| Psychiatric diagnostic evaluation | CPT 90791 | $308.70 |
| Psychiatric eval with medical services | CPT 90792 | $227.43 |
| ED visit level 1 | CPT 99281 | $104.25 |
| ED visit level 2 | CPT 99282 | $152.79 |
| ED visit level 3 | CPT 99283 | $85.00 |
| ED visit level 4 | CPT 99284 | $86.25 |
| ED visit level 5 | CPT 99285 | $93.75 |
| Critical care, first hour | CPT 99291 | $3,053.49 |
| CT head without contrast | CPT 70450 | $2,265.05 |
| CT head with contrast | CPT 70460 | $2,674.49 |
| CT head with and without contrast | CPT 70470 | $3,438.91 |
| CT neck with contrast | CPT 70491 | $2,975.65 |
| MRI brain without contrast | CPT 70551 | $3,558.09 |
| MRI brain with contrast | CPT 70552 | $3,927.80 |
| MRI brain with and without contrast | CPT 70553 | $4,929.29 |
| Chest X-ray single view | CPT 71045 | $500.35 |
| Chest X-ray 2 views | CPT 71046 | $627.39 |
| Chest X-ray 3 views | CPT 71047 | $837.83 |
| CT chest without contrast | CPT 71250 | $2,390.00 |
| CT chest with contrast | CPT 71260 | $2,905.16 |
| CT chest with and without contrast | CPT 71270 | $3,126.86 |
| MRI chest without contrast | CPT 71550 | $2,686.03 |
| MRI chest with contrast | CPT 71551 | $3,403.03 |
| MRI chest with and without contrast | CPT 71552 | $4,002.13 |
| Lumbosacral spine X-ray | CPT 72100 | $606.55 |
| CT cervical spine without contrast | CPT 72125 | $2,900.04 |
| CT thoracic spine without contrast | CPT 72128 | $2,573.90 |
| CT lumbar spine without contrast | CPT 72131 | $2,822.51 |
| MRI cervical spine without contrast | CPT 72141 | $3,818.23 |
| MRI thoracic spine without contrast | CPT 72146 | $3,486.96 |
| MRI lumbar spine without contrast | CPT 72148 | $3,512.59 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,819.51 |
| MRI cervical spine with and without contrast | CPT 72156 | $4,707.59 |
| MRI lumbar spine with contrast | CPT 72158 | $4,308.41 |
| CT pelvis without contrast | CPT 72192 | $1,974.15 |
| CT pelvis with contrast | CPT 72193 | $2,661.68 |
| Shoulder X-ray | CPT 73030 | $579.84 |
| Humerus X-ray | CPT 73060 | $576.58 |
| Hand X-ray 3 views | CPT 73130 | $509.47 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,287.69 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,957.92 |
| Knee X-ray 1-2 views | CPT 73560 | $517.94 |
| Ankle X-ray 3 views | CPT 73610 | $504.26 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,510.67 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,054.03 |
| CT abdomen without contrast | CPT 74150 | $2,357.96 |
| CT abdomen with contrast | CPT 74160 | $2,930.15 |
| CT abdomen with and without contrast | CPT 74170 | $3,349.20 |
| CT abdomen and pelvis without contrast | CPT 74176 | $4,395.55 |
| CT abdomen and pelvis with contrast | CPT 74177 | $5,537.36 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $6,504.26 |
| MRI abdomen without contrast | CPT 74181 | $3,387.01 |
| MRI abdomen with and without contrast | CPT 74183 | $4,014.30 |
| Abdominal ultrasound complete | CPT 76700 | $1,649.60 |
| Abdominal ultrasound limited | CPT 76705 | $1,493.24 |
| Retroperitoneal ultrasound complete | CPT 76770 | $1,372.06 |
| Obstetric ultrasound first trimester | CPT 76801 | $875.62 |
| Obstetric ultrasound after first trimester | CPT 76805 | $1,122.53 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,266.52 |
| Transvaginal ultrasound | CPT 76830 | $1,004.61 |
| Pelvic ultrasound complete | CPT 76856 | $1,405.29 |
| Scrotal ultrasound | CPT 76870 | $1,281.50 |
| Diagnostic mammography unilateral | CPT 77065 | $432.60 |
| Diagnostic mammography bilateral | CPT 77066 | $478.20 |
| Screening mammography bilateral | CPT 77067 | $487.32 |
