|
|
|
| OHS CPT-CODE* |
DESCRIPTION |
TOTAL |
| 70140 |
RADIOLOGIC EXAMINATION, FACIAL BONES; LESS
THAN THREE VIEWS |
60.00 |
| 70150 |
RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE,
MINIMUM OF THREE VIEWS |
72.50 |
| 70160 |
RADIOLOGIC EXAMINATION, NASAL BONES; COMPLETE,
MINIMUM OF THREE VIEWS |
73.00 |
| 70210 |
RADIOLOGIC EXAMINATION, SINUSES, PARANASAL,
LESS THAN THREE VIEWS |
50.00 |
| 70220 |
RADIOLOGIC EXAMINATION, SINUSES, PARANASAL,
COMPLETE, MINIMUM OF THREE VIEWS |
73.00 |
| 70250 |
RADIOLOGIC EXAMINATION, SKULL; LESS THAN
FOUR VIEWS, WITH OR W/O STEREO |
60.50 |
| 70260 |
RADIOLOGIC EXAMINATION, SKULL, COMPLETE,
MINIMUM OF FOUR VIEWS, WITH OR W/O STEREO |
86.00 |
| 70450 |
COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR
BRAIN; W/O CONTRAST MATERIAL |
458.00 |
| 70460 |
COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR
BRAIN; WITH CONTRAST MATERIAL |
600.00 |
| 70470 |
COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR
BRAIN; W/O CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL
AND FURTHER SECTIONS |
613.00 |
| 70551 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
BRAIN (INCLUDING BRAIN STEM);W/O CONTRAST MATERIAL |
826.00 |
| 71010 |
RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW,
FRONTAL |
58.50 |
| 71020 |
RADIOLOGIC EXAMINATION, CHEST; TWO VIEWS,
FRONTAL AND LATERAL |
74.00 |
| 71100 |
RADIOLOGIC EXAMINATION, RIBS, UNILATERAL;
TWO VIEWS |
67.00 |
| 71101 |
RADIOLOGIC EXAMINATION, RIBS, UNILATERAL;
INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS |
75.00 |
| 71110 |
RADIOLOGIC EXAMINATION, RIBS, BILATERAL;
THREE VIEWS |
85.00 |
| 71250 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORAX;
W/O CONTRAST MATERIAL |
630.00 |
| 71260 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORAX;
WITH CONTRAST MATERIAL(S) |
672.00 |
| 71270 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORAX;
W/O CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL AND
FURTHER SECTIONS |
735.00 |
| 72010 |
RADIOLOGIC EXAMINATION, SPINE, ENTIRE,
SURVEY STUDY, ANTEROPOSTERIOR AND LATERAL |
128.50 |
| 72040 |
RADIOLOGIC EXAMINATION SPINE, CERVICAL;
ANTEROPOSTERIOR AND LATERAL |
64.00 |
| 72050 |
RADIOLOGIC EXAMINATION, SPINE, CERVICAL;
MINIMUM OF FOUR VIEWS |
104.00 |
| 72052 |
RADIOLOGIC EXAMINATION, SPINE, CERVICAL;
COMPLETE, INCLUDING OBLIQUE AND FLEXION AND/OR EXTENSION
STUDIES |
129.00 |
| 72070 |
RADIOLOGIC EXAMINATION, SPINE; THORACIC,
ANTEROPOSTERIOR AND LATERAL |
83.50 |
| 72100 |
RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL;
ANTEROPOSTERIOR AND LATERAL |
83.00 |
| 72110 |
RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL;
COMPLETE, W/OBLIQUE VIEWS |
119.00 |
| 72125 |
COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL
SPINE; W/O CONTRAST MATERIAL |
431.00 |
| 72126 |
COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL
SPINE; WITH CONTRAST MATERIAL |
489.00 |
| 72127 |
COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL
SPINE; W/O CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S)
AND FURTHER SECTIONS |
567.00 |
| 72128 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC
SPINE; W/O CONTRAST MATERIAL |
431.00 |
| 72129 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC
SPINE; WITH CONTRAST MATERIAL |
494.00 |
| 72130 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC
SPINE; W/O CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S)
AND FURTHER SECTIONS |
567.00 |
| 72131 |
COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE;
W/O CONTRAST MATERIAL |
431.00 |
| 72132 |
COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE;
WITH CONTRAST MATERIAL |
489.00 |
| 72133 |
COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE;
W/O CONTRAST MATERIAL,FOLLOWED BY CONTRAST MATERIAL(S) AND
FURTHER SECTIONS |
562.50 |
| 72141 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, CERVICAL; W/O CONTRAST MATERIAL
|
901.00 |
| 72146 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, THORACIC; W/O CONTRAST MATERIAL |
945.00 |
