| emergency |
| ED visit level 1 | CPT | 99281 | 18 | $253.77 | $109.12 | $76.12 | $187.97 | $253.77 |
| ED visit level 2 | CPT | 99282 | 18 | $467.49 | $201.02 | $136.91 | $345.49 | $467.49 |
| ED visit level 3 | CPT | 99283 | 18 | $815.55 | $350.69 | $239.38 | $603.02 | $815.55 |
| ED visit level 4 | CPT | 99284 | 18 | $1,266 | $544.38 | $368.13 | $949.83 | $1,266 |
| ED visit level 5 | CPT | 99285 | 18 | $1,835.97 | $789.47 | $530.04 | $1,362.18 | $1,835.97 |
| Critical care, first hour | CPT | 99291 | 17 | $2,536.44 | $1,090.67 | $1,359.99 | $1,799.98 | $2,536.44 |
| imaging |
| CT head without contrast | CPT | 70450 | 18 | $2,577.5 | $1,108.32 | $48.96 | $1,924.55 | $2,577.5 |
| CT head with contrast | CPT | 70460 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| CT head with and without contrast | CPT | 70470 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| CT neck with contrast | CPT | 70491 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| MRI brain without contrast | CPT | 70551 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI brain with contrast | CPT | 70552 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| MRI brain with and without contrast | CPT | 70553 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| Chest X-ray single view | CPT | 71045 | 18 | $466.95 | $200.79 | $16.75 | $353.01 | $466.95 |
| Chest X-ray 2 views | CPT | 71046 | 18 | $466.95 | $200.79 | $23.03 | $353.01 | $466.95 |
| CT chest without contrast | CPT | 71250 | 18 | $951.45 | $409.12 | $48.96 | $742.69 | $951.45 |
| CT chest with contrast | CPT | 71260 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| CT chest with and without contrast | CPT | 71270 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| MRI chest without contrast | CPT | 71550 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI chest with and without contrast | CPT | 71552 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| Lumbosacral spine X-ray | CPT | 72100 | 18 | $466.95 | $200.79 | $91.93 | $353.01 | $466.95 |
| CT cervical spine without contrast | CPT | 72125 | 18 | $951.45 | $409.12 | $48.96 | $742.69 | $951.45 |
| CT thoracic spine without contrast | CPT | 72128 | 18 | $951.45 | $409.12 | $48.96 | $742.69 | $951.45 |
| CT lumbar spine without contrast | CPT | 72131 | 18 | $951.45 | $409.12 | $48.96 | $742.69 | $951.45 |
| MRI cervical spine without contrast | CPT | 72141 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI thoracic spine without contrast | CPT | 72146 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI lumbar spine without contrast | CPT | 72148 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| MRI cervical spine with and without contrast | CPT | 72156 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| MRI lumbar spine with contrast | CPT | 72158 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| CT pelvis without contrast | CPT | 72192 | 18 | $951.45 | $409.12 | $48.96 | $742.69 | $951.45 |
| CT pelvis with contrast | CPT | 72193 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| Shoulder X-ray | CPT | 73030 | 18 | $466.95 | $200.79 | $76.12 | $353.01 | $466.95 |
| Humerus X-ray | CPT | 73060 | 18 | $466.95 | $200.79 | $76.12 | $353.01 | $466.95 |
| Hand X-ray 3 views | CPT | 73130 | 18 | $466.95 | $200.79 | $76.12 | $353.01 | $466.95 |
| MRI upper extremity joint without contrast | CPT | 73221 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| Knee X-ray 1-2 views | CPT | 73560 | 18 | $466.95 | $200.79 | $76.12 | $353.01 | $466.95 |
| Ankle X-ray 3 views | CPT | 73610 | 18 | $466.95 | $200.79 | $76.12 | $353.01 | $466.95 |
| MRI lower extremity joint without contrast | CPT | 73721 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| CT abdomen without contrast | CPT | 74150 | 18 | $951.45 | $409.12 | $48.96 | $742.69 | $951.45 |