| EKG tracing only | CPT 93005 | $194.67 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,655.45 |
| Transthoracic echocardiogram | CPT 93307 | $1,797.39 |
| Stress echocardiogram | CPT 93350 | $2,533.23 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $76.70 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $87.50 |
| COPD w MCC | MS-DRG 190 | $87.50 |
| COPD w CC | MS-DRG 191 | $87.50 |
| COPD w/o CC/MCC | MS-DRG 192 | $87.50 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $87.50 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $87.50 |
| AMI discharged alive w CC | MS-DRG 281 | $76.70 |
| Heart failure & shock w MCC | MS-DRG 291 | $87.50 |
| Heart failure & shock w CC | MS-DRG 292 | $76.70 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $87.50 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $87.50 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $76.70 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $87.50 |
| GI hemorrhage w CC | MS-DRG 378 | $76.70 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $87.50 |
| Kidney/UTI w MCC | MS-DRG 689 | $87.50 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $87.50 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $87.50 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $87.50 |
| Initial hospital care, high complexity | CPT 99223 | $130.30 |
| Hospital discharge, <30 min | CPT 99238 | $81.44 |
| Hospital discharge, >30 min | CPT 99239 | $81.44 |
| Basic metabolic panel (BMP) | CPT 80048 | $201.20 |
| Electrolyte panel | CPT 80051 | $68.56 |
| Comprehensive metabolic panel | CPT 80053 | $280.65 |
| Lipid panel | CPT 80061 | $168.52 |
| Renal function panel | CPT 80069 | $125.59 |
| Hepatic function panel | CPT 80076 | $127.51 |
| Urinalysis non-automated | CPT 81002 | $19.87 |
| Urinalysis automated | CPT 81003 | $55.11 |
| Glucose quantitative | CPT 82947 | $39.09 |
| Hemoglobin A1c | CPT 83036 | $107.01 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $148.66 |
| Complete blood count with automated differential | CPT 85025 | $71.77 |
| Complete blood count without differential | CPT 85027 | $62.16 |
| Urine culture bacterial | CPT 87086 | $83.94 |
| Urine culture identification | CPT 87088 | $62.80 |
| Tissue exam by pathologist level IV | CPT 88305 | $81.70 |
| Fetal non-stress test | CPT 59025 | $592.20 |
| Vaginal delivery only | CPT 59409 | $4,374.17 |
| Office visit, new patient, 15-29 min | CPT 99202 | $194.04 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $342.09 |
| Office visit, new patient, 45-59 min | CPT 99204 | $394.38 |
| Office visit, new patient, 60-74 min | CPT 99205 | $576.45 |
| Office visit, established patient, 5 min | CPT 99211 | $143.01 |
| Office visit, established patient, 10-19 min | CPT 99212 | $95.13 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $136.08 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $148.05 |
| Office visit, established patient, 40-54 min | CPT 99215 | $548.10 |
| Upper GI endoscopy diagnostic | CPT 43235 | $295.85 |
| Upper GI endoscopy with biopsy | CPT 43239 | $306.40 |
| Sigmoidoscopy diagnostic | CPT 45330 | $141.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $176.70 |
| Colonoscopy diagnostic | CPT 45378 | $270.70 |
| Colonoscopy with biopsy | CPT 45380 | $270.70 |
| Colonoscopy with polyp removal | CPT 45385 | $342.10 |
| Shoulder arthroscopy with decompression | CPT 29826 | $55.90 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $55.90 |
| Laparoscopic cholecystectomy | CPT 47562 | $14,727 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $13,181 |
| Intravitreal injection | CPT 67028 | $2,856.18 |
| PCI with drug-eluting stent | CPT 92928 | $18,354 |