| 72147 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, THORACIC; WITH CONTRAST MATERIAL
|
1,024.00 |
| 72148 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, LUMBAR; W/O CONTRAST MATERIAL |
901.00 |
| 72149 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS LUMBAR; WITH CONTRAST MATERIAL |
976.50 |
| 72170 |
RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR
ONLY |
65.00 |
| 72190 |
RADIOLOGIC EXAMINATION, PELVIS; COMPLETE,
MINIMUM OF THREE VIEWS |
80.00 |
| 73000 |
RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE |
50.00 |
| 73010 |
RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE |
55.00 |
| 73020 |
RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW |
51.50 |
| 73030 |
RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE,
MINIMUM OF TWO VIEWS |
75.50 |
| 73060 |
RADIOLOGIC EXAMINATION, HUMERUS, MINIMUM
OF TWO VIEWS |
66.50 |
| 73070 |
RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR
AND LATERAL VIEWS |
66.50 |
| 73080 |
RADIOLOGIC EXAMINATION, ELBOW; COMPLETE,
MINIMUM OF THREE VIEWS |
68.50 |
| 73090 |
RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR
AND LATERAL VIEWS |
66.50 |
| 73100 |
RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR
AND LATERAL VIEWS |
66.50 |
| 73110 |
RADIOLOGIC EXAMINATION, WRIST; COMPLETE,
MINIMUM OF THREE VIEWS |
67.00 |
| 73120 |
RADIOLOGIC EXAMINATION, HAND; TWO VIEWS |
57.00 |
| 73130 |
RADIOLOGIC EXAMINATION, HAND; MINIMUM OF
THREE VIEWS |
76.00 |
| 73140 |
RADIOLOGIC EXAMINATION, FINGER OR FINGERS,
MINIMUM OF TWO VIEWS |
55.50 |
| 73500 |
RADIOLOGIC EXAMINATION, HIP; UNILATERAL,
ONE VIEW |
68.50 |
| 73510 |
RADIOLOGIC EXAMINATION, HIP; COMPLETE,
MINIMUM OF TWO VIEWS |
73.00 |
| 73550 |
RADIOLOGIC EXAMINATION, FEMUR; ANTEROPOSTERIOR
AND LATERAL VIEWS |
70.50 |
| 73560 |
RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR
AND LATERAL VIEWS |
63.50 |
| 73562 |
RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR
AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS |
85.00 |
| 73564 |
RADIOLOGIC EXAMINATION, KNEE; COMPLETE,
INCLUDING OBLIQUE, AND TUNNEL, AND/OR PATELLAR AND/OR STANDING
VIEW |
99.50 |
| 73590 |
RADIOLOGIC EXAMINATION; TIBIA AND FIBULA,
ANTEROPOSTERIOR AND LATERAL VIEWS |
74.50 |
| 73600 |
RADIOLOGIC EXAMINATION, ANKLE; ANTEROPOSTERIOR
AND LATERAL VIEWS |
61.50 |
| 73610 |
RADIOLOGIC EXAMINATION, ANKLE; COMPLETE,
MINIMUM OF THREE VIEWS |
62.50 |
| 73620 |
RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR
AND LATERAL VIEWS |
60.00 |
| 73630 |
RADIOLOGIC EXAMINATION, FOOT; COMPLETE,
MINIMUM OF THREE VIEWS |
52.00 |
| 73650 |
RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM
OF TWO VIEWS |
62.00 |
| 73660 |
RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM
OF TWO VIEWS |
63.00 |
| 73720 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
LOWER EXTREMITY, OTHER THAN JOINT |
901.00 |
| 74000 |
RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE
ANTEROPOSTERIOR VIEW |
72.00 |
| 74010 |
RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR
AND ADDITIONAL OBLIQUE AND CONE VIEWS |
80.00 |
| 74020 |
RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE,
INCLUDING DECUBITUS AND/OR ERECT VIEWS |
95.00 |
| 74022 |
RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE
ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS
VIEWS, UPRIGHT PA CHEST |
102.50 |
| 74150 |
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN;
W/O CONTRAST MATERIAL |
630.00 |
| 74160 |
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN;
WITH CONTRAST MATERIAL(S) |
651.50 |
| 74170 |
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN;
W/O CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND
FURTHER SECTIONS |
726.50 |
| 74220 |
RADIOLOGIC EXAMINATION; ESOPHAGUS |
100.00 |
| 74230 |
SWALLOWING FUNCTION, PHARYNX AND/OR ESOPHAGUS,
WITH CINERADIOGRAPHY AND/OR VIDEO |
100.00 |
| 74240 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, W/O KUB |
131.00 |
| 74241 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITH KUB
|
131.00 |
