| Psychiatric diagnostic evaluation | CPT 90791 | $340.80 |
| Psychotherapy 30 minutes | CPT 90832 | $263.00 |
| Psychotherapy 45 minutes | CPT 90834 | $206.00 |
| Psychotherapy 60 minutes | CPT 90837 | $302.00 |
| ED visit level 1 | CPT 99281 | $450.98 |
| ED visit level 2 | CPT 99282 | $525.18 |
| ED visit level 3 | CPT 99283 | $784.55 |
| ED visit level 4 | CPT 99284 | $1,195.59 |
| ED visit level 5 | CPT 99285 | $1,994.79 |
| Critical care, first hour | CPT 99291 | $1,939.14 |
| CT head without contrast | CPT 70450 | $2,196.00 |
| CT head with contrast | CPT 70460 | $1,656.00 |
| CT head with and without contrast | CPT 70470 | $1,940.50 |
| CT neck with contrast | CPT 70491 | $2,477.00 |
| MRI brain without contrast | CPT 70551 | $2,573.76 |
| MRI brain with contrast | CPT 70552 | $2,794.56 |
| MRI brain with and without contrast | CPT 70553 | $3,633.60 |
| Chest X-ray single view | CPT 71045 | $305.50 |
| Chest X-ray 2 views | CPT 71046 | $343.20 |
| Chest X-ray 3 views | CPT 71047 | $267.84 |
| CT chest without contrast | CPT 71250 | $2,216.00 |
| CT chest with contrast | CPT 71260 | $2,604.00 |
| CT chest with and without contrast | CPT 71270 | $3,031.00 |
| MRI chest without contrast | CPT 71550 | $2,191.68 |
| MRI chest with contrast | CPT 71551 | $2,828.16 |
| MRI chest with and without contrast | CPT 71552 | $3,315.84 |
| Lumbosacral spine X-ray | CPT 72100 | $492.70 |
| CT cervical spine without contrast | CPT 72125 | $2,469.00 |
| CT thoracic spine without contrast | CPT 72128 | $1,830.72 |
| CT lumbar spine without contrast | CPT 72131 | $1,877.76 |
| MRI cervical spine without contrast | CPT 72141 | $3,211.00 |
| MRI thoracic spine without contrast | CPT 72146 | $2,587.20 |
| MRI lumbar spine without contrast | CPT 72148 | $2,611.20 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,825.28 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,985.50 |
| MRI lumbar spine with contrast | CPT 72158 | $3,623.04 |
| CT pelvis without contrast | CPT 72192 | $1,718.40 |
| CT pelvis with contrast | CPT 72193 | $1,936.32 |
| Shoulder X-ray | CPT 73030 | $400.00 |
| Humerus X-ray | CPT 73060 | $301.00 |
| Hand X-ray 3 views | CPT 73130 | $423.80 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,836.60 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,312.96 |
| Knee X-ray 1-2 views | CPT 73560 | $285.00 |
| Ankle X-ray 3 views | CPT 73610 | $320.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,091.77 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,258.24 |
| CT abdomen without contrast | CPT 74150 | $1,688.64 |
| CT abdomen with contrast | CPT 74160 | $2,065.92 |
| CT abdomen with and without contrast | CPT 74170 | $2,390.40 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,997.12 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,516.48 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,932.16 |
| MRI abdomen without contrast | CPT 74181 | $2,541.12 |
| MRI abdomen with and without contrast | CPT 74183 | $3,607.68 |
| Abdominal ultrasound complete | CPT 76700 | $1,105.00 |
| Abdominal ultrasound limited | CPT 76705 | $881.40 |
| Retroperitoneal ultrasound complete | CPT 76770 | $707.52 |
| Obstetric ultrasound first trimester | CPT 76801 | $640.32 |
| Obstetric ultrasound after first trimester | CPT 76805 | $741.12 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $821.76 |
| Transvaginal ultrasound | CPT 76830 | $317.00 |
| Pelvic ultrasound complete | CPT 76856 | $910.00 |
| Scrotal ultrasound | CPT 76870 | $869.70 |
| Diagnostic mammography unilateral | CPT 77065 | $419.90 |
| Diagnostic mammography bilateral | CPT 77066 | $474.50 |
| Screening mammography bilateral | CPT 77067 | $293.00 |
| EKG complete | CPT 93000 | $70.60 |
| EKG tracing only | CPT 93005 | $440.00 |
| EKG interpretation only | CPT 93010 | $32.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,094.00 |
| Transthoracic echocardiogram | CPT 93307 | $1,372.95 |
| Stress echocardiogram | CPT 93350 | $683.90 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $5,614.57 |
| COPD w MCC | MS-DRG 190 | $32,672 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | — |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | — |
