| Psychiatric diagnostic evaluation | CPT 90791 | $171.11 |
| Psychiatric eval with medical services | CPT 90792 | $171.11 |
| Psychotherapy 30 minutes | CPT 90832 | $171.11 |
| Psychotherapy 45 minutes | CPT 90834 | $171.11 |
| Psychotherapy 60 minutes | CPT 90837 | $171.11 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $171.11 |
| ED visit level 1 | CPT 99281 | $93.77 |
| ED visit level 2 | CPT 99282 | $168.65 |
| ED visit level 3 | CPT 99283 | $294.88 |
| ED visit level 4 | CPT 99284 | $453.49 |
| ED visit level 5 | CPT 99285 | $652.94 |
| Critical care, first hour | CPT 99291 | $897.36 |
| CT head without contrast | CPT 70450 | $113.25 |
| CT head with contrast | CPT 70460 | $189.59 |
| CT head with and without contrast | CPT 70470 | $189.59 |
| CT neck with contrast | CPT 70491 | $189.59 |
| MRI brain without contrast | CPT 70551 | $257.43 |
| MRI brain with contrast | CPT 70552 | $380.34 |
| MRI brain with and without contrast | CPT 70553 | $380.34 |
| Chest X-ray single view | CPT 71045 | $93.77 |
| Chest X-ray 2 views | CPT 71046 | $93.77 |
| Chest X-ray 3 views | CPT 71047 | $93.77 |
| CT chest without contrast | CPT 71250 | $113.25 |
| CT chest with contrast | CPT 71260 | $189.59 |
| CT chest with and without contrast | CPT 71270 | $189.59 |
| MRI chest without contrast | CPT 71550 | $257.43 |
| MRI chest with contrast | CPT 71551 | $841.4 |
| MRI chest with and without contrast | CPT 71552 | $380.34 |
| Lumbosacral spine X-ray | CPT 72100 | $113.25 |
| CT cervical spine without contrast | CPT 72125 | $113.25 |
| CT thoracic spine without contrast | CPT 72128 | $2,674.35 |
| CT lumbar spine without contrast | CPT 72131 | $113.25 |
| MRI cervical spine without contrast | CPT 72141 | $257.43 |
| MRI thoracic spine without contrast | CPT 72146 | $4,728.83 |
| MRI lumbar spine without contrast | CPT 72148 | $257.43 |
| MRI lumbar spine with and without contrast | CPT 72149 | $380.34 |
| MRI cervical spine with and without contrast | CPT 72156 | $380.34 |
| MRI lumbar spine with contrast | CPT 72158 | $380.34 |
| CT pelvis without contrast | CPT 72192 | $113.25 |
| CT pelvis with contrast | CPT 72193 | $189.59 |
| Shoulder X-ray | CPT 73030 | $93.77 |
| Humerus X-ray | CPT 73060 | $93.77 |
| Hand X-ray 3 views | CPT 73130 | $93.77 |
| MRI upper extremity joint without contrast | CPT 73221 | $4,728.83 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $380.34 |
| Knee X-ray 1-2 views | CPT 73560 | $93.77 |
| Ankle X-ray 3 views | CPT 73610 | $93.77 |
| MRI lower extremity joint without contrast | CPT 73721 | $257.43 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,728.83 |
| CT abdomen without contrast | CPT 74150 | $113.25 |
| CT abdomen with contrast | CPT 74160 | $189.59 |
| CT abdomen with and without contrast | CPT 74170 | $4,602.6 |
| CT abdomen and pelvis without contrast | CPT 74176 | $257.43 |
| CT abdomen and pelvis with contrast | CPT 74177 | $6,198 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $380.34 |
| MRI abdomen without contrast | CPT 74181 | $4,728.83 |
| MRI abdomen with and without contrast | CPT 74183 | $4,728.83 |
| Abdominal ultrasound complete | CPT 76700 | $113.25 |
| Abdominal ultrasound limited | CPT 76705 | $734.14 |
| Retroperitoneal ultrasound complete | CPT 76770 | $113.25 |
