| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $156 | $62.4 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $264 | $105.6 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $400 | $160 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $714 | $285.6 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $1,120 | $448 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $1,447 | $578.8 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $1,091 | $436.4 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $1,288 | $515.2 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $1,567 | $626.8 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $1,336 | $534.4 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $440 | $176 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $304 | $121.6 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $298 | $119.2 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $1,363 | $545.2 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $1,682 | $672.8 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $1,922 | $768.8 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $354 | $141.6 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $1,626 | $650.4 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $1,710 | $684 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $1,626 | $650.4 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $1,442 | $576.8 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $1,699 | $679.6 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $454 | $181.6 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $333 | $133.2 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $397 | $158.8 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $1,428 | $571.2 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $1,868 | $747.2 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $317 | $126.8 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $460 | $184 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $1,826 | $730.4 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $1,442 | $576.8 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $1,750 | $700 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $1,935 | $774 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $3,056 | $1,222.4 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $3,104 | $1,241.6 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $3,496 | $1,398.4 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $712 | $284.8 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $435 | $174 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $593 | $237.2 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $317 | $126.8 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $471 | $188.4 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $550 | $220 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $640 | $256 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $376 | $150.4 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $632 | $252.8 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $398 | $159.2 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $1,660 | $664 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $733 | $293.2 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $1,053 | $421.2 | — | — | — |
| inpatient |
| Initial hospital care, low complexity | CPT | 99221 | 0 | $216 | $86.4 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $144 | $57.6 | — | — | — |
| General health panel | CPT | 80050 | 0 | $260 | $104 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $66 | $26.4 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $102 | $40.8 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $89 | $35.6 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $74 | $29.6 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $73 | $29.2 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $20 | $8 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $22 | $8.8 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $166 | $66.4 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $78 | $31.2 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $142 | $56.8 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $118 | $47.2 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $43 | $17.2 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $63 | $25.2 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $540 | $216 | — | — | — |
| maternity |
| Vaginal delivery only | CPT | 59409 | 0 | $1,839 | $735.6 | — | — | — |
| office |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $136 | $54.4 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $55 | $22 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $109 | $43.6 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $168 | $67.2 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $2,534 | $1,013.6 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $1,584 | $633.6 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $1,788 | $715.2 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $2,196 | $878.4 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $1,302 | $520.8 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $2,264 | $905.6 | — | — | — |
| surgery |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $6,765 | $2,706 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $7,317 | $2,926.8 | — | — | — |
