| ED visit level 1 | CPT 99281 | $620 |
| ED visit level 2 | CPT 99282 | $620 |
| ED visit level 3 | CPT 99283 | $1,020 |
| ED visit level 4 | CPT 99284 | $1,020 |
| ED visit level 5 | CPT 99285 | $1,159 |
| Critical care, first hour | CPT 99291 | $1,059.5 |
| CT head without contrast | CPT 70450 | $180 |
| CT head with contrast | CPT 70460 | $229.48 |
| CT head with and without contrast | CPT 70470 | $229.48 |
| CT neck with contrast | CPT 70491 | $229.48 |
| MRI brain without contrast | CPT 70551 | $959.31 |
| MRI brain with contrast | CPT 70552 | $473.13 |
| MRI brain with and without contrast | CPT 70553 | $473.13 |
| Chest X-ray single view | CPT 71045 | $74.27 |
| Chest X-ray 2 views | CPT 71046 | $74.27 |
| Chest X-ray 3 views | CPT 71047 | $74.27 |
| CT chest without contrast | CPT 71250 | $180 |
| CT chest with contrast | CPT 71260 | $229.48 |
| CT chest with and without contrast | CPT 71270 | $229.48 |
| MRI chest without contrast | CPT 71550 | $295.78 |
| MRI chest with contrast | CPT 71551 | $775 |
| MRI chest with and without contrast | CPT 71552 | $608.88 |
| Lumbosacral spine X-ray | CPT 72100 | $96.96 |
| CT cervical spine without contrast | CPT 72125 | $180 |
| CT thoracic spine without contrast | CPT 72128 | $180 |
| CT lumbar spine without contrast | CPT 72131 | $180 |
| MRI cervical spine without contrast | CPT 72141 | $295.78 |
| MRI thoracic spine without contrast | CPT 72146 | $295.78 |
| MRI lumbar spine without contrast | CPT 72148 | $295.78 |
| MRI lumbar spine with and without contrast | CPT 72149 | $473.13 |
| MRI cervical spine with and without contrast | CPT 72156 | $473.13 |
| MRI lumbar spine with contrast | CPT 72158 | $473.13 |
| CT pelvis without contrast | CPT 72192 | $180 |
| CT pelvis with contrast | CPT 72193 | $229.48 |
| Shoulder X-ray | CPT 73030 | $69.12 |
| Humerus X-ray | CPT 73060 | $69.12 |
| Hand X-ray 3 views | CPT 73130 | $69.12 |
| MRI upper extremity joint without contrast | CPT 73221 | $295.78 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $608.88 |
| Knee X-ray 1-2 views | CPT 73560 | $69.12 |
| Ankle X-ray 3 views | CPT 73610 | $69.12 |
| MRI lower extremity joint without contrast | CPT 73721 | $844.5 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,065.6 |
| CT abdomen without contrast | CPT 74150 | $180 |
| CT abdomen with contrast | CPT 74160 | $229.48 |
| CT abdomen with and without contrast | CPT 74170 | $229.48 |
| CT abdomen and pelvis without contrast | CPT 74176 | $295.78 |
| CT abdomen and pelvis with contrast | CPT 74177 | $473.13 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $473.13 |
| MRI abdomen without contrast | CPT 74181 | $295.78 |
| MRI abdomen with and without contrast | CPT 74183 | $473.13 |
| Abdominal ultrasound complete | CPT 76700 | $156.11 |
| Abdominal ultrasound limited | CPT 76705 | $128.13 |
| Retroperitoneal ultrasound complete | CPT 76770 | $140.05 |
| Obstetric ultrasound first trimester | CPT 76801 | $154.44 |
| Obstetric ultrasound after first trimester | CPT 76805 | $154.44 |
| Transvaginal ultrasound | CPT 76830 | $154.44 |
| Pelvic ultrasound complete | CPT 76856 | $154.44 |
| Diagnostic mammography unilateral | CPT 77065 | $127.33 |
| Diagnostic mammography bilateral | CPT 77066 | $163.3 |
| Screening mammography bilateral | CPT 77067 | $128.31 |
| EKG complete | CPT 93000 | $173.7 |
| EKG tracing only | CPT 93005 | $139.46 |
| Transthoracic echocardiogram complete | CPT 93306 | $605.13 |
| Transthoracic echocardiogram | CPT 93307 | $273.25 |
| Stress echocardiogram | CPT 93350 | $561.16 |
| Basic metabolic panel (BMP) | CPT 80048 | $12.39 |
| General health panel | CPT 80050 | $56.18 |
| Electrolyte panel | CPT 80051 | $10.26 |
| Comprehensive metabolic panel | CPT 80053 | $9.13 |
| Lipid panel | CPT 80061 | $21.18 |
| Renal function panel | CPT 80069 | $12.71 |
| Hepatic function panel | CPT 80076 | $11.96 |
| Urinalysis non-automated | CPT 81002 | $3.77 |
| Urinalysis automated | CPT 81003 | $1.95 |
| Glucose quantitative | CPT 82947 | $6.05 |
| Hemoglobin A1c | CPT 83036 | $14.2 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $14.53 |
| Complete blood count with automated differential | CPT 85025 | $11.34 |
| Complete blood count without differential | CPT 85027 | $9.45 |
| Urine culture bacterial | CPT 87086 | $6.98 |
| Urine culture identification | CPT 87088 | $11.8 |
| Tissue exam by pathologist level IV | CPT 88305 | $143.56 |
| Fetal non-stress test | CPT 59025 | $314.2 |
| Vaginal delivery only | CPT 59409 | $2,504.54 |
| Office visit, new patient, 15-29 min | CPT 99202 | $121.93 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $160.23 |
| Office visit, new patient, 45-59 min | CPT 99204 | $212.63 |
| Office visit, new patient, 60-74 min | CPT 99205 | $290.72 |
| Office visit, established patient, 5 min | CPT 99211 | $105.31 |
| Office visit, established patient, 10-19 min | CPT 99212 | $105.31 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $105.31 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $212.63 |
| Office visit, established patient, 40-54 min | CPT 99215 | $290.72 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,159 |
| Upper GI endoscopy with biopsy | CPT 43239 | $906.76 |
| Sigmoidoscopy diagnostic | CPT 45330 | $888.9 |
| Sigmoidoscopy with biopsy | CPT 45331 | $888.9 |
| Colonoscopy diagnostic | CPT 45378 | $888.9 |
| Colonoscopy with biopsy | CPT 45380 | $1,061.68 |
| Colonoscopy with polyp removal | CPT 45385 | $1,161.41 |
| Total shoulder arthroplasty | CPT 23472 | $11,305 |
| Total hip replacement | CPT 27130 | $11,305 |
| Total knee replacement | CPT 27447 | $11,305 |
| Knee revision arthroplasty single component | CPT 27486 | $7,085.31 |
| Knee revision arthroplasty all components | CPT 27487 | $11,305 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $5,878.99 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,645.54 |
| ACL reconstruction | CPT 29888 | $5,837.75 |
| Laparoscopic appendectomy | CPT 44970 | $4,715.37 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $4,785.06 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,010.18 |
| Cataract surgery with lens implant | CPT 66984 | $2,600 |
| PCI single major coronary artery | CPT 92920 | $4,732.6 |
| PCI with drug-eluting stent | CPT 92928 | $9,219.82 |
| PCI bypass graft | CPT 92937 | $9,219.82 |
| Left heart catheterization | CPT 93452 | $3,725.98 |
| Coronary angiography with cath | CPT 93455 | $3,131.24 |
| Coronary angiography with bypass cath | CPT 93458 | $4,200 |
