| Psychiatric diagnostic evaluation | CPT 90791 | $39.59 |
| Psychiatric eval with medical services | CPT 90792 | $41.11 |
| Psychotherapy 45 minutes | CPT 90834 | $35.02 |
| Psychotherapy 60 minutes | CPT 90837 | $47.20 |
| ED visit level 1 | CPT 99281 | $40.48 |
| ED visit level 2 | CPT 99282 | $79.75 |
| ED visit level 3 | CPT 99283 | $108.05 |
| ED visit level 4 | CPT 99284 | $498.90 |
| ED visit level 5 | CPT 99285 | $645.53 |
| CT head without contrast | CPT 70450 | $456.17 |
| CT head with contrast | CPT 70460 | $398.29 |
| CT head with and without contrast | CPT 70470 | $565.70 |
| CT neck with contrast | CPT 70491 | $522.07 |
| MRI brain without contrast | CPT 70551 | $809.31 |
| MRI brain with and without contrast | CPT 70553 | $1,162.16 |
| Chest X-ray single view | CPT 71045 | $54.20 |
| Chest X-ray 2 views | CPT 71046 | $63.80 |
| Chest X-ray 3 views | CPT 71047 | $98.66 |
| CT chest without contrast | CPT 71250 | $507.98 |
| CT chest with contrast | CPT 71260 | $611.76 |
| CT chest with and without contrast | CPT 71270 | $732.20 |
| Lumbosacral spine X-ray | CPT 72100 | $88.31 |
| CT cervical spine without contrast | CPT 72125 | $640.69 |
| CT thoracic spine without contrast | CPT 72128 | $567.37 |
| CT lumbar spine without contrast | CPT 72131 | $527.37 |
| MRI cervical spine without contrast | CPT 72141 | $770.68 |
| MRI thoracic spine without contrast | CPT 72146 | $809.31 |
| MRI lumbar spine without contrast | CPT 72148 | $770.98 |
| CT pelvis without contrast | CPT 72192 | $429.35 |
| CT pelvis with contrast | CPT 72193 | $595.24 |
| Shoulder X-ray | CPT 73030 | $74.61 |
| Humerus X-ray | CPT 73060 | $74.61 |
| Hand X-ray 3 views | CPT 73130 | $76.28 |
| MRI upper extremity joint without contrast | CPT 73221 | $809.31 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $809.31 |
| Knee X-ray 1-2 views | CPT 73560 | $52.22 |
| Ankle X-ray 3 views | CPT 73610 | $80.54 |
| MRI lower extremity joint without contrast | CPT 73721 | $809.31 |
| CT abdomen without contrast | CPT 74150 | $387.08 |
| CT abdomen with contrast | CPT 74160 | $477.83 |
| CT abdomen with and without contrast | CPT 74170 | $569.79 |
| CT abdomen and pelvis without contrast | CPT 74176 | $831.43 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,072.47 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,330.78 |
| Abdominal ultrasound complete | CPT 76700 | $206.91 |
| Abdominal ultrasound limited | CPT 76705 | $168.54 |
| Retroperitoneal ultrasound complete | CPT 76770 | $147.53 |
| Obstetric ultrasound first trimester | CPT 76801 | $205.39 |
| Transvaginal ultrasound | CPT 76830 | $222.90 |
| Pelvic ultrasound complete | CPT 76856 | $233.10 |
| Scrotal ultrasound | CPT 76870 | $230.21 |
| Diagnostic mammography unilateral | CPT 77065 | $121.05 |
| Diagnostic mammography bilateral | CPT 77066 | $143.32 |
| Screening mammography bilateral | CPT 77067 | $7.58 |
| EKG tracing only | CPT 93005 | $60.45 |
| Transthoracic echocardiogram complete | CPT 93306 | $603.06 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $21,376 |
| COPD w MCC | MS-DRG 190 | $15,152 |
| COPD w CC | MS-DRG 191 | $11,531 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,781.90 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $11,024 |
| AMI discharged alive w MCC | MS-DRG 280 | $21,942 |
| AMI discharged alive w CC | MS-DRG 281 | $12,572 |
| Heart failure & shock w MCC | MS-DRG 291 | $17,561 |
| Heart failure & shock w CC | MS-DRG 292 | $11,613 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,742.30 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,064 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $7,743.67 |
| GI hemorrhage w CC | MS-DRG 378 | $13,415 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $8,623.22 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $10,664 |
| Kidney/UTI w MCC | MS-DRG 689 | $15,872 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $11,073 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $26,571 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $13,998 |
| Basic metabolic panel (BMP) | CPT 80048 | $37.57 |
| Comprehensive metabolic panel | CPT 80053 | $43.63 |
| Lipid panel | CPT 80061 | $68.78 |
| Renal function panel | CPT 80069 | $59.39 |
| Hepatic function panel | CPT 80076 | $53.14 |
| Urinalysis non-automated | CPT 81002 | $3.50 |
| Urinalysis automated | CPT 81003 | $9.54 |
| Glucose quantitative | CPT 82947 | $33.03 |
| Hemoglobin A1c | CPT 83036 | $20.30 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $46.51 |
| Complete blood count with automated differential | CPT 85025 | $20.76 |
| Complete blood count without differential | CPT 85027 | $16.29 |
| Urine culture bacterial | CPT 87086 | $35.78 |
| Office visit, established patient, 5 min | CPT 99211 | $104.90 |