| 74245 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER; WITH SMALL BOWEL, INCLUDES MULTIPLE SERIAL
FILMS |
142.00 |
| 74246 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM,
EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT
DELAYED FILMS, W/O KUB |
142.00 |
| 74247 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM,
EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT
DELAYED FILMS, WITH KUB |
142.00 |
| 74250 |
RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES
MULTIPLE SERIAL FILMS |
101.00 |
| 74270 |
RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA |
129.00 |
| 74280 |
RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST
WITH SPECIFIC HIGH DENSITY BARIUM, WITH OR W/O GLUCAGON
|
147.00 |
| 74290 |
CHOLECYSTOGRAPHY, ORAL CONTRAST |
100.00 |
| 74400 |
UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH
OR W/O KUB, WITH OR W/O TOMOGRAPHY |
158.00 |
| 74405 |
UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH
OR W/O KUB, WITH OR W/O TOMOGRAPHY WITH SPECIAL HYPERTENSIVE
CONTRAST CONCENTRATION AND/OR CLEARANCE STUDIES
|
168.00 |
| 74415 |
UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR
BOLUS TECHNIQUE; WITH NEPHROTOMOGRAPHY |
210.00 |
| 74456 |
URETHROCYSTOGRAPHY, VOIDING; COMPLETE PROCEDURE
(74456 [COMPLETE PROCEDURE] HAS BEEN DELETED, SEE 51600,
74455) |
110.00 |
| 76090 |
MAMMOGRAPHY; UNILATERAL |
61.50 |
| 76091 |
MAMMOGRAPHY; BILATERAL |
75.00 |
| 76092 |
SCREENING MAMMOGRAPHY, BILATERAL (TWO VIEW
FILM STUDY OF EACH BREAST) |
60.00 |
| 76100 |
RADIOLOGIC EXAMINATION, SINGLE PLANE BODY
SECTION, (EG, TOMOGRAPHY), OTHER THAN WITH UROGRAPHY |
131.00 |
| 76536 |
ECHOGRAPHY, SOFT TISSUES OF HEAD AND NECK
(EG, THYROID, PARATHYROID, PAROTID), B-SCAN AND/OR REAL
TIME W/IMAGE DOCUMENTATION |
168.00 |
| 76645 |
ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL),
B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION |
65.00 |
| 76700 |
ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL
TIME W/IMAGE DOCUMENTATION; COMPLETE |
200.00 |
| 76705 |
ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL
TIME W/IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN,
QUADRANT, FOLLOW-UP) |
126.00 |
| 76770 |
ECHOGRAPHY, RETROPERITONEAL (EG, RENAL,
AORTA, NODES), B-SCAN AND/OR REALTIME WITH IMAGE DOCUMENTATION;
COMPLETE |
158.00 |
| 76805 |
ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR
REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL
AND MATERNAL EVALUATION) |
168.00 |
| 76815 |
ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR
REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (GESTATIONAL
AGE, HEARTBEAT, PLACENTAL LOCATION, FETAL POSITION, OR EMERGENCY
IN THE DELIVERY ROOM) |
105.00 |
| 76816 |
ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR
REAL TIME WITH IMAGE DOCUMENTATION; FOLLOW-UP OR REPEAT |
105.00 |
| 76855 |
ECHOGRAPHY, PELVIC AREA (DOPPLER) (76855
HAS BEEN DELETED. TO REPORT, SEE (93975, 93979)
|
142.00 |
| 76856 |
ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN
AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE |
158.00 |
| 80002 |
AUTOMATED MULTICHANNEL TEST; 1 OR 2 CLINICAL
CHEMISTRY TEST(S) |
31.00 |
| 80003 |
3 CLINICAL CHEMISTRY TESTS |
42.00 |
| 80004 |
4 CLINICAL CHEMISTRY TESTS |
52.00 |
| 80005 |
5 CLINICAL CHEMISTRY TESTS |
52.00 |
| 80006 |
6 CLINICAL CHEMISTRY TESTS |
68.00 |
| 80007 |
7 CLINICAL CHEMISTRY TESTS |
68.00 |
| 80008 |
8 CLINICAL CHEMISTRY TESTS |
68.00 |
| 80009 |
9 CLINICAL CHEMISTRY TESTS |
68.00 |
| 80010 |
10 CLINICAL CHEMISTRY TESTS |
68.00 |
| 80011 |
11 CLINICAL CHEMISTRY TESTS |
68.00 |
| 80012 |
12 CLINICAL CHEMISTRY TESTS |
73.00 |
| 80016 |
13-16 CLINICAL CHEMISTRY TESTS |
73.00 |
| 80018 |
17-18 CLINICAL CHEMISTRY TESTS |
78.00 |
| 80019 |
19 OR MORE CLINICAL CHEMISTRY TESTS |
75.00 |
| 80031 |
THERAPEUTIC QUANTITATIVE DRUG MONITORING
IN BODY FLUIDS AND/OR EXCRETA (80031HAS BEEN DELETED. TO
REPORT, SEE THERAPEUTIC DRUG ASSAYS) |
62.00 |
| 80058 |
HEPATIC FUNCTION PANEL |
81.00 |
| 80061 |
LIPID PANEL |
69.00 |
| 80063 |
CARDIAC INJURY PANEL (80063 HAS BEEN DELETED.
