| ED visit level 1 | CPT 99281 | $241.18 |
| ED visit level 2 | CPT 99282 | $241.18 |
| ED visit level 3 | CPT 99283 | $241.18 |
| ED visit level 4 | CPT 99284 | $241.18 |
| ED visit level 5 | CPT 99285 | $241.18 |
| Critical care, first hour | CPT 99291 | $241.18 |
| CT head without contrast | CPT 70450 | $1,074.27 |
| CT head with contrast | CPT 70460 | $1,244.97 |
| CT head with and without contrast | CPT 70470 | $557.25 |
| CT neck with contrast | CPT 70491 | $1,166.45 |
| MRI brain without contrast | CPT 70551 | $1,564.75 |
| MRI brain with contrast | CPT 70552 | $1,735.45 |
| MRI brain with and without contrast | CPT 70553 | $2,019.95 |
| Chest X-ray single view | CPT 71045 | $152.49 |
| Chest X-ray 2 views | CPT 71046 | $182.65 |
| Chest X-ray 3 views | CPT 71047 | $218.61 |
| CT chest without contrast | CPT 71250 | $1,277.97 |
| CT chest with contrast | CPT 71260 | $2,299.08 |
| CT chest with and without contrast | CPT 71270 | $1,619.37 |
| MRI chest without contrast | CPT 71550 | $1,564.75 |
| MRI chest with contrast | CPT 71551 | $1,441.13 |
| MRI chest with and without contrast | CPT 71552 | $2,019.95 |
| Lumbosacral spine X-ray | CPT 72100 | $228.74 |
| CT cervical spine without contrast | CPT 72125 | $1,192.62 |
| CT thoracic spine without contrast | CPT 72128 | $1,192.62 |
| CT lumbar spine without contrast | CPT 72131 | $1,192.62 |
| MRI cervical spine without contrast | CPT 72141 | $1,638.72 |
| MRI thoracic spine without contrast | CPT 72146 | $1,638.72 |
| MRI lumbar spine without contrast | CPT 72148 | $1,638.72 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,809.42 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,093.92 |
| MRI lumbar spine with contrast | CPT 72158 | $2,093.92 |
| CT pelvis without contrast | CPT 72192 | $1,138.00 |
| CT pelvis with contrast | CPT 72193 | $1,308.70 |
| Shoulder X-ray | CPT 73030 | $342.02 |
| Humerus X-ray | CPT 73060 | $203.40 |
| Hand X-ray 3 views | CPT 73130 | $316.54 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,777.90 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,280.60 |
| Knee X-ray 1-2 views | CPT 73560 | $304.78 |
| Ankle X-ray 3 views | CPT 73610 | $259.46 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,518.60 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,917.53 |
| CT abdomen without contrast | CPT 74150 | $1,172.14 |
| CT abdomen with contrast | CPT 74160 | $1,342.84 |
| CT abdomen with and without contrast | CPT 74170 | $1,627.34 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,826.49 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,341.80 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,224.79 |
| MRI abdomen without contrast | CPT 74181 | $1,564.75 |
| MRI abdomen with and without contrast | CPT 74183 | $2,019.95 |
| Abdominal ultrasound complete | CPT 76700 | $611.68 |
| Abdominal ultrasound limited | CPT 76705 | $769.30 |
| Retroperitoneal ultrasound complete | CPT 76770 | $463.74 |
| Obstetric ultrasound first trimester | CPT 76801 | $384.08 |
| Obstetric ultrasound after first trimester | CPT 76805 | $455.20 |
| Transvaginal ultrasound | CPT 76830 | $421.06 |
| Pelvic ultrasound complete | CPT 76856 | $483.65 |
| Scrotal ultrasound | CPT 76870 | $403.99 |
| EKG tracing only | CPT 93005 | $53.04 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,226.20 |
| Transthoracic echocardiogram | CPT 93307 | $575.70 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $90.76 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $90.76 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $90.76 |
| COPD w MCC | MS-DRG 190 | $90.76 |
| COPD w CC | MS-DRG 191 | $90.76 |
| COPD w/o CC/MCC | MS-DRG 192 | $90.76 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $90.76 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $90.76 |
| AMI discharged alive w MCC | MS-DRG 280 | $90.76 |
| Heart failure & shock w MCC | MS-DRG 291 | $90.76 |
| Heart failure & shock w CC | MS-DRG 292 | $92.88 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $90.76 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $90.76 |
| Kidney/UTI w MCC | MS-DRG 689 | $90.76 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $100.00 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $90.76 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $90.76 |
| Basic metabolic panel (BMP) | CPT 80048 | $74.54 |
| General health panel | CPT 80050 | $260.60 |
| Electrolyte panel | CPT 80051 | $17.20 |
| Comprehensive metabolic panel | CPT 80053 | $96.16 |
| Lipid panel | CPT 80061 | $125.44 |
| Renal function panel | CPT 80069 | $78.52 |
| Hepatic function panel | CPT 80076 | $57.28 |
| Urinalysis non-automated | CPT 81002 | $130.59 |
| Urinalysis automated | CPT 81003 | $51.94 |
| Glucose quantitative | CPT 82947 | $5.25 |
| Hemoglobin A1c | CPT 83036 | $109.76 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $150.92 |
| Complete blood count with automated differential | CPT 85025 | $8.63 |
| Complete blood count without differential | CPT 85027 | $35.10 |
| Urine culture bacterial | CPT 87086 | $64.30 |
| Tissue exam by pathologist level IV | CPT 88305 | $100.78 |
| Vaginal delivery only | CPT 59409 | $786.15 |
| Office visit, new patient, 15-29 min | CPT 99202 | $34.65 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $62.59 |
| Office visit, new patient, 45-59 min | CPT 99204 | $62.59 |
| Office visit, new patient, 60-74 min | CPT 99205 | $100.71 |
| Office visit, established patient, 5 min | CPT 99211 | $25.61 |
| Office visit, established patient, 10-19 min | CPT 99212 | $35.28 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $241.18 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $241.18 |
| Office visit, established patient, 40-54 min | CPT 99215 | $241.18 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | $901.68 |
| Sigmoidoscopy diagnostic | CPT 45330 | $45.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | — |
| Colonoscopy diagnostic | CPT 45378 | $56.90 |
| Colonoscopy with biopsy | CPT 45380 | — |
| Colonoscopy with polyp removal | CPT 45385 | — |
| Complex cataract surgery | CPT 66982 | $2,557.09 |
| Cataract surgery with lens implant | CPT 66984 | $2,458.65 |
