| Psychotherapy 30 minutes | CPT 90832 | $153.00 |
| Psychotherapy 45 minutes | CPT 90834 | $189.00 |
| Psychotherapy 60 minutes | CPT 90837 | $193.00 |
| ED visit level 1 | CPT 99281 | $65.00 |
| ED visit level 2 | CPT 99282 | $106.00 |
| ED visit level 3 | CPT 99283 | $177.00 |
| ED visit level 4 | CPT 99284 | $339.00 |
| ED visit level 5 | CPT 99285 | $1,084.00 |
| Critical care, first hour | CPT 99291 | $1,626.00 |
| CT head without contrast | CPT 70450 | $401.00 |
| CT head with contrast | CPT 70460 | $492.00 |
| CT head with and without contrast | CPT 70470 | $599.00 |
| CT neck with contrast | CPT 70491 | $357.00 |
| MRI brain without contrast | CPT 70551 | $564.00 |
| MRI brain with and without contrast | CPT 70553 | $880.00 |
| Chest X-ray single view | CPT 71045 | $52.00 |
| Chest X-ray 2 views | CPT 71046 | $53.00 |
| Chest X-ray 3 views | CPT 71047 | $87.00 |
| CT chest without contrast | CPT 71250 | $402.00 |
| CT chest with contrast | CPT 71260 | $596.00 |
| CT chest with and without contrast | CPT 71270 | $725.00 |
| MRI chest without contrast | CPT 71550 | $564.00 |
| MRI chest with contrast | CPT 71551 | $880.00 |
| MRI chest with and without contrast | CPT 71552 | $1,129.00 |
| Lumbosacral spine X-ray | CPT 72100 | $81.00 |
| CT cervical spine without contrast | CPT 72125 | $511.00 |
| CT thoracic spine without contrast | CPT 72128 | $497.00 |
| CT lumbar spine without contrast | CPT 72131 | $533.50 |
| MRI cervical spine without contrast | CPT 72141 | $564.00 |
| MRI thoracic spine without contrast | CPT 72146 | $564.00 |
| MRI lumbar spine without contrast | CPT 72148 | $564.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $880.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,129.00 |
| MRI lumbar spine with contrast | CPT 72158 | $1,129.00 |
| CT pelvis without contrast | CPT 72192 | $503.00 |
| CT pelvis with contrast | CPT 72193 | $572.00 |
| Shoulder X-ray | CPT 73030 | $55.00 |
| Humerus X-ray | CPT 73060 | $53.00 |
| Hand X-ray 3 views | CPT 73130 | $58.00 |
| MRI upper extremity joint without contrast | CPT 73221 | $564.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,129.00 |
| Knee X-ray 1-2 views | CPT 73560 | $49.00 |
| Ankle X-ray 3 views | CPT 73610 | $58.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $564.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,129.00 |
| CT abdomen without contrast | CPT 74150 | $498.00 |
| CT abdomen with contrast | CPT 74160 | $584.00 |
| CT abdomen with and without contrast | CPT 74170 | $705.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,066.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,257.50 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,302.00 |
| MRI abdomen without contrast | CPT 74181 | $564.00 |
| MRI abdomen with and without contrast | CPT 74183 | $1,129.00 |
| Abdominal ultrasound complete | CPT 76700 | $174.00 |
| Abdominal ultrasound limited | CPT 76705 | $110.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $141.00 |
| Obstetric ultrasound first trimester | CPT 76801 | $245.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $245.00 |
| Transvaginal ultrasound | CPT 76830 | $127.00 |
| Pelvic ultrasound complete | CPT 76856 | $141.00 |
| Scrotal ultrasound | CPT 76870 | $155.00 |
| EKG complete | CPT 93000 | $8.00 |
| EKG tracing only | CPT 93005 | $48.00 |
| Transthoracic echocardiogram | CPT 93307 | $515.00 |
| Initial hospital care, low complexity | CPT 99221 | $50.00 |
| Initial hospital care, moderate complexity | CPT 99222 | $67.00 |
| Initial hospital care, high complexity | CPT 99223 | $99.00 |
| Hospital discharge, <30 min | CPT 99238 | $39.00 |
| Hospital discharge, >30 min | CPT 99239 | $52.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $35.00 |
| General health panel | CPT 80050 | $120.00 |
| Electrolyte panel | CPT 80051 | $18.00 |
| Comprehensive metabolic panel | CPT 80053 | $66.50 |
| Lipid panel | CPT 80061 | $13.50 |
| Renal function panel | CPT 80069 | $54.00 |
| Hepatic function panel | CPT 80076 | $31.00 |
| Urinalysis non-automated | CPT 81002 | $2.00 |
| Urinalysis automated | CPT 81003 | $9.00 |
| Glucose quantitative | CPT 82947 | $4.00 |
| Hemoglobin A1c | CPT 83036 | $12.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $17.50 |
| Complete blood count with automated differential | CPT 85025 | $20.00 |
| Complete blood count without differential | CPT 85027 | $18.00 |
| Urine culture bacterial | CPT 87086 | $28.00 |
| Urine culture identification | CPT 87088 | $20.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $62.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | $36.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $55.50 |
| Office visit, new patient, 45-59 min | CPT 99204 | $82.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $100.50 |
| Office visit, established patient, 5 min | CPT 99211 | $101.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $101.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $53.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $66.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $73.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $717.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $253.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $108.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $158.00 |
| Colonoscopy diagnostic | CPT 45378 | $540.00 |
| Colonoscopy with biopsy | CPT 45380 | $724.50 |
| Colonoscopy with polyp removal | CPT 45385 | $850.00 |
| Laparoscopic appendectomy | CPT 44970 | $2,063.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $2,231.50 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $3,007.00 |
| Open umbilical hernia repair | CPT 49560 | $2,461.00 |
| Umbilical hernia repair age 5+ | CPT 49585 | $2,461.00 |
| Lap inguinal hernia repair | CPT 49650 | $2,461.00 |
| Cataract surgery with lens implant | CPT 66984 | $1,565.00 |
