| Psychiatric diagnostic evaluation | CPT 90791 | $132.17 |
| Psychotherapy 30 minutes | CPT 90832 | $98.76 |
| Psychotherapy 45 minutes | CPT 90834 | $115.37 |
| Psychotherapy 60 minutes | CPT 90837 | $162.83 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $201.91 |
| ED visit level 1 | CPT 99281 | $99.8 |
| ED visit level 2 | CPT 99282 | $197.23 |
| ED visit level 3 | CPT 99283 | $300.07 |
| ED visit level 4 | CPT 99284 | $458.64 |
| ED visit level 5 | CPT 99285 | $811.54 |
| Critical care, first hour | CPT 99291 | $945.02 |
| CT head without contrast | CPT 70450 | $460.94 |
| CT head with contrast | CPT 70460 | $609.8 |
| CT head with and without contrast | CPT 70470 | $606.95 |
| CT neck with contrast | CPT 70491 | $639.58 |
| MRI brain without contrast | CPT 70551 | $962.95 |
| MRI brain with contrast | CPT 70552 | $1,064.24 |
| MRI brain with and without contrast | CPT 70553 | $1,211.73 |
| Chest X-ray single view | CPT 71045 | $106.11 |
| Chest X-ray 2 views | CPT 71046 | $140.4 |
| Chest X-ray 3 views | CPT 71047 | $74.63 |
| CT chest without contrast | CPT 71250 | $628.62 |
| CT chest with contrast | CPT 71260 | $625.89 |
| CT chest with and without contrast | CPT 71270 | $774.4 |
| MRI chest without contrast | CPT 71550 | $1,580.28 |
| MRI chest with and without contrast | CPT 71552 | $1,631.96 |
| Lumbosacral spine X-ray | CPT 72100 | $151.89 |
| CT cervical spine without contrast | CPT 72125 | $628.62 |
| CT thoracic spine without contrast | CPT 72128 | $628.62 |
| CT lumbar spine without contrast | CPT 72131 | $628.62 |
| MRI cervical spine without contrast | CPT 72141 | $921.55 |
| MRI thoracic spine without contrast | CPT 72146 | $923.94 |
| MRI lumbar spine without contrast | CPT 72148 | $915.73 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,069.04 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,223.03 |
| MRI lumbar spine with contrast | CPT 72158 | $1,214.81 |
| CT pelvis without contrast | CPT 72192 | $609.8 |
| CT pelvis with contrast | CPT 72193 | $621.78 |
| Shoulder X-ray | CPT 73030 | $127.46 |
| Humerus X-ray | CPT 73060 | $102.38 |
| Hand X-ray 3 views | CPT 73130 | $130.22 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,037.9 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,270.25 |
| Knee X-ray 1-2 views | CPT 73560 | $127.64 |
| Ankle X-ray 3 views | CPT 73610 | $131.69 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,037.9 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,264.77 |
| CT abdomen without contrast | CPT 74150 | $486.96 |
| CT abdomen with contrast | CPT 74160 | $633.07 |
| CT abdomen with and without contrast | CPT 74170 | $745.66 |
| CT abdomen and pelvis without contrast | CPT 74176 | $636.28 |
| CT abdomen and pelvis with contrast | CPT 74177 | $737.44 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,010.86 |
| MRI abdomen without contrast | CPT 74181 | $1,198.73 |
| MRI abdomen with and without contrast | CPT 74183 | $1,371.2 |
| Abdominal ultrasound complete | CPT 76700 | $236.12 |
| Abdominal ultrasound limited | CPT 76705 | $179.43 |
| Retroperitoneal ultrasound complete | CPT 76770 | $223.11 |
| Obstetric ultrasound first trimester | CPT 76801 | $213.54 |
| Obstetric ultrasound after first trimester | CPT 76805 | $248.44 |
| Transvaginal ultrasound | CPT 76830 | $166.42 |
| Pelvic ultrasound complete | CPT 76856 | $210.11 |
| Scrotal ultrasound | CPT 76870 | $209.09 |
| Screening mammography bilateral | CPT 77067 | $320.58 |
| EKG complete | CPT 93000 | $25.25 |
| EKG tracing only | CPT 93005 | $109.65 |
| EKG interpretation only | CPT 93010 | $14.04 |
| Transthoracic echocardiogram complete | CPT 93306 | $930.97 |
| Stress echocardiogram | CPT 93350 | $899.12 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $9,192.12 |
| COPD w MCC | MS-DRG 190 | $6,906.88 |
| COPD w CC | MS-DRG 191 | $5,577.43 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $5,391.09 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,500.1 |
| AMI discharged alive w MCC | MS-DRG 280 | $9,400.05 |
| AMI discharged alive w CC | MS-DRG 281 | $5,959.64 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $4,975.23 |
| Heart failure & shock w MCC | MS-DRG 291 | $7,791.34 |
| Heart failure & shock w CC | MS-DRG 292 | $5,607.56 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,186.19 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $7,390.55 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,038.51 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,186.69 |
| GI hemorrhage w CC | MS-DRG 378 | $6,269.02 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,509.64 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,259 |
| Kidney/UTI w MCC | MS-DRG 689 | $7,171.06 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $5,409.17 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $11,100 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $6,482.98 |
| Initial hospital care, low complexity | CPT 99221 | $138.74 |
| Initial hospital care, moderate complexity | CPT 99222 | $205.38 |
| Initial hospital care, high complexity | CPT 99223 | $287.14 |
| Hospital discharge, <30 min | CPT 99238 | $117.39 |
| Hospital discharge, >30 min | CPT 99239 | $172.86 |
| Basic metabolic panel (BMP) | CPT 80048 | $45.68 |
| General health panel | CPT 80050 | $106.49 |
| Electrolyte panel | CPT 80051 | $27.36 |
| Comprehensive metabolic panel | CPT 80053 | $88.22 |
| Lipid panel | CPT 80061 | $111.72 |
| Renal function panel | CPT 80069 | $23.87 |
| Hepatic function panel | CPT 80076 | $68.46 |
| Urinalysis automated | CPT 81003 | $18.06 |
| Glucose quantitative | CPT 82947 | $15.97 |
| Hemoglobin A1c | CPT 83036 | $53.76 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $59.76 |
| Complete blood count with automated differential | CPT 85025 | $65.46 |
| Complete blood count without differential | CPT 85027 | $18.83 |
| Urine culture bacterial | CPT 87086 | $33.13 |
| Urine culture identification | CPT 87088 | $30.32 |
| Tissue exam by pathologist level IV | CPT 88305 | $98.94 |
| Fetal non-stress test | CPT 59025 | $240.58 |
| Office visit, new patient, 15-29 min | CPT 99202 | $68.45 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $115.55 |
| Office visit, new patient, 45-59 min | CPT 99204 | $188.05 |
| Office visit, new patient, 60-74 min | CPT 99205 | $255.76 |
| Office visit, established patient, 5 min | CPT 99211 | $17.93 |
| Office visit, established patient, 10-19 min | CPT 99212 | $41.33 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $73.23 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $80.81 |
| Office visit, established patient, 40-54 min | CPT 99215 | $117.39 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,433.95 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,507.74 |
| Sigmoidoscopy diagnostic | CPT 45330 | $934.52 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,182.74 |
| Colonoscopy diagnostic | CPT 45378 | $1,421.38 |
| Colonoscopy with biopsy | CPT 45380 | $1,547.25 |
| Colonoscopy with polyp removal | CPT 45385 | $1,631.11 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $2,686.91 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $2,686.91 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $10,379 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $8,638.88 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $12,531 |