| CT abdomen with contrast | CPT | 74160 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| CT abdomen with and without contrast | CPT | 74170 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 18 | $2,577.5 | $1,108.32 | $114.45 | $1,924.55 | $2,577.5 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 18 | $2,577.5 | $1,108.32 | $48.95 | $1,924.55 | $2,577.5 |
| MRI abdomen without contrast | CPT | 74181 | 18 | $2,076.92 | $893.08 | $48.95 | $1,566.93 | $2,076.92 |
| MRI abdomen with and without contrast | CPT | 74183 | 18 | $3,639.6 | $1,565.03 | $48.95 | $2,734.78 | $3,639.6 |
| Abdominal ultrasound complete | CPT | 76700 | 18 | $1,434.65 | $616.9 | $48.96 | $1,212.38 | $1,369.66 |
| Abdominal ultrasound limited | CPT | 76705 | 18 | $1,104.24 | $474.82 | $48.96 | $888.91 | $1,049.03 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 18 | $1,434.65 | $616.9 | $48.96 | $1,212.38 | $1,369.66 |
| Pelvic ultrasound complete | CPT | 76856 | 18 | $1,434.65 | $616.9 | $48.96 | $1,212.38 | $1,369.66 |
| Scrotal ultrasound | CPT | 76870 | 18 | $1,104.24 | $474.82 | $91.93 | $888.91 | $1,049.03 |
| EKG tracing only | CPT | 93005 | 18 | $128.97 | $55.46 | $51.35 | $99.95 | $128.97 |
| Transthoracic echocardiogram complete | CPT | 93306 | 18 | $2,270.91 | $976.49 | $474.02 | $1,816.11 | $2,270.91 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 17 | $82.7 | $35.56 | $48.78 | $70.3 | $81.3 |
| General health panel | CPT | 80050 | 7 | $81.3 | $34.96 | $48.78 | $67.48 | $81.3 |
| Electrolyte panel | CPT | 80051 | 17 | $82.7 | $35.56 | $48.78 | $70.3 | $81.3 |
| Comprehensive metabolic panel | CPT | 80053 | 17 | $82.7 | $35.56 | $48.78 | $70.3 | $82.7 |
| Lipid panel | CPT | 80061 | 17 | $82.7 | $35.56 | $48.78 | $70.3 | $81.3 |
| Renal function panel | CPT | 80069 | 17 | $82.7 | $35.56 | $48.78 | $70.3 | $81.3 |
| Hepatic function panel | CPT | 80076 | 17 | $82.7 | $35.56 | $48.78 | $70.3 | $81.3 |
| Urinalysis non-automated | CPT | 81002 | 17 | $26.94 | $11.58 | $16.15 | $22.9 | $26.91 |
| Urinalysis automated | CPT | 81003 | 17 | $26.94 | $11.58 | $16.15 | $22.9 | $26.91 |
| Glucose quantitative | CPT | 82947 | 17 | $47.96 | $20.62 | $27 | $35.73 | $47.96 |
| Hemoglobin A1c | CPT | 83036 | 17 | $89.32 | $38.41 | $11.14 | $43.16 | $84.85 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 17 | $129.28 | $55.59 | $8.9 | $100.84 | $129.28 |
| Complete blood count with automated differential | CPT | 85025 | 17 | $54.98 | $23.64 | $32.99 | $46.73 | $54.98 |
| Complete blood count without differential | CPT | 85027 | 17 | $54.98 | $23.64 | $32.99 | $46.73 | $54.98 |
| Urine culture bacterial | CPT | 87086 | 17 | $70.77 | $30.43 | $42.46 | $60.15 | $70.77 |
| Tissue exam by pathologist level IV | CPT | 88305 | 18 | $855.63 | $367.92 | $46.19 | $277.89 | $855.63 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 8 | $7,101.8 | $3,053.77 | $410 | $4,446.98 | $7,101.8 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 18 | $4,681.03 | $2,012.84 | $564 | $3,260.47 | $4,681.03 |
| surgery |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 8 | $12,856 | $5,527.87 | $1,383 | $12,856 | $12,856 |
| ACL reconstruction | CPT | 29888 | 8 | $27,085 | $11,646 | $1,383 | $27,085 | $27,085 |
| Lap inguinal hernia repair | CPT | 49650 | 8 | $8,202.04 | $3,526.88 | $1,759 | $8,180.93 | $8,202.04 |
| Lap salpingo-oophorectomy | CPT | 58661 | 8 | $11,509 | $4,948.67 | $1,383 | $7,058.56 | $11,509 |
| Complex cataract surgery | CPT | 66982 | 8 | $13,802 | $5,935 | $1,383 | $13,802 | $13,802 |
| Cataract surgery with lens implant | CPT | 66984 | 8 | $14,791 | $6,359.91 | $1,383 | $14,791 | $14,791 |
| PCI with drug-eluting stent | CPT | 92928 | 13 | $29,725 | $12,782 | $20,213 | $26,158 | $28,239 |
| Left heart catheterization | CPT | 93452 | 18 | $11,521 | $4,953.89 | $48.95 | $7,694.87 | $11,521 |
| Coronary angiography with bypass cath | CPT | 93458 | 18 | $11,521 | $4,953.89 | $48.95 | $7,694.87 | $11,521 |