TO REPORT, SEE CODES FOR SPECIFIC TESTS) |
81.00 |
| 80064 |
CARDIAC INJURY PANEL; W/CREATINE PHOSPHOKINASE
AND/OR LACTIC DEHYDROGENASE ISOENZYME DETERMINATION (80064
HAS BEEN DELETED. TO REPORT SEE CODES FOR SPECIFIC TESTS)
|
81.00 |
| 80070 |
THYROID PANEL (80070 HAS BEE DELETED. TO
REPORT, SEE 80091) |
77.00 |
| 80073 |
RENAL PANEL (80073 HAS BEEN DELETED. TO
REPORT, SEE CODES 80002 - 80019) |
53.00 |
| 81000 |
URINALYSIS |
14.00 |
| 81002 |
URINALYSIS, W/O MICROSCOPY |
14.00 |
| 81015 |
URINALYSIS, MICROSCOPIC ONLY |
10.00 |
| 82150 |
AMYLASE |
31.00 |
| 82250 |
BILIRUBIN; TOTAL OR DIRECT |
25.00 |
| 82251 |
BILIRUBIN; TOTAL AND DIRECT |
35.00 |
| 82270 |
BLOOD, OCCULT; FECES SCREENING |
19.00 |
| 82310 |
CALCIUM, BLOOD; CHEMICAL |
21.00 |
| 82372 |
CARBAMAZEPINE, SERUM (82372 HAS BEEN DELETED.
TO REPORT, USE 80156) |
50.00 |
| 82374 |
CARBON DIOXIDE (BICARBONATE), COMBINING
POWER OR CONTENT |
22.00 |
| 82435 |
CHLORIDE; BLOOD (SPECIFY CHEMICAL OR ELECTROMETRIC) |
22.00 |
| 82465 |
CHOLESTEROL, SERUM, TOTAL |
20.00 |
| 82550 |
CREATINE PHOSPHOKINASE (CPK), TIMED KINETIC
ULTRAVIOLET METHOD |
13.00 |
| 82552 |
CREATINE PHOSPHOKINASE (CPK), ISOENZYMES |
52.00 |
| 82555 |
CREATINE PHOSPHOKINASE (CPK), COLORIMETRIC |
26.00 |
| 82565 |
CREATINE |
22.00 |
| 82660 |
DRUG SCREEN (AMPHETAMINES, BARBITURATES,
ALKALOIDS) (82660 HAS BEEN DELETED. (TO REPORT, SEE 80100,
80101) |
76.50 |
| 82803 |
GASES, pH, pCO2,
p02 SIMULTANEOUS |
73.00 |
| 82947 |
GLUCOSE; EXCEPT URINE |
19.50 |
| 82948 |
GLUCOSE; STICK TEST |
11.00 |
| 83615 |
LACTIC DEHYDROGENASE (LDH), KINETIC ULTRAVIOLET
METHOD |
22.00 |
| 83620 |
LACTIC DEHYDROGENASE (LDH), COLORIMETRIC
OR FLUOROMETRIC (83620 HAS BEEN (DELETED. TO REPORT, USE
83615) |
22.00 |
| 83705 |
LIPIDS, FRACTIONATED (83705 HAS BEEN DELETED.
TO REPORT CHOLESTEROL, SEE 82465, 83718-83721. FOR TRIGLYCERIDES,
SEE 84478) |
58.00 |
| 83718 |
LIPOPROTEIN HIGH DENSITY CHOLESTEROL BY
PRECIPITATION METHOD |
40.00 |
| 83725 |
LITHIUM, BLOOD, QUANTITATIVE (83725 HAS
BEEN DELETED. TO REPORT, USE 80178) |
27.00 |
| 84045 |
PHENYTOIN (84045 HAS BEEN DELETED. TO REPORT,
SEE 80185) |
50.00 |
| 84075 |
PHOSPHATASE, ALKALINE |
26.00 |
| 84132 |
POTASSIUM; SERUM |
23.00 |
| 84155 |
PROTEIN; TOTAL, EXCEPT REFRACTOMETRY |
16.00 |
| 84165 |
PROTEIN, TOTAL, SERUM; ELECTROPHORETIC
FRACTIONATION AND QUANTITATION |
31.00 |
| 84295 |
SODIUM; SERUM |
26.00 |
| 84420 |
THEOPHYLLINE, BLOOD OR SALIVA (84420 HAS
BEEN DELETED. TO REPORT, USE 80198) |
52.00 |
| 84435 |
THYROXINE, (T-4), CPB OR RESIN UPTAKE |
37.00 |
| 84436 |
THYROXINE, TRUE (TT-4), RIA |
37.00 |
| 84439 |
THYROXINE, FREE (FT-4), RIA (UNBOUND T-4
ONLY) |
37.00 |
| 84443 |
THYROID STIMULATING HORMONE |
56.00 |
| 84450 |
TRANSAMINASE, GLUTAMIC OXALOACETIC, (SGOT),
BLOOD; TIMED KINETIC ULTRAVIOLET METHOD |
22.00 |
| 84455 |
TRANSAMINASE, GLUTAMIC OXALOACETIC, BLOOD;
COLORIMETRIC OR FLUOROMETRIC (84455 HAS BEEN DELETED. TO
REPORT, USE 84450) |
