| ED visit level 1 | CPT 99281 | $253.75 |
| ED visit level 2 | CPT 99282 | $410 |
| ED visit level 3 | CPT 99283 | $600 |
| ED visit level 4 | CPT 99284 | $932 |
| ED visit level 5 | CPT 99285 | $1,420 |
| Critical care, first hour | CPT 99291 | $569 |
| CT head without contrast | CPT 70450 | $1,285 |
| CT head with contrast | CPT 70460 | $1,350 |
| CT neck with contrast | CPT 70491 | $1,190 |
| MRI brain without contrast | CPT 70551 | $1,463 |
| MRI brain with contrast | CPT 70552 | $1,500 |
| MRI brain with and without contrast | CPT 70553 | $1,830 |
| Chest X-ray single view | CPT 71045 | $177 |
| Chest X-ray 2 views | CPT 71046 | $240 |
| CT chest without contrast | CPT 71250 | $1,250 |
| CT chest with contrast | CPT 71260 | $900 |
| CT chest with and without contrast | CPT 71270 | $900 |
| Lumbosacral spine X-ray | CPT 72100 | $262 |
| CT cervical spine without contrast | CPT 72125 | $1,395 |
| CT thoracic spine without contrast | CPT 72128 | $1,505 |
| CT lumbar spine without contrast | CPT 72131 | $1,505 |
| MRI cervical spine without contrast | CPT 72141 | $1,376 |
| MRI thoracic spine without contrast | CPT 72146 | $1,413 |
| MRI lumbar spine without contrast | CPT 72148 | $1,424 |
| CT pelvis without contrast | CPT 72192 | $1,425 |
| Shoulder X-ray | CPT 73030 | $255 |
| Humerus X-ray | CPT 73060 | $199 |
| Hand X-ray 3 views | CPT 73130 | $215 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,655 |
| Knee X-ray 1-2 views | CPT 73560 | $190 |
| Ankle X-ray 3 views | CPT 73610 | $220 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,300 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,450 |
| CT abdomen without contrast | CPT 74150 | $1,283 |
| CT abdomen with contrast | CPT 74160 | $1,393 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,300 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,431 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,440 |
| MRI abdomen without contrast | CPT 74181 | $1,600 |
| MRI abdomen with and without contrast | CPT 74183 | $1,740 |
| Abdominal ultrasound complete | CPT 76700 | $502 |
| Abdominal ultrasound limited | CPT 76705 | $439 |
| Retroperitoneal ultrasound complete | CPT 76770 | $418 |
| Obstetric ultrasound first trimester | CPT 76801 | $418 |
| Obstetric ultrasound after first trimester | CPT 76805 | $418 |
| Transvaginal ultrasound | CPT 76830 | $200 |
| Pelvic ultrasound complete | CPT 76856 | $495 |
| Scrotal ultrasound | CPT 76870 | $500 |
| EKG complete | CPT 93000 | $274 |
| EKG tracing only | CPT 93005 | $245 |
| EKG interpretation only | CPT 93010 | $29 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,179 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | — |
| COPD w/o CC/MCC | MS-DRG 192 | — |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,711 |
| Heart failure & shock w MCC | MS-DRG 291 | — |
| Heart failure & shock w CC | MS-DRG 292 | $11,375 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $4,062.9 |
| GI hemorrhage w CC | MS-DRG 378 | $3,347.2 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,139 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,561 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $16,718 |
| Initial hospital care, low complexity | CPT 99221 | $224 |
| Initial hospital care, moderate complexity | CPT 99222 | $247 |
| Initial hospital care, high complexity | CPT 99223 | $339 |
| Hospital discharge, <30 min | CPT 99238 | $140 |
| Hospital discharge, >30 min | CPT 99239 | $205 |
| Basic metabolic panel (BMP) | CPT 80048 | $157 |
| Electrolyte panel | CPT 80051 | $75 |
| Comprehensive metabolic panel | CPT 80053 | $277 |
| Lipid panel | CPT 80061 | $192 |
| Renal function panel | CPT 80069 | $194 |
| Hepatic function panel | CPT 80076 | $157 |
| Urinalysis non-automated | CPT 81002 | $29 |
| Urinalysis automated | CPT 81003 | $25 |
| Glucose quantitative | CPT 82947 | $21 |
| Hemoglobin A1c | CPT 83036 | $97 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $145 |
| Complete blood count with automated differential | CPT 85025 | $48 |
| Complete blood count without differential | CPT 85027 | $36 |
| Urine culture bacterial | CPT 87086 | $86 |
| Tissue exam by pathologist level IV | CPT 88305 | $333 |
| Fetal non-stress test | CPT 59025 | $455 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $3,522 |
| Vaginal delivery only | CPT 59409 | $1,797 |
| Vaginal delivery with postpartum | CPT 59410 | $2,132 |
| Routine obstetric care with C-section | CPT 59510 | $4,089 |
| C-section delivery only | CPT 59514 | $759 |
| Office visit, new patient, 15-29 min | CPT 99202 | $150 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $211 |
| Office visit, new patient, 45-59 min | CPT 99204 | $279 |
| Office visit, new patient, 60-74 min | CPT 99205 | $349 |
| Office visit, established patient, 5 min | CPT 99211 | $167 |
| Office visit, established patient, 10-19 min | CPT 99212 | $85 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $115 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $165 |
| Office visit, established patient, 40-54 min | CPT 99215 | $226 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,596 |
| Colonoscopy diagnostic | CPT 45378 | $3,029 |
| Colonoscopy with biopsy | CPT 45380 | $2,596 |
| Colonoscopy with polyp removal | CPT 45385 | $3,462 |
| Lap salpingo-oophorectomy | CPT 58661 | $3,732.5 |