| Obstetric ultrasound first trimester | CPT 76801 | $113.25 |
| Obstetric ultrasound after first trimester | CPT 76805 | $113.25 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $257.43 |
| Transvaginal ultrasound | CPT 76830 | $496.65 |
| Pelvic ultrasound complete | CPT 76856 | $113.25 |
| Scrotal ultrasound | CPT 76870 | $113.25 |
| Diagnostic mammography unilateral | CPT 77065 | $84.97 |
| Diagnostic mammography bilateral | CPT 77066 | $108.26 |
| Screening mammography bilateral | CPT 77067 | $89.55 |
| EKG tracing only | CPT 93005 | $63.26 |
| Transthoracic echocardiogram complete | CPT 93306 | $583.93 |
| Transthoracic echocardiogram | CPT 93307 | $257.43 |
| Stress echocardiogram | CPT 93350 | $583.93 |
| Basic metabolic panel (BMP) | CPT 80048 | $336.94 |
| Electrolyte panel | CPT 80051 | $7.01 |
| Comprehensive metabolic panel | CPT 80053 | $439.46 |
| Lipid panel | CPT 80061 | $13.39 |
| Renal function panel | CPT 80069 | $8.68 |
| Hepatic function panel | CPT 80076 | $8.17 |
| Urinalysis non-automated | CPT 81002 | $3.48 |
| Urinalysis automated | CPT 81003 | $2.25 |
| Glucose quantitative | CPT 82947 | $313.91 |
| Hemoglobin A1c | CPT 83036 | $110.4 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $164.85 |
| Complete blood count with automated differential | CPT 85025 | $7.77 |
| Complete blood count without differential | CPT 85027 | $6.47 |
| Urine culture bacterial | CPT 87086 | $8.07 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $56.9 |
| Fetal non-stress test | CPT 59025 | $214.24 |
| Vaginal delivery only | CPT 59409 | $3,386.14 |
| Upper GI endoscopy diagnostic | CPT 43235 | $998.48 |
| Upper GI endoscopy with biopsy | CPT 43239 | $998.48 |
| Sigmoidoscopy diagnostic | CPT 45330 | $970.95 |
| Sigmoidoscopy with biopsy | CPT 45331 | $970.95 |
| Colonoscopy diagnostic | CPT 45378 | $970.95 |
| Colonoscopy with biopsy | CPT 45380 | $1,255.7 |
| Colonoscopy with polyp removal | CPT 45385 | $1,255.7 |
| Total shoulder arthroplasty | CPT 23472 | $19,585 |
| Total hip replacement | CPT 27130 | $13,703 |
| Total knee replacement | CPT 27447 | $13,703 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,607.93 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,455.44 |
| ACL reconstruction | CPT 29888 | $7,607.93 |
| Open appendectomy | CPT 44950 | $6,645.21 |
| Laparoscopic appendectomy | CPT 44970 | $6,213.48 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,213.48 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,213.48 |
| Lap inguinal hernia repair | CPT 49650 | $6,213.48 |
| Vaginal hysterectomy | CPT 58260 | $5,257.22 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,213.48 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $11,088 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,213.48 |
| Complex cataract surgery | CPT 66982 | $2,428.93 |
| Cataract surgery with lens implant | CPT 66984 | $2,428.93 |
| Intravitreal injection | CPT 67028 | $353.24 |
| Vitrectomy mechanical | CPT 67042 | $4,284.27 |
| PCI single major coronary artery | CPT 92920 | $6,072 |
| PCI with drug-eluting stent | CPT 92928 | $12,077 |
| PCI bypass graft | CPT 92937 | $12,077 |
| Left heart catheterization | CPT 93452 | $3,425.41 |
| Coronary angiography with cath | CPT 93455 | $3,425.41 |
| Coronary angiography with bypass cath | CPT 93458 | $3,425.41 |
