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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%.

AWCC

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P.O. Box 950
Little Rock, Arkansas 72203-0950
Telephone 1-501-682-3930 / 1-800-622-4472
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