| Cardiac arrhythmia w MCC | MS-DRG 308 | — |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,641.18 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $65,844 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $25,459 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,113.66 |
| Initial hospital care, low complexity | CPT 99221 | $177.60 |
| Initial hospital care, moderate complexity | CPT 99222 | $214.60 |
| Initial hospital care, high complexity | CPT 99223 | $307.80 |
| Hospital discharge, <30 min | CPT 99238 | $134.40 |
| Hospital discharge, >30 min | CPT 99239 | $192.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $138.00 |
| General health panel | CPT 80050 | — |
| Electrolyte panel | CPT 80051 | $85.00 |
| Comprehensive metabolic panel | CPT 80053 | $178.56 |
| Lipid panel | CPT 80061 | $137.00 |
| Renal function panel | CPT 80069 | $158.00 |
| Hepatic function panel | CPT 80076 | $145.00 |
| Urinalysis non-automated | CPT 81002 | $10.00 |
| Urinalysis automated | CPT 81003 | $44.16 |
| Glucose quantitative | CPT 82947 | $46.08 |
| Hemoglobin A1c | CPT 83036 | $95.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $139.94 |
| Complete blood count with automated differential | CPT 85025 | $97.00 |
| Complete blood count without differential | CPT 85027 | $86.00 |
| Urine culture identification | CPT 87088 | $74.88 |
| Tissue exam by pathologist level IV | CPT 88305 | $253.44 |
| Fetal non-stress test | CPT 59025 | $898.00 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $4,220.00 |
| Vaginal delivery only | CPT 59409 | $2,961.36 |
| Vaginal delivery with postpartum | CPT 59410 | $2,090.00 |
| Routine obstetric care with C-section | CPT 59510 | $4,674.00 |
| C-section delivery only | CPT 59514 | $1,838.00 |
| C-section with postpartum | CPT 59515 | — |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | — |
| Office visit, new patient, 15-29 min | CPT 99202 | $152.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $198.92 |
| Office visit, new patient, 45-59 min | CPT 99204 | $302.52 |
| Office visit, new patient, 60-74 min | CPT 99205 | $380.44 |
| Office visit, established patient, 5 min | CPT 99211 | $150.72 |
| Office visit, established patient, 10-19 min | CPT 99212 | $176.64 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $96.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $223.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $323.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,522.80 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,744.85 |
| Sigmoidoscopy diagnostic | CPT 45330 | $432.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $846.45 |
| Colonoscopy diagnostic | CPT 45378 | $2,020.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,749.60 |
| Colonoscopy with polyp removal | CPT 45385 | $393.60 |
| Total shoulder arthroplasty | CPT 23472 | $1,400.00 |
| Total hip replacement | CPT 27130 | $3,160.00 |
| Total knee replacement | CPT 27447 | $4,423.49 |
| Knee revision arthroplasty all components | CPT 27487 | — |
| Shoulder arthroscopy with decompression | CPT 29826 | $758.26 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $3,865.75 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,595.00 |
| ACL reconstruction | CPT 29888 | $2,745.68 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $120,439 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $37,027 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $71,312 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $31,900 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | — |
| Open appendectomy | CPT 44950 | — |
| Laparoscopic appendectomy | CPT 44970 | $1,303.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,232.34 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,973.29 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | — |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | — |
| Lap inguinal hernia repair | CPT 49650 | $1,679.46 |
| Vaginal hysterectomy | CPT 58260 | $3,909.00 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $2,346.88 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $3,583.25 |
| Lap salpingo-oophorectomy | CPT 58661 | $1,306.00 |
| PCI single major coronary artery | CPT 92920 | — |
| PCI with drug-eluting stent | CPT 92928 | $7,021.00 |
| Coronary angiography with bypass cath | CPT 93458 | $7,367.00 |
