| ED visit level 1 | CPT 99281 | $348.98 |
| ED visit level 2 | CPT 99282 | $610.06 |
| ED visit level 3 | CPT 99283 | $870.11 |
| ED visit level 4 | CPT 99284 | $1,610.46 |
| ED visit level 5 | CPT 99285 | $2,567.94 |
| Critical care, first hour | CPT 99291 | $1,977.38 |
| CT head without contrast | CPT 70450 | $880.62 |
| CT head with contrast | CPT 70460 | $943.8 |
| CT head with and without contrast | CPT 70470 | $1,052.22 |
| CT neck with contrast | CPT 70491 | $660.66 |
| MRI brain without contrast | CPT 70551 | $720.17 |
| MRI brain with contrast | CPT 70552 | $1,132.17 |
| MRI brain with and without contrast | CPT 70553 | $1,120.67 |
| Chest X-ray single view | CPT 71045 | $190.65 |
| Chest X-ray 2 views | CPT 71046 | $213.44 |
| Chest X-ray 3 views | CPT 71047 | $239.81 |
| CT chest without contrast | CPT 71250 | $1,293.63 |
| CT chest with contrast | CPT 71260 | $1,408.29 |
| CT chest with and without contrast | CPT 71270 | $1,566.24 |
| MRI chest without contrast | CPT 71550 | $721.27 |
| MRI chest with contrast | CPT 71551 | $1,326.39 |
| MRI chest with and without contrast | CPT 71552 | $2,112.63 |
| Lumbosacral spine X-ray | CPT 72100 | $324.68 |
| CT cervical spine without contrast | CPT 72125 | $1,100.78 |
| CT thoracic spine without contrast | CPT 72128 | $1,617.04 |
| CT lumbar spine without contrast | CPT 72131 | $1,617.04 |
| MRI cervical spine without contrast | CPT 72141 | $1,029.99 |
| MRI thoracic spine without contrast | CPT 72146 | $1,339.26 |
| MRI lumbar spine without contrast | CPT 72148 | $937.48 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,470.3 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,137.59 |
| MRI lumbar spine with contrast | CPT 72158 | $2,112.63 |
| CT pelvis without contrast | CPT 72192 | $1,293.63 |
| CT pelvis with contrast | CPT 72193 | $985.8 |
| Shoulder X-ray | CPT 73030 | $389.76 |
| Humerus X-ray | CPT 73060 | $389.76 |
| Hand X-ray 3 views | CPT 73130 | $311.81 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,007.14 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,112.63 |
| Knee X-ray 1-2 views | CPT 73560 | $389.76 |
| Ankle X-ray 3 views | CPT 73610 | $311.81 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,482.78 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,478.84 |
| CT abdomen without contrast | CPT 74150 | $1,293.63 |
| CT abdomen with contrast | CPT 74160 | $1,408.29 |
| CT abdomen with and without contrast | CPT 74170 | $1,566.24 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,898.91 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,802.26 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,992.47 |
| MRI abdomen without contrast | CPT 74181 | $1,338.09 |
| MRI abdomen with and without contrast | CPT 74183 | $2,112.63 |
| Abdominal ultrasound complete | CPT 76700 | $496.28 |
| Abdominal ultrasound limited | CPT 76705 | $397.02 |
| Retroperitoneal ultrasound complete | CPT 76770 | $397.02 |
| Obstetric ultrasound first trimester | CPT 76801 | $397.02 |
| Obstetric ultrasound after first trimester | CPT 76805 | $277.91 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $627.12 |
| Transvaginal ultrasound | CPT 76830 | $397.02 |
| Pelvic ultrasound complete | CPT 76856 | $397.02 |
| Scrotal ultrasound | CPT 76870 | $496.28 |
| Diagnostic mammography unilateral | CPT 77065 | $299.13 |
| Diagnostic mammography bilateral | CPT 77066 | $322.53 |
| Screening mammography bilateral | CPT 77067 | $271.83 |
| EKG tracing only | CPT 93005 | $160.54 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,079.72 |
| Basic metabolic panel (BMP) | CPT 80048 | $44.85 |
| General health panel | CPT 80050 | $189.93 |
| Electrolyte panel | CPT 80051 | $37.05 |
| Comprehensive metabolic panel | CPT 80053 | $217.91 |
| Lipid panel | CPT 80061 | $104.44 |
| Renal function panel | CPT 80069 | $64.43 |
| Hepatic function panel | CPT 80076 | $65.52 |
| Urinalysis non-automated | CPT 81002 | $2.73 |
| Urinalysis automated | CPT 81003 | $26.91 |
| Glucose quantitative | CPT 82947 | $22.23 |
| Hemoglobin A1c | CPT 83036 | $118.13 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $201.79 |
| Complete blood count with automated differential | CPT 85025 | $200.85 |
| Complete blood count without differential | CPT 85027 | $56.55 |
| Urine culture bacterial | CPT 87086 | $54.21 |
| Urine culture identification | CPT 87088 | $37.05 |
| Tissue exam by pathologist level IV | CPT 88305 | $161.27 |
| Fetal non-stress test | CPT 59025 | $271.5 |
| Office visit, established patient, 5 min | CPT 99211 | $286.19 |
| Upper GI endoscopy diagnostic | CPT 43235 | $773.68 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,243.42 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,107.6 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,126.32 |
| Colonoscopy diagnostic | CPT 45378 | $775.32 |
| Colonoscopy with biopsy | CPT 45380 | $1,019.66 |
| Colonoscopy with polyp removal | CPT 45385 | $1,034.22 |
| PCI single major coronary artery | CPT 92920 | $5,294.29 |
| PCI with drug-eluting stent | CPT 92928 | $7,290.66 |
| PCI bypass graft | CPT 92937 | $7,290.66 |
| Left heart catheterization | CPT 93452 | $6,271.2 |
| Coronary angiography with cath | CPT 93455 | $4,396.94 |
| Coronary angiography with bypass cath | CPT 93458 | $5,205.1 |
