| Psychotherapy 30 minutes | CPT 90832 | $152.00 |
| Psychotherapy 45 minutes | CPT 90834 | $152.00 |
| Psychotherapy 60 minutes | CPT 90837 | $160.00 |
| ED visit level 1 | CPT 99281 | $132.00 |
| ED visit level 2 | CPT 99282 | $271.00 |
| ED visit level 3 | CPT 99283 | $128.00 |
| ED visit level 4 | CPT 99284 | $178.00 |
| ED visit level 5 | CPT 99285 | $305.00 |
| Critical care, first hour | CPT 99291 | $1,575.00 |
| CT head without contrast | CPT 70450 | $110.00 |
| CT head with contrast | CPT 70460 | $184.00 |
| CT head with and without contrast | CPT 70470 | $184.00 |
| CT neck with contrast | CPT 70491 | $184.00 |
| MRI brain without contrast | CPT 70551 | $245.00 |
| MRI brain with contrast | CPT 70552 | $385.00 |
| MRI brain with and without contrast | CPT 70553 | $385.00 |
| Chest X-ray single view | CPT 71045 | $133.00 |
| Chest X-ray 2 views | CPT 71046 | $91.00 |
| Chest X-ray 3 views | CPT 71047 | $91.00 |
| CT chest without contrast | CPT 71250 | $110.00 |
| CT chest with contrast | CPT 71260 | $184.00 |
| CT chest with and without contrast | CPT 71270 | $184.00 |
| MRI chest without contrast | CPT 71550 | $245.00 |
| MRI chest with contrast | CPT 71551 | $801.00 |
| MRI chest with and without contrast | CPT 71552 | $385.00 |
| Lumbosacral spine X-ray | CPT 72100 | $110.00 |
| CT cervical spine without contrast | CPT 72125 | $110.00 |
| CT thoracic spine without contrast | CPT 72128 | $110.00 |
| CT lumbar spine without contrast | CPT 72131 | $110.00 |
| MRI cervical spine without contrast | CPT 72141 | $245.00 |
| MRI thoracic spine without contrast | CPT 72146 | $245.00 |
| MRI lumbar spine without contrast | CPT 72148 | $245.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $385.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $385.00 |
| MRI lumbar spine with contrast | CPT 72158 | $385.00 |
| CT pelvis without contrast | CPT 72192 | $110.00 |
| CT pelvis with contrast | CPT 72193 | $184.00 |
| Shoulder X-ray | CPT 73030 | $91.00 |
| Humerus X-ray | CPT 73060 | $91.00 |
| Hand X-ray 3 views | CPT 73130 | $91.00 |
| MRI upper extremity joint without contrast | CPT 73221 | $245.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $385.00 |
| Knee X-ray 1-2 views | CPT 73560 | $91.00 |
| Ankle X-ray 3 views | CPT 73610 | $91.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $245.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $385.00 |
| CT abdomen without contrast | CPT 74150 | $110.00 |
| CT abdomen with contrast | CPT 74160 | $184.00 |
| CT abdomen with and without contrast | CPT 74170 | $184.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $245.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $385.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $385.00 |
| MRI abdomen without contrast | CPT 74181 | $245.00 |
| MRI abdomen with and without contrast | CPT 74183 | $385.00 |
| Abdominal ultrasound complete | CPT 76700 | $110.00 |
| Abdominal ultrasound limited | CPT 76705 | $110.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $110.00 |
| Obstetric ultrasound first trimester | CPT 76801 | $110.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $169.00 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $233.00 |
| Transvaginal ultrasound | CPT 76830 | $110.00 |
| Pelvic ultrasound complete | CPT 76856 | $110.00 |
| Scrotal ultrasound | CPT 76870 | $110.00 |
| Diagnostic mammography unilateral | CPT 77065 | $223.00 |
| Diagnostic mammography bilateral | CPT 77066 | $272.00 |
| Screening mammography bilateral | CPT 77067 | $204.50 |
| EKG complete | CPT 93000 | $24.00 |
| EKG tracing only | CPT 93005 | $61.00 |
| EKG interpretation only | CPT 93010 | $14.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $552.00 |
| Initial hospital care, low complexity | CPT 99221 | $150.00 |
| Initial hospital care, moderate complexity | CPT 99222 | $203.00 |
| Initial hospital care, high complexity | CPT 99223 | $300.00 |
| Hospital discharge, <30 min | CPT 99238 | $142.00 |
| Hospital discharge, >30 min | CPT 99239 | $158.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $40.00 |
| Electrolyte panel | CPT 80051 | $34.00 |
| Comprehensive metabolic panel | CPT 80053 | $50.00 |
| Lipid panel | CPT 80061 | $54.00 |
| Hepatic function panel | CPT 80076 | $39.00 |
| Urinalysis automated | CPT 81003 | $12.00 |
| Glucose quantitative | CPT 82947 | $25.00 |
| Hemoglobin A1c | CPT 83036 | $14.50 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $121.00 |
| Complete blood count with automated differential | CPT 85025 | $29.00 |
| Complete blood count without differential | CPT 85027 | $47.00 |
| Urine culture bacterial | CPT 87086 | $38.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $132.00 |
| Fetal non-stress test | CPT 59025 | $244.00 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $5,670.00 |
| Vaginal delivery only | CPT 59409 | $2,363.00 |
| Vaginal delivery with postpartum | CPT 59410 | $1,539.00 |
| Routine obstetric care with C-section | CPT 59510 | $6,889.00 |
| C-section delivery only | CPT 59514 | $218.00 |
| C-section with postpartum | CPT 59515 | $1,871.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | $93.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $158.00 |
| Office visit, new patient, 45-59 min | CPT 99204 | $242.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $304.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $55.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $91.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $214.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $224.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $864.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $864.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $871.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $871.00 |
| Colonoscopy diagnostic | CPT 45378 | $871.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,124.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,124.00 |
| Total shoulder arthroplasty | CPT 23472 | $17,756 |
| Hip hemiarthroplasty | CPT 27125 | $1,868.00 |
| Total hip replacement | CPT 27130 | $12,540 |
| Total knee replacement | CPT 27447 | $12,540 |
| Knee revision arthroplasty single component | CPT 27486 | $2,130.00 |
| Knee revision arthroplasty all components | CPT 27487 | $3,162.00 |
| Shoulder arthroscopy with decompression | CPT 29826 | $6,376.50 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,816.00 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,084.00 |
| ACL reconstruction | CPT 29888 | $6,816.00 |
| Laparoscopic appendectomy | CPT 44970 | $5,498.00 |
| Major joint replacement w/o MCC | MS-DRG 470 | $7,172.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,498.00 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,498.00 |
| Open umbilical hernia repair | CPT 49560 | $1,100.00 |
| Umbilical hernia repair age 5+ | CPT 49585 | $665.00 |
| Lap inguinal hernia repair | CPT 49650 | $5,498.00 |
| Total abdominal hysterectomy | CPT 58150 | $1,486.00 |
| Vaginal hysterectomy | CPT 58260 | $4,739.00 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $9,808.00 |
| Lap salpingo-oophorectomy | CPT 58661 | $985.00 |
| Cataract surgery with lens implant | CPT 66984 | $2,331.00 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $7,172.00 |
