| ED visit level 1 | CPT 99281 | $75.25 |
| ED visit level 2 | CPT 99282 | $127.00 |
| ED visit level 3 | CPT 99283 | $368.25 |
| ED visit level 4 | CPT 99284 | $696.50 |
| ED visit level 5 | CPT 99285 | $1,030.69 |
| Critical care, first hour | CPT 99291 | $1,531.89 |
| CT head without contrast | CPT 70450 | $1,369.00 |
| CT head with contrast | CPT 70460 | $1,788.25 |
| CT head with and without contrast | CPT 70470 | $2,028.00 |
| CT neck with contrast | CPT 70491 | $1,788.25 |
| MRI brain without contrast | CPT 70551 | $1,958.00 |
| MRI brain with contrast | CPT 70552 | $2,330.00 |
| MRI brain with and without contrast | CPT 70553 | $2,648.75 |
| Chest X-ray single view | CPT 71045 | $608.22 |
| Chest X-ray 2 views | CPT 71046 | $499.97 |
| Chest X-ray 3 views | CPT 71047 | $161.26 |
| CT chest without contrast | CPT 71250 | $1,394.50 |
| CT chest with contrast | CPT 71260 | $1,822.00 |
| CT chest with and without contrast | CPT 71270 | $2,066.00 |
| MRI chest without contrast | CPT 71550 | $1,866.25 |
| MRI chest with contrast | CPT 71551 | $1,866.25 |
| MRI chest with and without contrast | CPT 71552 | $1,866.25 |
| Lumbosacral spine X-ray | CPT 72100 | $545.17 |
| CT cervical spine without contrast | CPT 72125 | $1,369.00 |
| CT thoracic spine without contrast | CPT 72128 | $1,394.50 |
| CT lumbar spine without contrast | CPT 72131 | $1,394.50 |
| MRI cervical spine without contrast | CPT 72141 | $1,958.00 |
| MRI thoracic spine without contrast | CPT 72146 | $1,866.25 |
| MRI lumbar spine without contrast | CPT 72148 | $1,866.25 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,220.75 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,648.75 |
| MRI lumbar spine with contrast | CPT 72158 | $2,524.50 |
| CT pelvis without contrast | CPT 72192 | $1,394.50 |
| CT pelvis with contrast | CPT 72193 | $1,822.00 |
| Shoulder X-ray | CPT 73030 | $817.75 |
| Humerus X-ray | CPT 73060 | $817.75 |
| Hand X-ray 3 views | CPT 73130 | $905.63 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,799.38 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,524.50 |
| Knee X-ray 1-2 views | CPT 73560 | $321.00 |
| Ankle X-ray 3 views | CPT 73610 | $405.75 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,799.38 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,524.50 |
| CT abdomen without contrast | CPT 74150 | $1,394.50 |
| CT abdomen with contrast | CPT 74160 | $1,822.00 |
| CT abdomen with and without contrast | CPT 74170 | $2,066.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,788.50 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,643.25 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $4,131.25 |
| MRI abdomen without contrast | CPT 74181 | $1,866.25 |
| MRI abdomen with and without contrast | CPT 74183 | $2,524.50 |
| Abdominal ultrasound complete | CPT 76700 | $544.75 |
| Abdominal ultrasound limited | CPT 76705 | $495.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $445.75 |
| Obstetric ultrasound first trimester | CPT 76801 | $938.56 |
| Obstetric ultrasound after first trimester | CPT 76805 | $988.22 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $476.53 |
| Transvaginal ultrasound | CPT 76830 | $1,012.21 |
| Pelvic ultrasound complete | CPT 76856 | $453.50 |
| Scrotal ultrasound | CPT 76870 | $357.00 |
| Diagnostic mammography unilateral | CPT 77065 | $252.12 |
| Diagnostic mammography bilateral | CPT 77066 | $329.07 |
| Screening mammography bilateral | CPT 77067 | $280.41 |
| EKG tracing only | CPT 93005 | $230.53 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,635.30 |
| Transthoracic echocardiogram | CPT 93307 | $652.30 |
| Stress echocardiogram | CPT 93350 | $1,050.16 |
| Basic metabolic panel (BMP) | CPT 80048 | $250.54 |
| Electrolyte panel | CPT 80051 | $208.13 |
| Comprehensive metabolic panel | CPT 80053 | $313.60 |
| Lipid panel | CPT 80061 | $397.85 |
| Renal function panel | CPT 80069 | $257.80 |
| Hepatic function panel | CPT 80076 | $243.29 |
| Urinalysis non-automated | CPT 81002 | $86.49 |
| Urinalysis automated | CPT 81003 | $75.89 |
| Glucose quantitative | CPT 82947 | $85.93 |
| Hemoglobin A1c | CPT 83036 | $210.37 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $363.26 |
| Complete blood count with automated differential | CPT 85025 | $207.02 |
| Complete blood count without differential | CPT 85027 | $164.61 |
| Urine culture bacterial | CPT 87086 | $20.09 |
| Urine culture identification | CPT 87088 | $108.75 |
| Tissue exam by pathologist level IV | CPT 88305 | $231.75 |
| Fetal non-stress test | CPT 59025 | $161.19 |
| Office visit, established patient, 5 min | CPT 99211 | $226.16 |
| Upper GI endoscopy diagnostic | CPT 43235 | $640.25 |
| Upper GI endoscopy with biopsy | CPT 43239 | $817.25 |
| Sigmoidoscopy diagnostic | CPT 45330 | $606.74 |
| Sigmoidoscopy with biopsy | CPT 45331 | $792.00 |
| Colonoscopy diagnostic | CPT 45378 | $542.25 |
| Colonoscopy with biopsy | CPT 45380 | $817.25 |
| Colonoscopy with polyp removal | CPT 45385 | $817.25 |
| Coronary angiography with bypass cath | CPT 93458 | $2,735.02 |
