| ED visit level 1 | CPT 99281 | $82.00 |
| ED visit level 2 | CPT 99282 | $152.00 |
| ED visit level 3 | CPT 99283 | $264.00 |
| ED visit level 4 | CPT 99284 | $410.00 |
| ED visit level 5 | CPT 99285 | $595.00 |
| CT head without contrast | CPT 70450 | $275.00 |
| CT head with contrast | CPT 70460 | $280.00 |
| CT head with and without contrast | CPT 70470 | $280.00 |
| CT neck with contrast | CPT 70491 | $280.00 |
| MRI brain without contrast | CPT 70551 | $625.00 |
| MRI brain with contrast | CPT 70552 | $647.00 |
| MRI brain with and without contrast | CPT 70553 | $650.00 |
| Chest X-ray single view | CPT 71045 | $20.00 |
| Chest X-ray 2 views | CPT 71046 | — |
| Chest X-ray 3 views | CPT 71047 | $30.00 |
| CT chest without contrast | CPT 71250 | $275.00 |
| CT chest with contrast | CPT 71260 | $285.00 |
| CT chest with and without contrast | CPT 71270 | $292.00 |
| MRI chest without contrast | CPT 71550 | $625.00 |
| MRI chest with contrast | CPT 71551 | $650.00 |
| MRI chest with and without contrast | CPT 71552 | $625.00 |
| Lumbosacral spine X-ray | CPT 72100 | $44.00 |
| CT cervical spine without contrast | CPT 72125 | $275.00 |
| CT thoracic spine without contrast | CPT 72128 | $285.00 |
| CT lumbar spine without contrast | CPT 72131 | $275.00 |
| MRI cervical spine without contrast | CPT 72141 | $635.00 |
| MRI thoracic spine without contrast | CPT 72146 | $635.00 |
| MRI lumbar spine without contrast | CPT 72148 | $625.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $650.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $647.00 |
| MRI lumbar spine with contrast | CPT 72158 | $647.00 |
| CT pelvis without contrast | CPT 72192 | $275.00 |
| CT pelvis with contrast | CPT 72193 | $300.00 |
| Shoulder X-ray | CPT 73030 | $39.00 |
| Humerus X-ray | CPT 73060 | $36.00 |
| Hand X-ray 3 views | CPT 73130 | $41.00 |
| MRI upper extremity joint without contrast | CPT 73221 | $625.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $625.00 |
| Knee X-ray 1-2 views | CPT 73560 | $36.00 |
| Ankle X-ray 3 views | CPT 73610 | $42.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $625.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $620.00 |
| CT abdomen without contrast | CPT 74150 | $275.00 |
| CT abdomen with contrast | CPT 74160 | $285.00 |
| CT abdomen with and without contrast | CPT 74170 | $285.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $300.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $383.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $378.00 |
| MRI abdomen without contrast | CPT 74181 | $625.00 |
| MRI abdomen with and without contrast | CPT 74183 | $625.00 |
| Abdominal ultrasound complete | CPT 76700 | $100.00 |
| Abdominal ultrasound limited | CPT 76705 | $80.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $100.00 |
| Obstetric ultrasound first trimester | CPT 76801 | $75.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $75.00 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $75.00 |
| Transvaginal ultrasound | CPT 76830 | $100.00 |
| Pelvic ultrasound complete | CPT 76856 | $75.00 |
| Scrotal ultrasound | CPT 76870 | $75.00 |
| Diagnostic mammography unilateral | CPT 77065 | $60.00 |
| Diagnostic mammography bilateral | CPT 77066 | $80.00 |
| Screening mammography bilateral | CPT 77067 | $72.50 |
| EKG complete | CPT 93000 | $30.00 |
| EKG tracing only | CPT 93005 | — |
| EKG interpretation only | CPT 93010 | $15.00 |
| Transthoracic echocardiogram | CPT 93307 | $160.00 |
| Stress echocardiogram | CPT 93350 | $233.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $13.50 |
| Electrolyte panel | CPT 80051 | $12.50 |
| Comprehensive metabolic panel | CPT 80053 | $20.00 |
| Lipid panel | CPT 80061 | $27.00 |
| Renal function panel | CPT 80069 | $18.00 |
| Hepatic function panel | CPT 80076 | $15.00 |
| Urinalysis non-automated | CPT 81002 | $5.00 |
| Urinalysis automated | CPT 81003 | $7.00 |
| Glucose quantitative | CPT 82947 | $6.00 |
| Hemoglobin A1c | CPT 83036 | $16.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $28.50 |
| Complete blood count with automated differential | CPT 85025 | $9.00 |
| Complete blood count without differential | CPT 85027 | $7.00 |
| Urine culture bacterial | CPT 87086 | $7.00 |
| Urine culture identification | CPT 87088 | $23.00 |
| Fetal non-stress test | CPT 59025 | $185.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | — |
| Office visit, new patient, 30-44 minutes | CPT 99203 | — |
| Office visit, new patient, 45-59 min | CPT 99204 | $30.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $30.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $40.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $100.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | — |
| Upper GI endoscopy diagnostic | CPT 43235 | $135.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $135.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $847.00 |
| Colonoscopy diagnostic | CPT 45378 | $135.00 |
| Colonoscopy with biopsy | CPT 45380 | $135.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,094.00 |
| Left heart catheterization | CPT 93452 | $2,035.00 |
| Coronary angiography with bypass cath | CPT 93458 | $2,035.00 |