22.00 |
| 84460 |
TRANSAMINASE, GLUTAMIC PYRUVIC (SGPT),
BLOOD; TIMED KINETIC ULTRAVIOLET METHOD |
18.00 |
| 84465 |
TRANSAMINASE, GLUTAMIC PYRUVIC, BLOOD;
COLORIMETRIC OR FLUOROMETRIC (84465 HAS (BEEN DELETED. TO
REPORT, USE 84460) |
18.00 |
| 84478 |
TRIGLYCERIDES, BLOOD |
24.00 |
| 84479 |
TRIDOTHYRONINE (T-3), RESIN UPTAKE |
26.00 |
| 84480 |
TRIDOTHYRONINE, TOTAL (TT-3) |
48.00 |
| 84520 |
UREA NITROGEN, (BUN); QUANTITATIVE |
19.00 |
| 84525 |
UREA NITROGEN, (BUN); SEMIQUANTITATIVE
(EG, REAGENT STRIP TEST) |
21.00 |
| 84550 |
URIC ACID; BLOOD, CHEMICAL |
22.00 |
| 84555 |
URIC ACID; UNICASE, ULTRAVIOLET METHOD |
22.00 |
| 84702 |
GONADOTROPIN, CHORIONIC; QUANTITATIVE |
34.00 |
| 84703 |
GONADOTROPIN, CHORIONIC; QUALITATIVE |
36.00 |
| 85002 |
BLEEDING TIME |
19.50 |
| 85007 |
BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT |
12.00 |
| 85009 |
BLOOD COUNT; DIFFERENTIAL WBC COUNT, BUFFY
COAT |
16.00 |
| 85012 |
BLOOD COUNT; EOSINOPHIL COUNT, DIRECT |
16.00 |
| 85014 |
BLOOD COUNT; HEMATOCRIT |
16.00 |
| 85018 |
BLOOD COUNT; HEMOGLOBIN, COLORIMETRIC |
16.00 |
| 85021 |
BLOOD COUNT; HEMOGRAM, AUTOMATED |
16.00 |
| 85022 |
BLOOD COUNT; HEMOGRAM, AUTOMATED, AND MANUAL
DIFFERENTIAL WBC COUNT |
25.00 |
| 85023 |
BLOOD COUNT; HEMOGRAM AND PLATELET COUNT,
AUTOMATED AND MANUAL DIFFERENTIAL WBC COUNT |
26.00 |
| 85024 |
BLOOD COUNT; HEMOGRAM AND PLATELET COUNT,
AUTOMATED, AND AUTOMATED PARTIALDIFFERENTIAL WBC COUNT
|
26.00 |
| 85025 |
BLOOD COUNT; HEMOGRAM AND PLATELET COUNT,
AUTOMATED AND AUTOMATED COMPLETE DIFFERENTIAL WBC
COUNT |
26.00 |
| 85027 |
BLOOD COUNT; HEMOGRAM AND PLATELET COUNT,
AUTOMATED |
26.00 |
| 85031 |
BLOOD COUNT; HEMOGRAM, MANUAL, COMPLETE
CBC |
25.00 |
| 85048 |
BLOOD COUNT; WHITE BLOOD CELL (WBC) |
16.00 |
| 85580 |
PLATELET; COUNT (REES-ECKER) (85580 HAS
BEEN DELETED. TO REPORT, USE 85590) |
18.00 |
| 85590 |
PLATELET, MANUAL COUNT |
18.00 |
| 85610 |
PROTHROMBIN TIME |
19.00 |
| 85650 |
SEDIMENTATION RATE (ESR); WINTROBE TYPE |
18.50 |
| 85651 |
SEDIMENTATION RATE (ESR); NON-AUTOMATED
|
19.00 |
| 85730 |
THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA
OR WHOLE BLOOD |
32.00 |
| 85732 |
THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTITION,
PLASMA |
23.00 |
| 86006 |
ANTIBODY, NON-RBC, QUALITATIVE; FIRST ANTIGEN,
SLIDE OR TUBE (86006 HAS BEEN (DELETED. TO REPORT, SEE 83519
AND 86336 AND CODE FOR SPECIFIC METHOD) |
27.00 |
| 86080 |
BLOOD TYPING; ABO ONLY (86080 HAS BEEN
DELETED. FOR BLOOD TYPING, SEE 86900-86910)
|
16.00 |
| 86082 |
BLOOD TYPING; ABO AND Rho(D) (86082 HAS
BEEN DELETED. TO REPORT, SEE 86900, 86901) |
21.00 |
| 86151 |
CARCINOEMBRYONIC ANTIGEN (CEA); RIA OR
EIA (86151 HAS BEEN DELETED. TO REPORT, SEE 82378) |
69.00 |
| 86287 |
HEPATITIS B SURFACE ANTIGEN, RIA OR EIA |
31.00 |
| 86300 |
HETEROPHILE ANTIBODIES; SCREENING, SLIDE
OR TUBE (86300 HAS BEEN DELETED. (TO REPORT, SEE 86308) |
23.00 |
| 86430 |
RHEUMATOID FACTOR; QUALITATIVE |
