| ED visit level 1 | CPT 99281 | $178.85 |
| ED visit level 2 | CPT 99282 | $407.20 |
| ED visit level 3 | CPT 99283 | $786.52 |
| ED visit level 4 | CPT 99284 | $1,091.18 |
| ED visit level 5 | CPT 99285 | $1,660.82 |
| Critical care, first hour | CPT 99291 | $2,476.36 |
| CT head without contrast | CPT 70450 | $1,255.10 |
| CT head with contrast | CPT 70460 | $1,509.69 |
| CT head with and without contrast | CPT 70470 | $1,850.66 |
| CT neck with contrast | CPT 70491 | $1,491.21 |
| MRI brain without contrast | CPT 70551 | $2,983.21 |
| MRI brain with contrast | CPT 70552 | $3,022.98 |
| MRI brain with and without contrast | CPT 70553 | $3,610.75 |
| Chest X-ray single view | CPT 71045 | $211.90 |
| Chest X-ray 2 views | CPT 71046 | $228.25 |
| Chest X-ray 3 views | CPT 71047 | $211.24 |
| CT chest without contrast | CPT 71250 | $1,285.68 |
| CT chest with contrast | CPT 71260 | $1,509.18 |
| CT chest with and without contrast | CPT 71270 | $2,014.98 |
| MRI chest without contrast | CPT 71550 | $2,135.65 |
| MRI chest with and without contrast | CPT 71552 | $2,916.17 |
| Lumbosacral spine X-ray | CPT 72100 | $500.53 |
| CT cervical spine without contrast | CPT 72125 | $1,473.23 |
| CT thoracic spine without contrast | CPT 72128 | $1,063.46 |
| CT lumbar spine without contrast | CPT 72131 | $1,506.10 |
| MRI cervical spine without contrast | CPT 72141 | $3,074.84 |
| MRI thoracic spine without contrast | CPT 72146 | $1,802.39 |
| MRI lumbar spine without contrast | CPT 72148 | $2,958.79 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,443.53 |
| MRI cervical spine with and without contrast | CPT 72156 | $4,077.19 |
| MRI lumbar spine with contrast | CPT 72158 | $4,165.00 |
| CT pelvis without contrast | CPT 72192 | $1,027.52 |
| CT pelvis with contrast | CPT 72193 | $2,180.84 |
| Shoulder X-ray | CPT 73030 | $334.65 |
| Humerus X-ray | CPT 73060 | $273.84 |
| Hand X-ray 3 views | CPT 73130 | $248.60 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,531.55 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,634.13 |
| Knee X-ray 1-2 views | CPT 73560 | $400.06 |
| Ankle X-ray 3 views | CPT 73610 | $340.69 |
| MRI lower extremity joint without contrast | CPT 73721 | $229.54 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $366.92 |
| CT abdomen without contrast | CPT 74150 | $1,236.00 |
| CT abdomen with contrast | CPT 74160 | $1,686.85 |
| CT abdomen with and without contrast | CPT 74170 | $1,809.06 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,944.63 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,244.86 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,160.08 |
| MRI abdomen without contrast | CPT 74181 | $1,669.39 |
| MRI abdomen with and without contrast | CPT 74183 | $2,918.74 |
| Abdominal ultrasound complete | CPT 76700 | $1,310.46 |
| Abdominal ultrasound limited | CPT 76705 | $993.86 |
| Retroperitoneal ultrasound complete | CPT 76770 | $579.23 |
| Obstetric ultrasound first trimester | CPT 76801 | $492.83 |
| Obstetric ultrasound after first trimester | CPT 76805 | $593.10 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $690.97 |
| Transvaginal ultrasound | CPT 76830 | $690.20 |
| Pelvic ultrasound complete | CPT 76856 | $927.90 |
| Scrotal ultrasound | CPT 76870 | $326.23 |
| Diagnostic mammography unilateral | CPT 77065 | $382.01 |
| Diagnostic mammography bilateral | CPT 77066 | $520.70 |
| Screening mammography bilateral | CPT 77067 | $402.59 |
| EKG tracing only | CPT 93005 | $167.14 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,573.75 |
| Transthoracic echocardiogram | CPT 93307 | $1,275.02 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $24,390 |
| COPD w MCC | MS-DRG 190 | $15,930 |
| COPD w CC | MS-DRG 191 | $14,977 |
| COPD w/o CC/MCC | MS-DRG 192 | $11,529 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $15,864 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $9,299.55 |
| AMI discharged alive w MCC | MS-DRG 280 | $17,483 |
| AMI discharged alive w CC | MS-DRG 281 | $8,866.18 |
| Heart failure & shock w MCC | MS-DRG 291 | $15,939 |
| Heart failure & shock w CC | MS-DRG 292 | $17,054 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,569 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $12,935 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $13,235 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $15,280 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $14,003 |
| Kidney/UTI w MCC | MS-DRG 689 | $18,141 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $17,071 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $23,200 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $16,712 |
| Basic metabolic panel (BMP) | CPT 80048 | $230.51 |
| General health panel | CPT 80050 | $596.90 |
| Electrolyte panel | CPT 80051 | $173.99 |
| Comprehensive metabolic panel | CPT 80053 | $309.25 |
| Lipid panel | CPT 80061 | $139.07 |
| Renal function panel | CPT 80069 | $163.83 |
| Hepatic function panel | CPT 80076 | $312.42 |
| Urinalysis non-automated | CPT 81002 | $22.23 |
| Urinalysis automated | CPT 81003 | $44.45 |
| Glucose quantitative | CPT 82947 | $56.52 |
| Hemoglobin A1c | CPT 83036 | $56.52 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $177.17 |
| Complete blood count with automated differential | CPT 85025 | $92.71 |
| Complete blood count without differential | CPT 85027 | $92.71 |
| Urine culture bacterial | CPT 87086 | $102.24 |
| Urine culture identification | CPT 87088 | $71.76 |
| Tissue exam by pathologist level IV | CPT 88305 | $289.62 |
| Office visit, new patient, 15-29 min | CPT 99202 | $193.78 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $222.25 |
| Office visit, new patient, 45-59 min | CPT 99204 | $285.75 |
| Office visit, new patient, 60-74 min | CPT 99205 | $371.48 |
| Office visit, established patient, 5 min | CPT 99211 | $83.19 |
| Office visit, established patient, 10-19 min | CPT 99212 | $111.13 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $142.88 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $190.50 |
| Office visit, established patient, 40-54 min | CPT 99215 | $247.65 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,863.71 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,863.71 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,812.11 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,812.11 |
| Colonoscopy diagnostic | CPT 45378 | $1,812.11 |
| Colonoscopy with biopsy | CPT 45380 | $2,343.79 |
| Colonoscopy with polyp removal | CPT 45385 | $2,343.79 |
