| ED visit level 1 | CPT 99281 | $116.67 |
| ED visit level 5 | CPT 99285 | $2,113.57 |
| CT head without contrast | CPT 70450 | $134.15 |
| CT head with contrast | CPT 70460 | $206.95 |
| CT head with and without contrast | CPT 70470 | $206.95 |
| CT neck with contrast | CPT 70491 | $206.95 |
| MRI brain without contrast | CPT 70551 | $276.00 |
| MRI brain with contrast | CPT 70552 | $433.16 |
| MRI brain with and without contrast | CPT 70553 | $433.16 |
| Chest X-ray single view | CPT 71045 | $106.62 |
| Chest X-ray 2 views | CPT 71046 | $106.62 |
| Chest X-ray 3 views | CPT 71047 | $106.62 |
| CT chest without contrast | CPT 71250 | $134.15 |
| CT chest with contrast | CPT 71260 | $206.95 |
| CT chest with and without contrast | CPT 71270 | $206.95 |
| MRI chest without contrast | CPT 71550 | $298.99 |
| MRI chest with contrast | CPT 71551 | $392.60 |
| MRI chest with and without contrast | CPT 71552 | $469.26 |
| Lumbosacral spine X-ray | CPT 72100 | $128.99 |
| CT cervical spine without contrast | CPT 72125 | $134.15 |
| CT thoracic spine without contrast | CPT 72128 | $134.15 |
| CT lumbar spine without contrast | CPT 72131 | $134.15 |
| MRI cervical spine without contrast | CPT 72141 | $276.00 |
| MRI thoracic spine without contrast | CPT 72146 | $276.00 |
| MRI lumbar spine without contrast | CPT 72148 | $276.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $433.16 |
| MRI cervical spine with and without contrast | CPT 72156 | $433.16 |
| MRI lumbar spine with contrast | CPT 72158 | $433.16 |
| CT pelvis without contrast | CPT 72192 | $134.15 |
| CT pelvis with contrast | CPT 72193 | $206.95 |
| Shoulder X-ray | CPT 73030 | $550.09 |
| Humerus X-ray | CPT 73060 | $277.39 |
| Hand X-ray 3 views | CPT 73130 | $407.33 |
| MRI upper extremity joint without contrast | CPT 73221 | $276.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $368.43 |
| Knee X-ray 1-2 views | CPT 73560 | $237.41 |
| Ankle X-ray 3 views | CPT 73610 | $85.29 |
| MRI lower extremity joint without contrast | CPT 73721 | $276.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $440.90 |
| CT abdomen without contrast | CPT 74150 | $134.15 |
| CT abdomen with contrast | CPT 74160 | $206.95 |
| CT abdomen with and without contrast | CPT 74170 | $206.95 |
| CT abdomen and pelvis without contrast | CPT 74176 | $276.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $433.16 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $433.16 |
| MRI abdomen without contrast | CPT 74181 | $276.00 |
| MRI abdomen with and without contrast | CPT 74183 | $354.51 |
| Abdominal ultrasound complete | CPT 76700 | $128.99 |
| Abdominal ultrasound limited | CPT 76705 | $128.99 |
| Retroperitoneal ultrasound complete | CPT 76770 | $765.64 |
| Obstetric ultrasound first trimester | CPT 76801 | $106.88 |
| Obstetric ultrasound after first trimester | CPT 76805 | $106.88 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $176.09 |
| Transvaginal ultrasound | CPT 76830 | $128.99 |
| Pelvic ultrasound complete | CPT 76856 | $128.99 |
| Scrotal ultrasound | CPT 76870 | $128.99 |
| EKG tracing only | CPT 93005 | $80.38 |
| Transthoracic echocardiogram complete | CPT 93306 | $629.80 |
| Transthoracic echocardiogram | CPT 93307 | $287.50 |
| Stress echocardiogram | CPT 93350 | $185.11 |
| Basic metabolic panel (BMP) | CPT 80048 | $10.58 |
| Electrolyte panel | CPT 80051 | $8.76 |
| Comprehensive metabolic panel | CPT 80053 | $13.20 |
| Lipid panel | CPT 80061 | $16.74 |
| Renal function panel | CPT 80069 | $10.85 |
| Hepatic function panel | CPT 80076 | $10.21 |
| Urinalysis non-automated | CPT 81002 | $2.92 |
| Urinalysis automated | CPT 81003 | $2.82 |
| Glucose quantitative | CPT 82947 | $4.92 |
| Hemoglobin A1c | CPT 83036 | $12.14 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $21.00 |
| Complete blood count with automated differential | CPT 85025 | $9.71 |
| Complete blood count without differential | CPT 85027 | $8.09 |
| Urine culture bacterial | CPT 87086 | $10.09 |
| Urine culture identification | CPT 87088 | $10.12 |
| Tissue exam by pathologist level IV | CPT 88305 | $71.21 |
| Fetal non-stress test | CPT 59025 | $15.78 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,063.55 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,021.01 |
| Sigmoidoscopy diagnostic | CPT 45330 | $857.85 |
| Sigmoidoscopy with biopsy | CPT 45331 | $857.85 |
| Colonoscopy diagnostic | CPT 45378 | $1,072.32 |
| Colonoscopy with biopsy | CPT 45380 | $1,155.00 |
| Colonoscopy with polyp removal | CPT 45385 | $429.26 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $2,398.52 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $1,088.27 |
| ACL reconstruction | CPT 29888 | $3,300.05 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,888.85 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,888.85 |
| Lap inguinal hernia repair | CPT 49650 | $1,888.85 |
| Vaginal hysterectomy | CPT 58260 | $1,526.99 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $1,888.85 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $3,110.01 |
| Lap salpingo-oophorectomy | CPT 58661 | $1,888.85 |
| Complex cataract surgery | CPT 66982 | $849.94 |
| Cataract surgery with lens implant | CPT 66984 | $849.94 |
| Intravitreal injection | CPT 67028 | $48.45 |
| Vitrectomy mechanical | CPT 67042 | $1,533.49 |
