| Psychiatric diagnostic evaluation | CPT 90791 | $1,026.79 |
| CT head without contrast | CPT 70450 | $456.64 |
| CT head with contrast | CPT 70460 | $339.43 |
| CT head with and without contrast | CPT 70470 | $344.85 |
| CT neck with contrast | CPT 70491 | $405.02 |
| MRI brain without contrast | CPT 70551 | $723.22 |
| MRI brain with contrast | CPT 70552 | $481.68 |
| MRI brain with and without contrast | CPT 70553 | $1,905.97 |
| Chest X-ray single view | CPT 71045 | $133.7 |
| Chest X-ray 2 views | CPT 71046 | $99.66 |
| CT chest without contrast | CPT 71250 | $514.89 |
| CT chest with contrast | CPT 71260 | $1,042.95 |
| CT chest with and without contrast | CPT 71270 | $347.15 |
| MRI chest without contrast | CPT 71550 | $2,451.5 |
| MRI chest with and without contrast | CPT 71552 | $3,889.02 |
| Lumbosacral spine X-ray | CPT 72100 | $452.75 |
| CT cervical spine without contrast | CPT 72125 | $395.48 |
| CT thoracic spine without contrast | CPT 72128 | $293.54 |
| CT lumbar spine without contrast | CPT 72131 | $382.76 |
| MRI cervical spine without contrast | CPT 72141 | $2,267.26 |
| MRI thoracic spine without contrast | CPT 72146 | $1,188.59 |
| MRI lumbar spine without contrast | CPT 72148 | $2,327.53 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,923 |
| MRI cervical spine with and without contrast | CPT 72156 | $903.41 |
| MRI lumbar spine with contrast | CPT 72158 | $2,916.97 |
| CT pelvis without contrast | CPT 72192 | $270.42 |
| CT pelvis with contrast | CPT 72193 | $275.03 |
| Shoulder X-ray | CPT 73030 | $293.26 |
| Humerus X-ray | CPT 73060 | $264.45 |
| Hand X-ray 3 views | CPT 73130 | $516.36 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,261.5 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,315.63 |
| Knee X-ray 1-2 views | CPT 73560 | $265 |
| Ankle X-ray 3 views | CPT 73610 | $369.28 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,412 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,373.93 |
| CT abdomen without contrast | CPT 74150 | $1,410.75 |
| CT abdomen with contrast | CPT 74160 | $1,178.25 |
| CT abdomen with and without contrast | CPT 74170 | $3,031.49 |
| CT abdomen and pelvis without contrast | CPT 74176 | $401.52 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,027.77 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $430.74 |
| MRI abdomen without contrast | CPT 74181 | $1,138 |
| MRI abdomen with and without contrast | CPT 74183 | $3,923 |
| Abdominal ultrasound complete | CPT 76700 | $653.29 |
| Abdominal ultrasound limited | CPT 76705 | $301.83 |
| Retroperitoneal ultrasound complete | CPT 76770 | $718.86 |
| Obstetric ultrasound first trimester | CPT 76801 | — |
| Obstetric ultrasound after first trimester | CPT 76805 | $246.81 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $179.02 |
| Transvaginal ultrasound | CPT 76830 | $375.21 |
| Pelvic ultrasound complete | CPT 76856 | $727.72 |
| Scrotal ultrasound | CPT 76870 | $946.07 |
| Diagnostic mammography unilateral | CPT 77065 | $418 |
| Diagnostic mammography bilateral | CPT 77066 | $352.39 |
| Screening mammography bilateral | CPT 77067 | $412.24 |
| Basic metabolic panel (BMP) | CPT 80048 | $117.7 |
| Electrolyte panel | CPT 80051 | $55.63 |
| Comprehensive metabolic panel | CPT 80053 | $131.69 |
| Lipid panel | CPT 80061 | $45.32 |
| Renal function panel | CPT 80069 | $25.82 |
| Hepatic function panel | CPT 80076 | $128.56 |
| Urinalysis automated | CPT 81003 | $38.5 |
| Glucose quantitative | CPT 82947 | $15.86 |
| Hemoglobin A1c | CPT 83036 | $87.47 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $150.85 |
| Complete blood count with automated differential | CPT 85025 | $70.62 |
| Complete blood count without differential | CPT 85027 | $29.7 |
| Urine culture bacterial | CPT 87086 | $74.44 |
| Urine culture identification | CPT 87088 | $96.66 |
| Tissue exam by pathologist level IV | CPT 88305 | $247.4 |
| Fetal non-stress test | CPT 59025 | $273.57 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $4,704 |
| Vaginal delivery only | CPT 59409 | $31.67 |
| Upper GI endoscopy diagnostic | CPT 43235 | $2,102.83 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,896.48 |
| Sigmoidoscopy diagnostic | CPT 45330 | $2,325.31 |
| Sigmoidoscopy with biopsy | CPT 45331 | $2,768.92 |
| Colonoscopy diagnostic | CPT 45378 | $2,569.3 |
| Colonoscopy with biopsy | CPT 45380 | $1,614.1 |
| Colonoscopy with polyp removal | CPT 45385 | $2,281.75 |
| Total shoulder arthroplasty | CPT 23472 | $8,426.98 |
| Total hip replacement | CPT 27130 | $11,855 |
| Total knee replacement | CPT 27447 | $14,448 |
| Knee revision arthroplasty single component | CPT 27486 | $10,285 |
| Shoulder arthroscopy with decompression | CPT 29826 | $3,125.19 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,408.61 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $4,711.63 |
| ACL reconstruction | CPT 29888 | $5,036.91 |
| Laparoscopic appendectomy | CPT 44970 | $6,385.2 |
| Laparoscopic cholecystectomy | CPT 47562 | $8,546.87 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $8,103.34 |
| Open umbilical hernia repair | CPT 49560 | $3,689.75 |
| Umbilical hernia repair age 5+ | CPT 49585 | $4,386.36 |
| Lap inguinal hernia repair | CPT 49650 | $7,781.43 |
| Lap incisional hernia repair | CPT 49652 | $8,978 |
| Total abdominal hysterectomy | CPT 58150 | $3,596.5 |
| Vaginal hysterectomy | CPT 58260 | $8,346 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $9,199.72 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,949.17 |
| Complex cataract surgery | CPT 66982 | $4,300.28 |
| Cataract surgery with lens implant | CPT 66984 | $3,930.29 |
| Intravitreal injection | CPT 67028 | $318.17 |
| Vitrectomy mechanical | CPT 67042 | $5,127 |
