| Psychiatric diagnostic evaluation | CPT 90791 | $586.00 |
| Psychotherapy 30 minutes | CPT 90832 | $244.00 |
| Psychotherapy 45 minutes | CPT 90834 | $293.00 |
| Psychotherapy 60 minutes | CPT 90837 | $439.00 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $439.00 |
| ED visit level 1 | CPT 99281 | $163.00 |
| ED visit level 2 | CPT 99282 | $244.50 |
| ED visit level 3 | CPT 99283 | $407.50 |
| ED visit level 4 | CPT 99284 | $734.50 |
| ED visit level 5 | CPT 99285 | $1,224.00 |
| CT head without contrast | CPT 70450 | $104.00 |
| CT head with contrast | CPT 70460 | $149.00 |
| CT head with and without contrast | CPT 70470 | $179.00 |
| CT neck with contrast | CPT 70491 | $234.00 |
| MRI brain without contrast | CPT 70551 | $432.00 |
| MRI brain with contrast | CPT 70552 | $638.00 |
| MRI brain with and without contrast | CPT 70553 | $727.00 |
| Chest X-ray single view | CPT 71045 | $119.00 |
| Chest X-ray 2 views | CPT 71046 | $49.00 |
| Chest X-ray 3 views | CPT 71047 | $178.00 |
| CT chest without contrast | CPT 71250 | $179.00 |
| CT chest with contrast | CPT 71260 | $234.00 |
| CT chest with and without contrast | CPT 71270 | $226.00 |
| MRI chest without contrast | CPT 71550 | $943.00 |
| MRI chest with and without contrast | CPT 71552 | $1,287.00 |
| Lumbosacral spine X-ray | CPT 72100 | $49.00 |
| CT cervical spine without contrast | CPT 72125 | $141.50 |
| CT thoracic spine without contrast | CPT 72128 | $139.00 |
| CT lumbar spine without contrast | CPT 72131 | $179.00 |
| MRI cervical spine without contrast | CPT 72141 | $412.00 |
| MRI thoracic spine without contrast | CPT 72146 | $412.00 |
| MRI lumbar spine without contrast | CPT 72148 | $412.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $638.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $727.00 |
| MRI lumbar spine with contrast | CPT 72158 | $727.00 |
| CT pelvis without contrast | CPT 72192 | $129.00 |
| CT pelvis with contrast | CPT 72193 | $234.00 |
| Shoulder X-ray | CPT 73030 | $49.00 |
| Humerus X-ray | CPT 73060 | $49.00 |
| Hand X-ray 3 views | CPT 73130 | $49.00 |
| MRI upper extremity joint without contrast | CPT 73221 | $461.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,002.00 |
| Knee X-ray 1-2 views | CPT 73560 | $32.00 |
| Ankle X-ray 3 views | CPT 73610 | $49.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $461.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,002.00 |
| CT abdomen without contrast | CPT 74150 | $124.00 |
| CT abdomen with contrast | CPT 74160 | $234.00 |
| CT abdomen with and without contrast | CPT 74170 | $268.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $159.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $308.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $353.00 |
| MRI abdomen without contrast | CPT 74181 | $717.00 |
| MRI abdomen with and without contrast | CPT 74183 | $1,090.00 |
| Abdominal ultrasound complete | CPT 76700 | $685.00 |
| Abdominal ultrasound limited | CPT 76705 | $536.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $655.00 |
| Obstetric ultrasound first trimester | CPT 76801 | $625.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $774.00 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $715.00 |
| Transvaginal ultrasound | CPT 76830 | $745.00 |
| Pelvic ultrasound complete | CPT 76856 | $625.00 |
| Scrotal ultrasound | CPT 76870 | $298.00 |
| EKG tracing only | CPT 93005 | $132.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $675.00 |
| Transthoracic echocardiogram | CPT 93307 | $498.00 |
| Stress echocardiogram | CPT 93350 | $664.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $29.00 |
| Electrolyte panel | CPT 80051 | $21.00 |
| Comprehensive metabolic panel | CPT 80053 | $40.00 |
| Lipid panel | CPT 80061 | $51.00 |
| Renal function panel | CPT 80069 | $32.00 |
| Hepatic function panel | CPT 80076 | $29.00 |
| Urinalysis non-automated | CPT 81002 | $10.00 |
| Urinalysis automated | CPT 81003 | $10.00 |
| Glucose quantitative | CPT 82947 | $10.00 |
| Hemoglobin A1c | CPT 83036 | $54.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $40.00 |
| Complete blood count with automated differential | CPT 85025 | $27.00 |
| Complete blood count without differential | CPT 85027 | $21.00 |
| Urine culture bacterial | CPT 87086 | $54.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $162.00 |
| Fetal non-stress test | CPT 59025 | $1,204.00 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $6,262.00 |
| Routine obstetric care with C-section | CPT 59510 | $8,911.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | $146.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $195.00 |
| Office visit, new patient, 45-59 min | CPT 99204 | $244.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $293.00 |
| Office visit, established patient, 5 min | CPT 99211 | $97.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $146.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $195.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $244.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $293.00 |
| PCI single major coronary artery | CPT 92920 | $1.00 |
| PCI with drug-eluting stent | CPT 92928 | $1.00 |
| PCI bypass graft | CPT 92937 | $1.00 |
| Left heart catheterization | CPT 93452 | $1.00 |
| Coronary angiography with cath | CPT 93455 | $1.00 |
| Coronary angiography with bypass cath | CPT 93458 | $1.00 |
