| ED visit level 1 | CPT 99281 | $153.00 |
| ED visit level 2 | CPT 99282 | $198.50 |
| ED visit level 3 | CPT 99283 | $248.00 |
| ED visit level 4 | CPT 99284 | $369.00 |
| ED visit level 5 | CPT 99285 | $596.50 |
| Critical care, first hour | CPT 99291 | $758.00 |
| CT head without contrast | CPT 70450 | $1,956.00 |
| CT head with contrast | CPT 70460 | $2,265.00 |
| CT head with and without contrast | CPT 70470 | $2,670.00 |
| CT neck with contrast | CPT 70491 | $3,114.00 |
| MRI brain without contrast | CPT 70551 | $3,909.00 |
| MRI brain with contrast | CPT 70552 | $3,909.00 |
| MRI brain with and without contrast | CPT 70553 | $5,491.00 |
| Chest X-ray single view | CPT 71045 | $238.75 |
| Chest X-ray 2 views | CPT 71046 | $259.25 |
| Chest X-ray 3 views | CPT 71047 | $73.00 |
| CT chest without contrast | CPT 71250 | $1,952.00 |
| CT chest with contrast | CPT 71260 | $2,157.00 |
| CT chest with and without contrast | CPT 71270 | $2,605.00 |
| MRI chest without contrast | CPT 71550 | $3,909.00 |
| MRI chest with and without contrast | CPT 71552 | $5,491.00 |
| Lumbosacral spine X-ray | CPT 72100 | $679.00 |
| CT cervical spine without contrast | CPT 72125 | $3,325.00 |
| CT thoracic spine without contrast | CPT 72128 | $2,948.00 |
| CT lumbar spine without contrast | CPT 72131 | $3,325.00 |
| MRI cervical spine without contrast | CPT 72141 | $3,909.00 |
| MRI thoracic spine without contrast | CPT 72146 | $3,909.00 |
| MRI lumbar spine without contrast | CPT 72148 | $3,909.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,909.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $5,491.00 |
| MRI lumbar spine with contrast | CPT 72158 | $5,491.00 |
| CT pelvis without contrast | CPT 72192 | $2,338.00 |
| CT pelvis with contrast | CPT 72193 | $2,338.00 |
| Shoulder X-ray | CPT 73030 | $468.00 |
| Humerus X-ray | CPT 73060 | $390.00 |
| Hand X-ray 3 views | CPT 73130 | $50.50 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,909.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $5,491.00 |
| Knee X-ray 1-2 views | CPT 73560 | $252.00 |
| Ankle X-ray 3 views | CPT 73610 | $50.50 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,909.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $5,491.00 |
| CT abdomen without contrast | CPT 74150 | $2,338.00 |
| CT abdomen with contrast | CPT 74160 | $2,587.00 |
| CT abdomen with and without contrast | CPT 74170 | $2,660.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,647.50 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,792.25 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $703.50 |
| MRI abdomen without contrast | CPT 74181 | $3,909.00 |
| MRI abdomen with and without contrast | CPT 74183 | $5,491.00 |
| Abdominal ultrasound complete | CPT 76700 | $1,541.00 |
| Abdominal ultrasound limited | CPT 76705 | $959.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $959.00 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,255.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $1,541.00 |
| Transvaginal ultrasound | CPT 76830 | $819.00 |
| Pelvic ultrasound complete | CPT 76856 | $1,255.00 |
| Scrotal ultrasound | CPT 76870 | $959.00 |
| Diagnostic mammography unilateral | CPT 77065 | $114.00 |
| Diagnostic mammography bilateral | CPT 77066 | $152.50 |
| Screening mammography bilateral | CPT 77067 | $100.00 |
| EKG tracing only | CPT 93005 | $341.00 |
| EKG interpretation only | CPT 93010 | $110.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,233.00 |
| Stress echocardiogram | CPT 93350 | $1,802.00 |
| Initial hospital care, low complexity | CPT 99221 | $155.00 |
| Initial hospital care, moderate complexity | CPT 99222 | $255.00 |
| Initial hospital care, high complexity | CPT 99223 | $360.00 |
| Hospital discharge, <30 min | CPT 99238 | $165.00 |
| Hospital discharge, >30 min | CPT 99239 | $200.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $315.00 |
| General health panel | CPT 80050 | $563.00 |
| Electrolyte panel | CPT 80051 | $205.00 |
| Comprehensive metabolic panel | CPT 80053 | $377.00 |
| Lipid panel | CPT 80061 | $330.00 |
| Renal function panel | CPT 80069 | $205.00 |
| Hepatic function panel | CPT 80076 | $250.00 |
| Urinalysis non-automated | CPT 81002 | $162.00 |
| Urinalysis automated | CPT 81003 | $58.00 |
| Glucose quantitative | CPT 82947 | $163.00 |
| Hemoglobin A1c | CPT 83036 | $285.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $289.00 |
| Complete blood count with automated differential | CPT 85025 | $26.00 |
| Complete blood count without differential | CPT 85027 | $187.00 |
| Urine culture bacterial | CPT 87086 | $14.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $200.00 |
| Fetal non-stress test | CPT 59025 | $160.50 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $3,750.00 |
| Vaginal delivery only | CPT 59409 | $2,060.00 |
| Vaginal delivery with postpartum | CPT 59410 | $2,350.00 |
| Routine obstetric care with C-section | CPT 59510 | $4,705.00 |
| C-section delivery only | CPT 59514 | $3,860.00 |
| C-section with postpartum | CPT 59515 | $2,800.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | $219.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $282.00 |
| Office visit, new patient, 45-59 min | CPT 99204 | $376.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $384.00 |
| Office visit, established patient, 5 min | CPT 99211 | $159.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $116.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $146.25 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $282.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $376.00 |
| Upper GI endoscopy diagnostic | CPT 43235 | $790.50 |
| Upper GI endoscopy with biopsy | CPT 43239 | $849.50 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,529.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $341.00 |
| Colonoscopy diagnostic | CPT 45378 | $1,130.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,202.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,480.00 |
| Total shoulder arthroplasty | CPT 23472 | $4,745.00 |
| Hip hemiarthroplasty | CPT 27125 | $3,756.50 |
| Total hip replacement | CPT 27130 | $4,896.00 |
| Total knee replacement | CPT 27447 | $5,564.50 |
| Knee revision arthroplasty single component | CPT 27486 | $5,405.00 |
| Knee revision arthroplasty all components | CPT 27487 | $7,273.00 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,150.00 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $3,030.00 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $1,949.50 |
| ACL reconstruction | CPT 29888 | $4,590.00 |
| Open appendectomy | CPT 44950 | $1,658.00 |
| Laparoscopic appendectomy | CPT 44970 | $1,606.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $2,063.00 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $2,223.50 |
| Lap inguinal hernia repair | CPT 49650 | $1,862.50 |
| Total abdominal hysterectomy | CPT 58150 | $4,868.50 |
| Vaginal hysterectomy | CPT 58260 | $4,485.00 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $3,050.00 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $4,491.00 |
| Lap salpingo-oophorectomy | CPT 58661 | $3,727.00 |