21.00 |
| 87040 |
CULTURE, BACTERIAL, DEFINITIVE; BLOOD |
47.00 |
| 87045 |
CULTURE, BACTERIAL, DEFINITIVE, STOOL |
47.00 |
| 87060 |
CULTURE, BACTERIAL, DEFINITIVE, THROAT
OR NOSE |
47.00 |
| 87070 |
CULTURE, BACTERIAL, DEFINITIVE, ANY OTHER
SOURCE |
43.50 |
| 87075 |
CULTURE, BACTERIAL, ANY SOURCE; ANAEROBIC |
47.00 |
| 87081 |
CULTURE, BACTERIAL, SCREENING ONLY, FOR
SINGLE ORGANISMS |
21.00 |
| 87082 |
CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS,
SCREENING ONLY, BY COMMERCIAL KIT; FOR SINGLE ORGANISMS
|
21.00 |
| 87086 |
CULTURE, BACTERIAL, URINE; QUANTITATIVE,
COLONY COUNT |
47.00 |
| 87177 |
OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION
AND IDENTIFICATION |
33.00 |
| 87205 |
SMEAR, PRIMARY SOURCE, WITH INTERPRETATION;
ROUTINE STAIN FOR BACTERIA, FUNGI, OR CELL TYPES |
18.00 |
| 87210 |
SMEAR, PRIMARY SOURCE, WITH INTERPRETATION;
WET MOUNT WITH SIMPLE STAIN FOR BACTERIA, FUNGI, OVA, AND/OR
PARASITES |
21.00 |
| 88150 |
CYTOPATHOLOGY, SMEARS, CERVICAL OR VAGINAL,
UP TO THREE SMEARS; SCREENING BYTECHNICIAN UNDER PHYSICIAN
SUPERVISION |
16.00 |
*CPT codes and descriptions only are copyright © 1993
American Medical Association.
Workers' compensation payments for the above procedures
shall be paid at the hospital's usual and customary or normal
billed charge amount less 5%.
| CPT-4 CODE* |
|
PROCEDURE DESCRIPTION |
| 1 |
92585 |
BRAINSTEM EVOKED RESPONSE RECORDING
(EVOKED RESPONSE [EEG] AUDIOMETRY) |
| 2 |
93017 |
CARDIOVASCULAR STRESS TESTING
WITH MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE |
| 3 |
93018 |
INTERPRETATION AND REPORT ONLY |
| 4 |
93041 |
RHYTHM ECG, ONE TO THREE LEADS;
TRACING ONLY W/O I & R |
| 5 |
93201 |
PHONOCARDIOGRAM WITH OR W/O
ECG LEAD; WITH SUPERVISION DURING RECORDING WITH I &
O |
| 6 |
93202 |
PHONOCARDIOGRAM WITH OR W/O
ECG; TRACING ONLY W/O I & R, ETC. |
| 7 |
93205 |
PHONOCARDIOGRAM WITH ECG LEAD,
WITH INDIRECT CAROTID ARTERY AND/OR JUGULAR VEIN |
| 8 |
93208 |
PHONOCARDIOGRAM WITH ECG LEAD,
WITH INDIRECT CAROTID ARTERY AND/OR JUGULAR VEIN |
| 9 |
93210 |
PHONOCARDIOGRAM, INTRACARDIAC |
| 10 |
93220 |
VECTORCARDIOGRAM (VGC) WITH
OR W/O ECG LEAD, WITH I & R |
| 11 |
93221 |
VECTORCARDIOGRAM (VGC) WITH
OR W/O ECG LEAD, TRACING ONLY W/O I & R |
| 12 |
93224 |
ELECTROCARDIOGRAPHIC MONITORING
FOR 24 HRS. BY CONTINUOUS ORIGINAL ECG WAVEFORM, ETC. |
| 13 |
93227 |
ELECTROCARDIOGRAPHIC MONITORING
FOR 24 HRS. BY CONTINUOUS ORIGINAL ECG WAVEFORM, ETC. |
| 14 |
93235 |
ELECTROCARDIOGRAPHIC MONITORING
FOR 24 HRS. BY CONTINUOUS COMPUTERIZED MONITORING, ETC. |
| 15 |
93278 |
SIGNAL-AVERAGED ELECTROCARDIOGRAPHY
(SAECG) WITH OR W/O ECG |
| 16 |
93307 |
ECHOCARDIOGRAPHY, REAL-TIME
WITH IMAGE DOCUMENTATION (2D) WITH OR W/O M-MODE |
| 17 |
93308 |
ECHOCARDIOGRAPHY, REAL-TIME
WITH IMAGE DOCUMENTATION (2D) WITH OR W/O M-MODE |
| 18 |
93320 |
DOPPLER ECHOCARDIOGRAPHY, PULSED
WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL |
