| ED visit level 1 | CPT 99281 | $319.48 |
| ED visit level 2 | CPT 99282 | $585.92 |
| ED visit level 3 | CPT 99283 | $832.00 |
| ED visit level 4 | CPT 99284 | $950.95 |
| ED visit level 5 | CPT 99285 | $1,100.74 |
| Critical care, first hour | CPT 99291 | $1,212.27 |
| CT head without contrast | CPT 70450 | $103.57 |
| CT head with contrast | CPT 70460 | $337.39 |
| CT head with and without contrast | CPT 70470 | $308.28 |
| CT neck with contrast | CPT 70491 | $402.07 |
| MRI brain without contrast | CPT 70551 | $196.82 |
| MRI brain with contrast | CPT 70552 | $1,094.53 |
| MRI brain with and without contrast | CPT 70553 | $1,086.27 |
| Chest X-ray single view | CPT 71045 | $88.91 |
| Chest X-ray 2 views | CPT 71046 | $83.70 |
| Chest X-ray 3 views | CPT 71047 | $88.91 |
| CT chest without contrast | CPT 71250 | $414.82 |
| CT chest with contrast | CPT 71260 | $600.19 |
| CT chest with and without contrast | CPT 71270 | $650.04 |
| MRI chest without contrast | CPT 71550 | $637.94 |
| MRI chest with contrast | CPT 71551 | $813.12 |
| MRI chest with and without contrast | CPT 71552 | $992.71 |
| Lumbosacral spine X-ray | CPT 72100 | $103.57 |
| CT cervical spine without contrast | CPT 72125 | $540.37 |
| CT thoracic spine without contrast | CPT 72128 | $540.37 |
| CT lumbar spine without contrast | CPT 72131 | $291.47 |
| MRI cervical spine without contrast | CPT 72141 | $617.60 |
| MRI thoracic spine without contrast | CPT 72146 | $617.60 |
| MRI lumbar spine without contrast | CPT 72148 | $617.60 |
| MRI lumbar spine with and without contrast | CPT 72149 | $617.60 |
| MRI cervical spine with and without contrast | CPT 72156 | $617.60 |
| MRI lumbar spine with contrast | CPT 72158 | $617.60 |
| CT pelvis without contrast | CPT 72192 | $447.77 |
| CT pelvis with contrast | CPT 72193 | $798.34 |
| Shoulder X-ray | CPT 73030 | $86.21 |
| Humerus X-ray | CPT 73060 | $86.21 |
| Hand X-ray 3 views | CPT 73130 | $86.21 |
| MRI upper extremity joint without contrast | CPT 73221 | $697.23 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $697.23 |
| Knee X-ray 1-2 views | CPT 73560 | $86.21 |
| Ankle X-ray 3 views | CPT 73610 | $86.21 |
| MRI lower extremity joint without contrast | CPT 73721 | $697.23 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $697.23 |
| CT abdomen without contrast | CPT 74150 | $452.07 |
| CT abdomen with contrast | CPT 74160 | $600.19 |
| CT abdomen with and without contrast | CPT 74170 | $798.34 |
| CT abdomen and pelvis without contrast | CPT 74176 | $229.48 |
| CT abdomen and pelvis with contrast | CPT 74177 | $798.34 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $798.34 |
| MRI abdomen without contrast | CPT 74181 | $739.22 |
| MRI abdomen with and without contrast | CPT 74183 | $1,075.43 |
| Abdominal ultrasound complete | CPT 76700 | $223.07 |
| Abdominal ultrasound limited | CPT 76705 | $223.07 |
| Retroperitoneal ultrasound complete | CPT 76770 | $527.24 |
| Pelvic ultrasound complete | CPT 76856 | $193.59 |
| Scrotal ultrasound | CPT 76870 | $144.43 |
| EKG complete | CPT 93000 | $60.49 |
| EKG tracing only | CPT 93005 | $68.75 |
| EKG interpretation only | CPT 93010 | $34.97 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,330.19 |
| Transthoracic echocardiogram | CPT 93307 | $1,465.46 |
| Stress echocardiogram | CPT 93350 | $719.74 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,850.23 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,947.44 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $11,649 |
| COPD w MCC | MS-DRG 190 | $7,792.09 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,785.93 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,007.76 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,940 |
| AMI discharged alive w CC | MS-DRG 281 | $7,986.98 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,334.36 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,156 |
| Heart failure & shock w CC | MS-DRG 292 | $7,377.81 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,547 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,393.23 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,905.88 |
| GI hemorrhage w CC | MS-DRG 378 | $7,310.84 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,811.70 |
| Kidney/UTI w MCC | MS-DRG 689 | $8,162.09 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $14,481 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,458.09 |
| Basic metabolic panel (BMP) | CPT 80048 | $53.00 |
| Electrolyte panel | CPT 80051 | $22.96 |
| Comprehensive metabolic panel | CPT 80053 | $40.89 |
| Lipid panel | CPT 80061 | $33.15 |
| Renal function panel | CPT 80069 | $40.89 |
| Hepatic function panel | CPT 80076 | $40.89 |
| Urinalysis non-automated | CPT 81002 | $8.42 |
| Urinalysis automated | CPT 81003 | $15.18 |
| Glucose quantitative | CPT 82947 | $60.00 |
| Hemoglobin A1c | CPT 83036 | $37.74 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $62.29 |
| Complete blood count with automated differential | CPT 85025 | $25.38 |
| Complete blood count without differential | CPT 85027 | $27.77 |
| Urine culture bacterial | CPT 87086 | $20.70 |
| Urine culture identification | CPT 87088 | $20.10 |
| Tissue exam by pathologist level IV | CPT 88305 | $88.42 |
| Office visit, new patient, 15-29 min | CPT 99202 | $171.55 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $141.49 |
| Office visit, new patient, 45-59 min | CPT 99204 | $128.05 |
| Office visit, new patient, 60-74 min | CPT 99205 | $234.05 |
| Office visit, established patient, 5 min | CPT 99211 | $105.53 |
| Office visit, established patient, 10-19 min | CPT 99212 | $128.05 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $141.49 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $128.05 |
| Office visit, established patient, 40-54 min | CPT 99215 | $234.05 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,345.11 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,031.67 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $16,614 |
| PCI single major coronary artery | CPT 92920 | $5,814.84 |
| PCI with drug-eluting stent | CPT 92928 | $11,615 |
| PCI bypass graft | CPT 92937 | $22,206 |
| Left heart catheterization | CPT 93452 | $7,794.98 |
| Coronary angiography with cath | CPT 93455 | $3,312.15 |
| Coronary angiography with bypass cath | CPT 93458 | $3,312.15 |
