| Psychiatric diagnostic evaluation | CPT 90791 | $151.50 |
| Psychiatric eval with medical services | CPT 90792 | $151.50 |
| Psychotherapy 30 minutes | CPT 90832 | $155.00 |
| Psychotherapy 45 minutes | CPT 90834 | $171.00 |
| Psychotherapy 60 minutes | CPT 90837 | $206.00 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $151.50 |
| ED visit level 1 | CPT 99281 | $318.00 |
| ED visit level 2 | CPT 99282 | $155.50 |
| ED visit level 3 | CPT 99283 | $271.00 |
| ED visit level 4 | CPT 99284 | $420.50 |
| ED visit level 5 | CPT 99285 | $610.00 |
| Critical care, first hour | CPT 99291 | $843.00 |
| CT head without contrast | CPT 70450 | $104.50 |
| CT head with contrast | CPT 70460 | $174.50 |
| CT head with and without contrast | CPT 70470 | $174.50 |
| CT neck with contrast | CPT 70491 | $174.50 |
| MRI brain without contrast | CPT 70551 | $232.50 |
| MRI brain with contrast | CPT 70552 | $365.00 |
| MRI brain with and without contrast | CPT 70553 | $365.00 |
| Chest X-ray single view | CPT 71045 | $86.00 |
| Chest X-ray 2 views | CPT 71046 | $86.00 |
| Chest X-ray 3 views | CPT 71047 | $86.00 |
| CT chest without contrast | CPT 71250 | $104.50 |
| CT chest with contrast | CPT 71260 | $174.50 |
| CT chest with and without contrast | CPT 71270 | $174.50 |
| MRI chest without contrast | CPT 71550 | $232.50 |
| Lumbosacral spine X-ray | CPT 72100 | $104.50 |
| CT cervical spine without contrast | CPT 72125 | $104.50 |
| CT thoracic spine without contrast | CPT 72128 | $104.50 |
| CT lumbar spine without contrast | CPT 72131 | $104.50 |
| MRI cervical spine without contrast | CPT 72141 | $232.50 |
| MRI thoracic spine without contrast | CPT 72146 | $232.50 |
| MRI lumbar spine without contrast | CPT 72148 | $232.50 |
| MRI lumbar spine with and without contrast | CPT 72149 | $365.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $365.00 |
| MRI lumbar spine with contrast | CPT 72158 | $365.00 |
| CT pelvis without contrast | CPT 72192 | $104.50 |
| Shoulder X-ray | CPT 73030 | $86.00 |
| Humerus X-ray | CPT 73060 | $86.00 |
| Hand X-ray 3 views | CPT 73130 | $86.00 |
| MRI upper extremity joint without contrast | CPT 73221 | $232.50 |
| Knee X-ray 1-2 views | CPT 73560 | $86.00 |
| Ankle X-ray 3 views | CPT 73610 | $86.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $232.50 |
| CT abdomen without contrast | CPT 74150 | $104.50 |
| CT abdomen with contrast | CPT 74160 | $174.50 |
| CT abdomen with and without contrast | CPT 74170 | $174.50 |
| CT abdomen and pelvis without contrast | CPT 74176 | $232.50 |
| CT abdomen and pelvis with contrast | CPT 74177 | $365.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $365.00 |
| MRI abdomen without contrast | CPT 74181 | $232.50 |
| MRI abdomen with and without contrast | CPT 74183 | $365.00 |
| Abdominal ultrasound complete | CPT 76700 | $104.50 |
| Abdominal ultrasound limited | CPT 76705 | $104.50 |
| Retroperitoneal ultrasound complete | CPT 76770 | $104.50 |
| Obstetric ultrasound first trimester | CPT 76801 | $104.50 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $232.50 |
| Transvaginal ultrasound | CPT 76830 | $104.50 |
| Pelvic ultrasound complete | CPT 76856 | $104.50 |
| Scrotal ultrasound | CPT 76870 | $104.50 |
| EKG tracing only | CPT 93005 | $58.50 |
| Transthoracic echocardiogram | CPT 93307 | $232.50 |
| Stress echocardiogram | CPT 93350 | $524.00 |
| Initial hospital care, high complexity | CPT 99223 | $460.00 |
| Hospital discharge, <30 min | CPT 99238 | $460.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $115.50 |
| Electrolyte panel | CPT 80051 | $249.00 |
| Comprehensive metabolic panel | CPT 80053 | $190.50 |
| Lipid panel | CPT 80061 | $84.50 |
| Renal function panel | CPT 80069 | $387.00 |
| Hepatic function panel | CPT 80076 | $153.50 |
| Urinalysis automated | CPT 81003 | $27.00 |
| Glucose quantitative | CPT 82947 | $75.00 |
| Hemoglobin A1c | CPT 83036 | $128.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $60.00 |
| Complete blood count with automated differential | CPT 85025 | $72.00 |
| Urine culture bacterial | CPT 87086 | $158.00 |
| Urine culture identification | CPT 87088 | $117.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $258.00 |
| Fetal non-stress test | CPT 59025 | $185.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $262.00 |
| Office visit, new patient, 45-59 min | CPT 99204 | $424.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $575.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $861.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $861.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $847.00 |
| Colonoscopy diagnostic | CPT 45378 | $868.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,121.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,121.00 |
| Total hip replacement | CPT 27130 | $12,198 |
| Total knee replacement | CPT 27447 | $12,198 |
| Shoulder arthroscopy with decompression | CPT 29826 | $18,342 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,075.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,481.50 |
| Cataract surgery with lens implant | CPT 66984 | $2,214.00 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $15,163 |
