerance test, three specimens 82951 12.87$ <br />Glucose, tolerance test, three specimens (CLIA waived) 82951QW 12.87$ <br />Hemoglobin A1C 83036 9.71$ <br />Hemoglobin A1C (CLIA waived) 83036QW 9.71$ <br />Basic Metabolic Profile **80048 8.46$ <br />Basic Metabolic Profile (CLIA waived)** 80048QW 8.46$ <br />Other <br />Routine venipuncture 36415 3.00$ <br />Health Coaching (HC) - Initial HC session is incorporated into screening visit; <br /> 2 additional HC sessions are advised and will be reimbursed as below: <br />Individual HC, Face-to-face, 15 minutes 98960 15.00$ <br />Individual HC, Phone, 15 minutes 98967 15.00$ <br />Office Visits <br /> New Patient, medically appropriate history/exam; 15-29 minutes 99202 70.70$ <br /> New Patient; medically appropriate history/exam; 30-44 minutes 99203 109.00$ <br /> New Patient, medically appropriate history/exam; 45-59 minutes 99204 162.93$ <br /> New Patient; medically appropriate history/exam; 60-74 minutes 99205 215.62$ <br /> Established Patient; evaluation and management; minimal problems 99211 22.25$ <br /> Established Patient; medically appropriate history/exam; 10-19 minutes 99212 54.79$ <br /> Established Patient; medically appropriate history/exam; 20-29 minutes 99213 88.29$ <br /> Established Patient; medically appropriate history/exam; 30-39 minutes 99214 124.76$ <br />Note: Office Visits listed above may be used to reimburse for consultations associated with WISEWOMAN <br />referrals, when applicable. <br />*Lipid Panel tests are: Total Serum Cholesterol, Lipoprotein (HDL and LDL) and Triglycerides. <br />**Basic <br />Metabolic Profile <br />1 The Clinical Laboratory Improvement Amendments of 1988 (CLIA) law specifies that laboratory <br />requirements be based on the complexity of the test performed and established provisions for categorizing a <br />test as waived. Tests may be waived from regulatory oversight if they meet certain requirements <br />established by the statute. CLIA waived tests employ methodologies that are so simple and accurate as to <br />render the likelihood of erroneous results negligible; pose no reasonable risk of harm to the patient if the <br />test is performed incorrectly; and/or are cleared by the Food and Drug Administration for home use. <br />North Carolina Breast and Cervical Cancer Control Program <br />Maximum Allowable Fees - WISEWOMAN Program <br />For the Period: 01/01/2022 - 12/31/2022 <br />Collection Container: 1 mL Serum / One SST Remarks: Includes NA, K, CL, CO2, <br />GLUC, BUN, CREA, CA <br />Revised: 01/03/2022 <br />DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18