| ED visit level 1 | CPT 99281 | $113.00 |
| ED visit level 2 | CPT 99282 | $205.00 |
| ED visit level 3 | CPT 99283 | $362.00 |
| ED visit level 4 | CPT 99284 | $573.00 |
| ED visit level 5 | CPT 99285 | $837.00 |
| Critical care, first hour | CPT 99291 | $1,537.00 |
| CT head without contrast | CPT 70450 | $588.00 |
| CT head with contrast | CPT 70460 | $717.00 |
| CT head with and without contrast | CPT 70470 | $863.00 |
| CT neck with contrast | CPT 70491 | $963.00 |
| MRI brain without contrast | CPT 70551 | $1,001.00 |
| MRI brain with and without contrast | CPT 70553 | $1,687.00 |
| Chest X-ray single view | CPT 71045 | $69.00 |
| Chest X-ray 2 views | CPT 71046 | $94.00 |
| Chest X-ray 3 views | CPT 71047 | $119.00 |
| CT chest without contrast | CPT 71250 | $751.00 |
| CT chest with contrast | CPT 71260 | $969.00 |
| CT chest with and without contrast | CPT 71270 | $1,194.00 |
| Lumbosacral spine X-ray | CPT 72100 | $118.00 |
| CT cervical spine without contrast | CPT 72125 | $858.00 |
| CT thoracic spine without contrast | CPT 72128 | $855.00 |
| CT lumbar spine without contrast | CPT 72131 | $851.00 |
| MRI cervical spine without contrast | CPT 72141 | $961.00 |
| MRI thoracic spine without contrast | CPT 72146 | $963.00 |
| MRI lumbar spine without contrast | CPT 72148 | $963.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,703.00 |
| MRI lumbar spine with contrast | CPT 72158 | $1,699.00 |
| CT pelvis without contrast | CPT 72192 | $617.00 |
| CT pelvis with contrast | CPT 72193 | $1,308.00 |
| Shoulder X-ray | CPT 73030 | $102.00 |
| Humerus X-ray | CPT 73060 | $98.00 |
| Hand X-ray 3 views | CPT 73130 | $113.00 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,085.00 |
| Knee X-ray 1-2 views | CPT 73560 | $107.00 |
| Ankle X-ray 3 views | CPT 73610 | $115.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,085.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $764.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,659.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,875.00 |
| MRI abdomen with and without contrast | CPT 74183 | $1,977.00 |
| Abdominal ultrasound complete | CPT 76700 | $328.00 |
| Abdominal ultrasound limited | CPT 76705 | $246.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $305.00 |
| Transvaginal ultrasound | CPT 76830 | $358.00 |
| Pelvic ultrasound complete | CPT 76856 | $302.00 |
| Scrotal ultrasound | CPT 76870 | $293.00 |
| Diagnostic mammography unilateral | CPT 77065 | $367.00 |
| Diagnostic mammography bilateral | CPT 77066 | $469.00 |
| Screening mammography bilateral | CPT 77067 | $389.00 |
| EKG complete | CPT 93000 | $98.00 |
| EKG tracing only | CPT 93005 | $61.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $524.00 |
| COPD w MCC | MS-DRG 190 | $28.50 |
| COPD w/o CC/MCC | MS-DRG 192 | $28.50 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $28.50 |
| Basic metabolic panel (BMP) | CPT 80048 | $39.00 |
| General health panel | CPT 80050 | $155.00 |
| Comprehensive metabolic panel | CPT 80053 | $48.00 |
| Lipid panel | CPT 80061 | $62.00 |
| Renal function panel | CPT 80069 | $39.00 |
| Hepatic function panel | CPT 80076 | $37.00 |
| Urinalysis automated | CPT 81003 | $11.00 |
| Glucose quantitative | CPT 82947 | $18.00 |
| Hemoglobin A1c | CPT 83036 | $44.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $78.00 |
| Complete blood count with automated differential | CPT 85025 | $36.00 |
| Complete blood count without differential | CPT 85027 | $29.00 |
| Urine culture bacterial | CPT 87086 | $37.00 |
| Urine culture identification | CPT 87088 | $37.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $76.00 |
| Office visit, established patient, 5 min | CPT 99211 | $34.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $48.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $57.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $73.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $85.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,607.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,633.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $346.00 |
| Colonoscopy diagnostic | CPT 45378 | $1,633.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,633.00 |
| Colonoscopy with polyp removal | CPT 45385 | $2,134.00 |
| Major joint replacement w/o MCC | MS-DRG 470 | $28.50 |
| OR procedure for obesity w CC | MS-DRG 620 | $28.50 |
