| ED visit level 1 | CPT 99281 | $75.00 |
| ED visit level 2 | CPT 99282 | $110.00 |
| ED visit level 3 | CPT 99283 | $225.00 |
| ED visit level 4 | CPT 99284 | $302.00 |
| ED visit level 5 | CPT 99285 | $437.00 |
| Critical care, first hour | CPT 99291 | $711.00 |
| CT head without contrast | CPT 70450 | $320.50 |
| CT head with contrast | CPT 70460 | $549.00 |
| CT head with and without contrast | CPT 70470 | $567.00 |
| CT neck with contrast | CPT 70491 | $591.00 |
| MRI brain without contrast | CPT 70551 | $738.50 |
| MRI brain with contrast | CPT 70552 | $971.50 |
| MRI brain with and without contrast | CPT 70553 | $1,356.00 |
| Chest X-ray single view | CPT 71045 | $87.50 |
| Chest X-ray 2 views | CPT 71046 | $152.00 |
| Chest X-ray 3 views | CPT 71047 | $179.50 |
| CT chest without contrast | CPT 71250 | $406.50 |
| CT chest with contrast | CPT 71260 | $591.00 |
| CT chest with and without contrast | CPT 71270 | $618.50 |
| MRI chest without contrast | CPT 71550 | $850.50 |
| MRI chest with contrast | CPT 71551 | $1,128.50 |
| MRI chest with and without contrast | CPT 71552 | $1,369.00 |
| Lumbosacral spine X-ray | CPT 72100 | $121.00 |
| CT cervical spine without contrast | CPT 72125 | $435.50 |
| CT thoracic spine without contrast | CPT 72128 | $410.50 |
| CT lumbar spine without contrast | CPT 72131 | $410.50 |
| MRI cervical spine without contrast | CPT 72141 | $866.50 |
| MRI thoracic spine without contrast | CPT 72146 | $807.00 |
| MRI lumbar spine without contrast | CPT 72148 | $816.50 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,074.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,369.50 |
| MRI lumbar spine with contrast | CPT 72158 | $1,433.00 |
| CT pelvis without contrast | CPT 72192 | $351.00 |
| CT pelvis with contrast | CPT 72193 | $576.00 |
| Shoulder X-ray | CPT 73030 | $91.00 |
| Humerus X-ray | CPT 73060 | $99.50 |
| Hand X-ray 3 views | CPT 73130 | $87.50 |
| MRI upper extremity joint without contrast | CPT 73221 | $816.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,263.50 |
| Knee X-ray 1-2 views | CPT 73560 | $265.00 |
| Ankle X-ray 3 views | CPT 73610 | $99.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $816.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,263.50 |
| CT abdomen without contrast | CPT 74150 | $107.00 |
| CT abdomen with contrast | CPT 74160 | $667.00 |
| CT abdomen with and without contrast | CPT 74170 | $693.50 |
| CT abdomen and pelvis without contrast | CPT 74176 | $769.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,251.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,331.00 |
| MRI abdomen without contrast | CPT 74181 | $850.50 |
| MRI abdomen with and without contrast | CPT 74183 | $1,276.00 |
| Abdominal ultrasound complete | CPT 76700 | $181.00 |
| Abdominal ultrasound limited | CPT 76705 | $119.50 |
| Retroperitoneal ultrasound complete | CPT 76770 | $142.00 |
| Obstetric ultrasound first trimester | CPT 76801 | $136.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $136.00 |
| Transvaginal ultrasound | CPT 76830 | $157.50 |
| Pelvic ultrasound complete | CPT 76856 | $141.00 |
| Scrotal ultrasound | CPT 76870 | $176.50 |
| Diagnostic mammography unilateral | CPT 77065 | $297.00 |
| Diagnostic mammography bilateral | CPT 77066 | $297.00 |
| Screening mammography bilateral | CPT 77067 | $103.50 |
| EKG tracing only | CPT 93005 | $70.00 |
| EKG interpretation only | CPT 93010 | $34.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $63.00 |
| Initial hospital care, low complexity | CPT 99221 | $144.00 |
| Initial hospital care, moderate complexity | CPT 99222 | $260.00 |
| Initial hospital care, high complexity | CPT 99223 | $344.00 |
| Hospital discharge, <30 min | CPT 99238 | $188.00 |
| Hospital discharge, >30 min | CPT 99239 | $177.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $38.00 |
| General health panel | CPT 80050 | $308.00 |
| Electrolyte panel | CPT 80051 | $70.00 |
| Comprehensive metabolic panel | CPT 80053 | $104.00 |
| Lipid panel | CPT 80061 | $70.00 |
| Renal function panel | CPT 80069 | $99.00 |
| Hepatic function panel | CPT 80076 | $88.00 |
| Urinalysis non-automated | CPT 81002 | $17.00 |
| Urinalysis automated | CPT 81003 | $55.00 |
| Glucose quantitative | CPT 82947 | $38.00 |
| Hemoglobin A1c | CPT 83036 | $80.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $60.50 |
| Complete blood count with automated differential | CPT 85025 | $77.00 |
| Complete blood count without differential | CPT 85027 | $24.00 |
| Urine culture bacterial | CPT 87086 | $60.00 |
| Urine culture identification | CPT 87088 | $10.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $46.00 |
| Fetal non-stress test | CPT 59025 | $171.50 |
| Office visit, new patient, 15-29 min | CPT 99202 | $135.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $202.00 |
| Office visit, new patient, 45-59 min | CPT 99204 | $323.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $359.00 |
| Office visit, established patient, 5 min | CPT 99211 | $71.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $95.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $135.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $134.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $206.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,811.50 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,858.50 |
| Colonoscopy diagnostic | CPT 45378 | $1,610.50 |
| Colonoscopy with biopsy | CPT 45380 | $1,972.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,924.50 |
| Knee revision arthroplasty all components | CPT 27487 | $2,767.00 |
| Shoulder arthroscopy with decompression | CPT 29826 | $26,961 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $4,419.00 |
| Major joint replacement w/o MCC | MS-DRG 470 | $54,864 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,667.00 |
| Cataract surgery with lens implant | CPT 66984 | $2,160.00 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $19,725 |
| PCI single major coronary artery | CPT 92920 | $5,376.50 |
| PCI with drug-eluting stent | CPT 92928 | $10,349 |
| PCI bypass graft | CPT 92937 | $11,107 |
| Left heart catheterization | CPT 93452 | $3,141.00 |
| Coronary angiography with cath | CPT 93455 | $3,237.50 |
| Coronary angiography with bypass cath | CPT 93458 | $9,438.00 |
