| Psychiatric diagnostic evaluation | CPT 90791 | $257.69 |
| Psychiatric eval with medical services | CPT 90792 | $295.5 |
| Psychotherapy 30 minutes | CPT 90832 | $90.73 |
| Psychotherapy 45 minutes | CPT 90834 | $119.86 |
| Psychotherapy 60 minutes | CPT 90837 | $167.56 |
| ED visit level 1 | CPT 99281 | $89.2 |
| ED visit level 2 | CPT 99282 | $150.06 |
| ED visit level 3 | CPT 99283 | $226.67 |
| ED visit level 4 | CPT 99284 | $313.77 |
| ED visit level 5 | CPT 99285 | $526.35 |
| Critical care, first hour | CPT 99291 | $698.61 |
| CT head without contrast | CPT 70450 | $864.27 |
| CT head with contrast | CPT 70460 | $864.27 |
| CT head with and without contrast | CPT 70470 | $1,156.68 |
| CT neck with contrast | CPT 70491 | $839.57 |
| MRI brain without contrast | CPT 70551 | $1,208.52 |
| MRI brain with contrast | CPT 70552 | $1,408.59 |
| MRI brain with and without contrast | CPT 70553 | $1,614.33 |
| Chest X-ray single view | CPT 71045 | $146.61 |
| Chest X-ray 2 views | CPT 71046 | $167.27 |
| Chest X-ray 3 views | CPT 71047 | $127.97 |
| CT chest without contrast | CPT 71250 | $924.62 |
| CT chest with contrast | CPT 71260 | $924.62 |
| CT chest with and without contrast | CPT 71270 | $1,264.82 |
| MRI chest without contrast | CPT 71550 | $1,447.07 |
| MRI chest with and without contrast | CPT 71552 | $1,558.04 |
| Lumbosacral spine X-ray | CPT 72100 | $204.53 |
| CT cervical spine without contrast | CPT 72125 | $957.83 |
| CT thoracic spine without contrast | CPT 72128 | $1,016.55 |
| CT lumbar spine without contrast | CPT 72131 | $1,057.65 |
| MRI cervical spine without contrast | CPT 72141 | $1,447.07 |
| MRI thoracic spine without contrast | CPT 72146 | $1,447.07 |
| MRI lumbar spine without contrast | CPT 72148 | $1,447.07 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,474.61 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,611.09 |
| MRI lumbar spine with contrast | CPT 72158 | $1,692.5 |
| CT pelvis without contrast | CPT 72192 | $886.95 |
| CT pelvis with contrast | CPT 72193 | $866.7 |
| Shoulder X-ray | CPT 73030 | $94.16 |
| Humerus X-ray | CPT 73060 | $147.02 |
| Hand X-ray 3 views | CPT 73130 | $161.6 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,408.59 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,397.39 |
| Knee X-ray 1-2 views | CPT 73560 | $138.51 |
| Ankle X-ray 3 views | CPT 73610 | $166.46 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,408.59 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,600.97 |
| CT abdomen without contrast | CPT 74150 | $970.38 |
| CT abdomen with contrast | CPT 74160 | $970.38 |
| CT abdomen with and without contrast | CPT 74170 | $1,111.73 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,313.42 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,434.51 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,578.29 |
| MRI abdomen without contrast | CPT 74181 | $1,447.07 |
| MRI abdomen with and without contrast | CPT 74183 | $1,600.97 |
| Abdominal ultrasound complete | CPT 76700 | $458.46 |
| Abdominal ultrasound limited | CPT 76705 | $208.95 |
| Retroperitoneal ultrasound complete | CPT 76770 | $462.51 |
| Obstetric ultrasound first trimester | CPT 76801 | $522.45 |
| Obstetric ultrasound after first trimester | CPT 76805 | $522.45 |
| Transvaginal ultrasound | CPT 76830 | $415.94 |
| Pelvic ultrasound complete | CPT 76856 | $398.52 |
| Scrotal ultrasound | CPT 76870 | $397.71 |
| Diagnostic mammography unilateral | CPT 77065 | $157.55 |
| Diagnostic mammography bilateral | CPT 77066 | $190.35 |
| Screening mammography bilateral | CPT 77067 | $168.97 |
| EKG tracing only | CPT 93005 | $92.26 |