| 19 |
93850 |
NON-INVASIVE STUDIES OF CEREBRAL
ARTERIES OTHER THAN CAROTID (93850 HAS BEEN DELETED; TO
REPORT, PLEASE SEE 93875 - 93882) |
| 20 |
93860 |
NON-INVASIVE STUDIES OF CAROTID
ARTERIES, NON-IMAGING (EG, PHONOANGIOGRAM)- (93860 HAS BEEN
DELETED; TO REPORT, PLEASE SEE 93875 - 93882) |
| 21 |
93870 |
NON-INVASIVE STUDIES OF CAROTID
ARTERIES, IMAGING (EG, FLOW IMAGING) - (93870 HAS BEEN DELETED;
TO REPORT, PLEASE SEE 93880 & 93882) |
| 22 |
93880 |
DUPLEX SCAN OF EXTRACRANIAL
ARTERIES; COMPLETE BILATERAL STUDY |
| 23 |
93882 |
DUPLEX SCAN OF EXTRACRANIAL
ARTERIES; FOLLOW-UP OR LIMITED STUDY |
| 24 |
93886 |
TRANSCRANIAL DOPPLER STUDY
OF THE INTERCRANIAL ARTERIES; COMPLETE |
| 25 |
93888 |
TRANSCRANIAL DOPPLER STUDY
OF THE INTERCRANIAL ARTERIES; FOLLOW-UP |
| 26 |
93890 |
NON-INVASIVE STUDIES OF UPPER
EXTREMITY ARTERIES (EG SEGMENTAL BLOOD) - (93890 HAS BEEN
DELETED; TO REPORT, PLEASE SEE 93920, 93931) |
| 27 |
93910 |
NON-INVASIVE STUDIES OF LOWER
EXTREMITY ARTERIES (EG SEGMENTAL BLOOD) - (93910 HAS BEEN
DELETED; TO REPORT, PLEASE SEE 93920, 93931) |
| 28 |
93920 |
NON-INVASIVE PHYSIOLOGIC STUDY
OF BILATERAL EXTREMITY ARTERIES, WITH |
| 29 |
93921 |
NON-INVASIVE PHYSIOLOGIC STUDY
OF BILATERAL EXTREMITY ARTERIES, WITH |
| 30 |
93925 |
DUPLEX SCAN OF LOWER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; COM |
| 31 |
93926 |
DUPLEX SCAN OF LOWER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; FOL |
| 32 |
93930 |
DUPLEX SCAN OF UPPER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; COM |
| 33 |
93931 |
DUPLEX SCAN OF UPPER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; FOL |
| 34 |
93950 |
NON-INVASIVE STUDIES OF EXTREMITY
VEINS (EG, DOPPLER STUDIES WITH EVALUATION) - (93950 HAS
BEEN DELETED; TO REPORT, PLEASE SEE 93965 - 93971) |
| 35 |
93960 |
QUANTITATIVE VENOUS FLOW STUDIES
(EG, CAPACITANCE AND OUTFLOW MEASURE) - (93960 HAS BEEN
DELETED; TO REPORT, PLEASE SEE 93965 - 93971) |
| 36 |
93965 |
NON-INVASIVE PHYSIOLOGIC STUDIES
OF EXTREMITY VEINS, BILATERAL, (EG, |
| 37 |
93970 |
DUPLEX SCAN OF EXTREMITY VEINS
INCLUDING RESPONSES TO COMPRESSION AND |
| 38 |
93971 |
DUPLEX SCAN OF EXTREMITY VEINS
INCLUDING RESPONSES TO COMPRESSION AND |
| 39 |
93975 |
DUPLEX SCAN OF ARTERIAL INFLOW
AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC |
| 40 |
93976 |
DUPLEX SCAN OF ARTERIAL INFLOW
AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC |
| 41 |
93978 |
DUPLEX SCAN OF AORTA, INFERIOR
VENA CAVA ILIAC VASCULATURE, OR BYPASS |
| 42 |
93979 |
DUPLEX SCAN OF AORTA, INFERIOR
VENA CAVA ILIAC VASCULATURE, OR BYPASS |
| 43 |
95863 |
ELECTROMYOGRAPHY; TWO EXTREMITIES
AND RELATED PARASPINAL AREAS |
| 44 |
95864 |
ELECTROMYOGRAPHY; FOUR EXTREMITIES
AND RELATED PARASPINAL AREAS |
| 45 |
95867 |
ELECTROMYOGRAPHY; CARNIAL NERVE-SUPPLIED
MUSCLES; UNILATERAL |
| 46 |
95868 |
ELECTROMYOGRAPHY; CARNIAL NERVE-SUPPLIED
MUSCLES; BILATERAL |
| 47 |
95925 |
SOMOTOSENSORY TESTING (E.G.
