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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-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.
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 codes and descriptions only are copyright © 1993 American Medical Association.
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