| EKG interpretation only | CPT 93010 | $13.18 |
| Transthoracic echocardiogram complete | CPT 93306 | $849.75 |
| Stress echocardiogram | CPT 93350 | $451.17 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $3,897.27 |
| COPD w MCC | MS-DRG 190 | $3,897.27 |
| COPD w CC | MS-DRG 191 | $3,897.27 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $3,897.27 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $3,897.27 |
| Heart failure & shock w MCC | MS-DRG 291 | $3,897.27 |
| Heart failure & shock w CC | MS-DRG 292 | $3,897.27 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $3,897.27 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $3,897.27 |
| Kidney/UTI w MCC | MS-DRG 689 | $3,897.27 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $3,897.27 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $3,897.27 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $3,897.27 |
| Initial hospital care, low complexity | CPT 99221 | $101.45 |
| Initial hospital care, moderate complexity | CPT 99222 | $149.45 |
| Initial hospital care, high complexity | CPT 99223 | $199.48 |
| Hospital discharge, <30 min | CPT 99238 | $93.34 |
| Hospital discharge, >30 min | CPT 99239 | $132.85 |
| Basic metabolic panel (BMP) | CPT 80048 | $74.24 |
| Electrolyte panel | CPT 80051 | $74.24 |
| Comprehensive metabolic panel | CPT 80053 | $103.58 |
| Lipid panel | CPT 80061 | $66.46 |
| Renal function panel | CPT 80069 | $145.29 |
| Hepatic function panel | CPT 80076 | $112.41 |
| Urinalysis non-automated | CPT 81002 | $7.7 |
| Urinalysis automated | CPT 81003 | $20.5 |
| Glucose quantitative | CPT 82947 | $44.19 |
| Hemoglobin A1c | CPT 83036 | $49.49 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $61.25 |
| Complete blood count with automated differential | CPT 85025 | $69.99 |
| Complete blood count without differential | CPT 85027 | $47.55 |
| Urine culture bacterial | CPT 87086 | $60.45 |
| Urine culture identification | CPT 87088 | $2.72 |
| Tissue exam by pathologist level IV | CPT 88305 | $70.07 |
| Fetal non-stress test | CPT 59025 | $37.83 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,631.4 |
| Vaginal delivery with postpartum | CPT 59410 | $1,159.75 |
| Routine obstetric care with C-section | CPT 59510 | $2,890.75 |
| C-section delivery only | CPT 59514 | $978.4 |
| C-section with postpartum | CPT 59515 | $1,424.89 |
| Office visit, new patient, 15-29 min | CPT 99202 | $66.61 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $94.31 |
| Office visit, new patient, 45-59 min | CPT 99204 | $190.74 |
| Office visit, new patient, 60-74 min | CPT 99205 | $271.3 |
| Office visit, established patient, 5 min | CPT 99211 | $26.07 |
| Office visit, established patient, 10-19 min | CPT 99212 | $48.12 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $75.92 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $111.55 |
| Office visit, established patient, 40-54 min | CPT 99215 | $165.41 |
| Upper GI endoscopy diagnostic | CPT 43235 | $294.78 |
| Upper GI endoscopy with biopsy | CPT 43239 | $887.34 |
| Sigmoidoscopy diagnostic | CPT 45330 | $109.98 |
| Sigmoidoscopy with biopsy | CPT 45331 | $685.79 |
| Colonoscopy diagnostic | CPT 45378 | $840.02 |
| Colonoscopy with biopsy | CPT 45380 | $1,004.22 |
| Colonoscopy with polyp removal | CPT 45385 | $1,041.29 |
| Total hip replacement | CPT 27130 | $1,956.4 |
| Total knee replacement | CPT 27447 | $1,971.73 |
| Laparoscopic appendectomy | CPT 44970 | $3,060.6 |
| Major joint replacement w/o MCC | MS-DRG 470 | $3,897.27 |
| Laparoscopic cholecystectomy | CPT 47562 | $3,060.6 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,047.36 |
| Lap inguinal hernia repair | CPT 49650 | $3,057.14 |
