| Psychiatric eval with medical services | CPT 90792 | $80.00 |
| Psychotherapy 30 minutes | CPT 90832 | $75.00 |
| ED visit level 1 | CPT 99281 | $100.00 |
| ED visit level 2 | CPT 99282 | $55.00 |
| ED visit level 3 | CPT 99283 | $55.00 |
| ED visit level 4 | CPT 99284 | $100.00 |
| ED visit level 5 | CPT 99285 | $55.00 |
| Critical care, first hour | CPT 99291 | — |
| CT head without contrast | CPT 70450 | $80.00 |
| CT head with contrast | CPT 70460 | $80.00 |
| CT head with and without contrast | CPT 70470 | $80.00 |
| CT neck with contrast | CPT 70491 | $80.00 |
| CT chest without contrast | CPT 71250 | $80.00 |
| CT chest with contrast | CPT 71260 | $80.00 |
| CT chest with and without contrast | CPT 71270 | $80.00 |
| CT cervical spine without contrast | CPT 72125 | $80.00 |
| CT thoracic spine without contrast | CPT 72128 | $80.00 |
| CT lumbar spine without contrast | CPT 72131 | $80.00 |
| CT pelvis without contrast | CPT 72192 | $80.00 |
| CT pelvis with contrast | CPT 72193 | $80.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $80.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $80.00 |
| CT abdomen without contrast | CPT 74150 | $80.00 |
| CT abdomen with contrast | CPT 74160 | $80.00 |
| CT abdomen with and without contrast | CPT 74170 | $80.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $80.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $80.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $80.00 |
| Abdominal ultrasound limited | CPT 76705 | $80.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $80.00 |
| EKG tracing only | CPT 93005 | $80.00 |
| EKG interpretation only | CPT 93010 | $80.00 |
| Initial hospital care, low complexity | CPT 99221 | $80.00 |
| Initial hospital care, moderate complexity | CPT 99222 | $80.00 |
| Initial hospital care, high complexity | CPT 99223 | $80.00 |
| Hospital discharge, <30 min | CPT 99238 | — |
| Hospital discharge, >30 min | CPT 99239 | $80.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $70.00 |
| General health panel | CPT 80050 | $75.00 |
| Electrolyte panel | CPT 80051 | $70.00 |
| Comprehensive metabolic panel | CPT 80053 | $70.00 |
| Lipid panel | CPT 80061 | $70.00 |
| Renal function panel | CPT 80069 | $70.00 |
| Hepatic function panel | CPT 80076 | $70.00 |
| Urinalysis automated | CPT 81003 | $70.00 |
| Glucose quantitative | CPT 82947 | $70.00 |
| Hemoglobin A1c | CPT 83036 | $70.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $70.00 |
| Complete blood count with automated differential | CPT 85025 | $70.00 |
| Urine culture bacterial | CPT 87086 | $70.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $70.00 |
| Fetal non-stress test | CPT 59025 | $80.00 |
| Vaginal delivery only | CPT 59409 | — |
| C-section delivery only | CPT 59514 | $80.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | — |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $100.00 |
| Office visit, new patient, 45-59 min | CPT 99204 | $80.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $100.00 |
| Office visit, established patient, 5 min | CPT 99211 | $100.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $100.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $23.94 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $47.68 |
| Office visit, established patient, 40-54 min | CPT 99215 | $100.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $80.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $80.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $80.00 |
| Colonoscopy diagnostic | CPT 45378 | $80.00 |
| Colonoscopy with biopsy | CPT 45380 | $80.00 |
| Colonoscopy with polyp removal | CPT 45385 | $80.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $80.00 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $80.00 |
| Open umbilical hernia repair | CPT 49560 | — |
| Umbilical hernia repair age 5+ | CPT 49585 | $80.00 |
| Total abdominal hysterectomy | CPT 58150 | $80.00 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $80.00 |
| Lap salpingo-oophorectomy | CPT 58661 | $80.00 |
