| ED visit level 1 | CPT 99281 | $96 |
| ED visit level 2 | CPT 99282 | $115 |
| ED visit level 3 | CPT 99283 | $155.5 |
| ED visit level 4 | CPT 99284 | $217.5 |
| ED visit level 5 | CPT 99285 | $315.5 |
| Critical care, first hour | CPT 99291 | $1,111 |
| CT head without contrast | CPT 70450 | $1,028 |
| CT head with contrast | CPT 70460 | $909.5 |
| CT head with and without contrast | CPT 70470 | $1,355 |
| CT neck with contrast | CPT 70491 | $822 |
| MRI brain without contrast | CPT 70551 | $1,393.5 |
| MRI brain with contrast | CPT 70552 | $3,088 |
| MRI brain with and without contrast | CPT 70553 | $3,088 |
| Chest X-ray single view | CPT 71045 | $175 |
| Chest X-ray 2 views | CPT 71046 | $175 |
| CT chest without contrast | CPT 71250 | $909.5 |
| CT chest with contrast | CPT 71260 | $909.5 |
| CT chest with and without contrast | CPT 71270 | $1,355 |
| MRI chest with and without contrast | CPT 71552 | $1,672 |
| Lumbosacral spine X-ray | CPT 72100 | $244 |
| CT cervical spine without contrast | CPT 72125 | $909.5 |
| CT thoracic spine without contrast | CPT 72128 | $909.5 |
| CT lumbar spine without contrast | CPT 72131 | $909.5 |
| MRI cervical spine without contrast | CPT 72141 | $1,671.5 |
| MRI thoracic spine without contrast | CPT 72146 | $1,671.5 |
| MRI lumbar spine without contrast | CPT 72148 | $1,393.5 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,088 |
| MRI lumbar spine with contrast | CPT 72158 | $2,780 |
| CT pelvis without contrast | CPT 72192 | $805 |
| CT pelvis with contrast | CPT 72193 | $805 |
| Shoulder X-ray | CPT 73030 | $369 |
| Humerus X-ray | CPT 73060 | $227 |
| Hand X-ray 3 views | CPT 73130 | $250 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,890 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,576 |
| Knee X-ray 1-2 views | CPT 73560 | $335.5 |
| Ankle X-ray 3 views | CPT 73610 | $344 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,180 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,338.5 |
| CT abdomen without contrast | CPT 74150 | $805 |
| CT abdomen with contrast | CPT 74160 | $805 |
| CT abdomen with and without contrast | CPT 74170 | $1,103 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,272.5 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,323 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,745 |
| MRI abdomen without contrast | CPT 74181 | $1,419 |
| MRI abdomen with and without contrast | CPT 74183 | $3,088 |
| Abdominal ultrasound complete | CPT 76700 | $354 |
| Abdominal ultrasound limited | CPT 76705 | $318 |
| Retroperitoneal ultrasound complete | CPT 76770 | $346 |
| Obstetric ultrasound first trimester | CPT 76801 | $328 |
| Obstetric ultrasound after first trimester | CPT 76805 | $328 |
| Transvaginal ultrasound | CPT 76830 | $239.5 |
| Pelvic ultrasound complete | CPT 76856 | $239.5 |
| Scrotal ultrasound | CPT 76870 | $199 |
| Diagnostic mammography unilateral | CPT 77065 | $216 |
| Diagnostic mammography bilateral | CPT 77066 | $237 |
| Screening mammography bilateral | CPT 77067 | $207 |
| EKG complete | CPT 93000 | $49.5 |
| EKG tracing only | CPT 93005 | $121 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,340.5 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10 |
| GI hemorrhage w CC | MS-DRG 378 | $5 |
| Basic metabolic panel (BMP) | CPT 80048 | $61 |
| General health panel | CPT 80050 | $275 |
| Electrolyte panel | CPT 80051 | $41 |
| Comprehensive metabolic panel | CPT 80053 | $135 |
| Lipid panel | CPT 80061 | $106.5 |
| Renal function panel | CPT 80069 | $75 |
| Hepatic function panel | CPT 80076 | $71.5 |
| Urinalysis automated | CPT 81003 | $30 |
| Glucose quantitative | CPT 82947 | $35.5 |
| Hemoglobin A1c | CPT 83036 | $79 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $106 |
| Complete blood count with automated differential | CPT 85025 | $85.5 |
| Complete blood count without differential | CPT 85027 | $72 |
| Urine culture bacterial | CPT 87086 | $74.5 |
| Urine culture identification | CPT 87088 | $54 |
| Tissue exam by pathologist level IV | CPT 88305 | $159 |
| Fetal non-stress test | CPT 59025 | $429 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $124.5 |
| Office visit, new patient, 45-59 min | CPT 99204 | $178 |
| Office visit, new patient, 60-74 min | CPT 99205 | $225.5 |
| Office visit, established patient, 5 min | CPT 99211 | $76.5 |
| Office visit, established patient, 10-19 min | CPT 99212 | $91.5 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $112 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $248 |
| Office visit, established patient, 40-54 min | CPT 99215 | $211 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,183.5 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,243.5 |
| Colonoscopy diagnostic | CPT 45378 | $1,333 |
| Colonoscopy with biopsy | CPT 45380 | $1,533 |
| Colonoscopy with polyp removal | CPT 45385 | $1,612 |
| Shoulder arthroscopy with decompression | CPT 29826 | $431 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $1,293 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $37,936 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,395 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,143.5 |
| PCI single major coronary artery | CPT 92920 | $5,049 |
| PCI with drug-eluting stent | CPT 92928 | $11,811 |
| Coronary angiography with cath | CPT 93455 | $5,303 |
| Coronary angiography with bypass cath | CPT 93458 | $6,263 |