CEREBRAL EVOKED POTENTIAL) 1 OR MORE NERVE |
| 48 |
95950 |
MONITORING FOR IDENTIFICATION
AND LATERALIZATION OF CEREBRAL SEIZURE |
| 49 |
97010 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; HOT OR COLD PACKS |
| 50 |
97012 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; TRACTION, MECHANICAL |
| 51 |
97014 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; ELECTRICAL STIMULATION |
| 52 |
97016 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; VASOPNEUMATIC DEVICES |
| 53 |
97018 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; PARAFFIN BATH |
| 54 |
97020 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; MICROWAVE |
| 55 |
97022 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; WHIRLPOOL |
| 56 |
97024 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; DIATHERMY |
| 57 |
97026 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; INFRARED |
| 58 |
97028 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; ULTRAVIOLET |
| 59 |
97039 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; UNLISTED MODALITY (SPECIFY) |
| 60 |
97110 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 61 |
97112 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 62 |
97114 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 63 |
97116 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 64 |
97118 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 65 |
97120 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 66 |
97122 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 67 |
97124 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 68 |
97126 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 69 |
97128 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 70 |
97138 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 71 |
97145 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, EA. ADDL. 15 MIN. |
| 72 |
97220 |
HUBBARD TANK, INITIAL 30 MINUTES,
EACH VISIT |
| 73 |
97221 |
HUBBARD TANK, EACH ADDITIONAL
15 MINUTES, UP TO ONE HOUR |
| 74 |
97240 |
POOL THERAPY OR HUBBARD TANK
WITH THERAPEUTIC EXERCISES, INITIAL 30 MIN. |
| 75 |
97241 |
POOL THERAPY OR HUBBARD TANK
WITH THERAPEUTIC EXERCISES, EA. ADD. 15 MIN. |
| 76 |
97260 |
MANIPULATION (CERVICAL, THORACIC,
LUMBOSACRAL, SACROILIAC, HAND, WRIST |
| 77 |
97261 |
MANIPULATION (CERVICAL, THORACIC,
LUMBOSACRAL, SACROILIAC, HAND, WRIST |
| 78 |
97500 |
ORTHOTICS TRAINING (DYNAMIC
BRACING, SPLINTING) UPPER EXTREMITIES |
| 79 |
97501 |
ORTHOTICS TRAINING (DYNAMIC
BRACING, SPLINTING) UPPER EXTREMITIES, EA. |
| 80 |
97520 |
PROSTHETIC TRAINING; INITIAL
30 MINUTES, EACH VISIT |
| 81 |
97521 |
PROSTHETIC TRAINING; EACH ADDITIONAL
15 MINUTES |
| 82 |
97530 |
KINETIC ACTIVITIES TO INCREASE
COORDINATION, STRENGTH AND/OR RANGE OF |
| 83 |
97531 |
KINETIC ACTIVITIES TO INCREASE
COORDINATION, STRENGTH AND/OR RANGE F |
| 84 |
97540 |
TRAINING IN ACTIVITIES OF DAILY
LIVING (SELF CARE SKILLS AND/OR DAILY |
| 85 |
97541 |
TRAINING IN ACTIVITIES OF DAILY
LIVING (SELF CARE SKILLS AND/OR LIFE |
| 86 |
97720 |
EXTREMITY TESTING FOR STRENGTH,
DEXTERITY, OR STAMINA; INITIAL 30 MIN. |
| 87 |
97721 |
EXTREMITY TESTING FOR STRENGTH,
DEXTERITY, OR STAMINA; EA. ADD. 15 MIN. |
| 88 |
97752 |
MUSCLE TESTING WITH TORQUE
CURVES DURING ISOMETRIC AND ISOKINETIC |
| 89 |
97798 |
OCCUPATIONAL THERAPY (97798
HAS BEEN DELETED; TO REPORT, PLEASE SEE 97799) |
| 90 |
97799 |
UNLISTED PHYSICAL MEDICINE
SERVICE OR PROCEDURE |
NOTE: SEE "PHYSICIANS' CURRENT PROCEDURAL
TERMINOLOGY" (CPT) CODE BOOK FOR COMPLETE PROCEDURE DESCRIPTION
ALL OTHER PROCEDURES NOT LISTED IN
THIS SCHEDULE SHALL BE PAID AT THE
HOSPITAL'S USUAL AND CUSTOMARY OR NORMAL BILLED CHARGE AMOUNTS.
*CPT codes and descriptions only are copyright
© 1993 American Medical Association.
Workers' compensation payments for the above
procedures shall be paid at the hospital's usual and customary
or normal billed charge amount less 5%.
State of Arkansas
Workers' Compensation Commission
324 Spring Street
P.O. Box 950
Little Rock, Arkansas 72203-0950
Telephone 1-501-682-3930 / 1-800-622-4472
Legal Advisor Direct 1-800-250-2511
Arkansas Relay System TDD 1-800-285-1131
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