| emergency |
| ED visit level 1 | CPT | 99281 | 57 | $325 | $178.12 | $1 | $30.8 | 0.22× | $1,280 |
| ED visit level 2 | CPT | 99282 | 57 | $500 | $203.3 | $1 | $31.75 | 0.13× | $1,280 |
| ED visit level 3 | CPT | 99283 | 57 | $700 | $244.39 | $1 | $31.75 | 0.08× | $1,280 |
| ED visit level 4 | CPT | 99284 | 57 | $1,000 | $297.66 | $1 | $31.75 | 0.05× | $1,280 |
| imaging |
| CT head without contrast | CPT | 70450 | 57 | $798 | $129.12 | $1 | $301.69 | 1.5× | $800 |
| CT head with and without contrast | CPT | 70470 | 57 | $1,246 | $209.93 | $1 | $352.53 | 1.3× | $800 |
| CT neck with contrast | CPT | 70491 | 57 | $1,046 | $209.93 | $1 | $352.53 | 1.3× | $1,120 |
| MRI brain without contrast | CPT | 70551 | 57 | $825 | $268.48 | $1 | $352.53 | 0.87× | $1,050 |
| MRI brain with and without contrast | CPT | 70553 | 57 | $1,025 | $439.91 | $1 | $438.47 | 0.74× | $1,050 |
| Chest X-ray single view | CPT | 71045 | 57 | $133 | $91.94 | $1 | $301.69 | 3.2× | $1,120 |
| Chest X-ray 2 views | CPT | 71046 | 57 | $133 | $91.94 | $1 | $301.69 | 3.1× | $1,120 |
| CT chest without contrast | CPT | 71250 | 57 | $798 | $129.12 | $1 | $325.36 | 1.5× | $800 |
| CT chest with contrast | CPT | 71260 | 57 | $1,046 | $209.93 | $1 | $352.53 | 1.3× | $800 |
| CT chest with and without contrast | CPT | 71270 | 57 | $1,246 | $209.93 | $1 | $352.53 | 1.2× | $800 |
| MRI chest without contrast | CPT | 71550 | 57 | $1,650 | $268.48 | $1 | $352.53 | 0.82× | $1,050 |
| Lumbosacral spine X-ray | CPT | 72100 | 57 | $178 | $129.12 | $1 | $2,907.04 | 28.1× | $4,069.86 |
| CT cervical spine without contrast | CPT | 72125 | 57 | $798 | $129.12 | $1 | $325.36 | 1.6× | $800 |
| CT thoracic spine without contrast | CPT | 72128 | 57 | $798 | $129.12 | $1 | $325.36 | 1.6× | $800 |
| CT lumbar spine without contrast | CPT | 72131 | 57 | $798 | $129.12 | $1 | $325.36 | 1.6× | $800 |
| MRI cervical spine without contrast | CPT | 72141 | 57 | $1,650 | $268.48 | $1 | $352.53 | 0.89× | $1,050 |
| MRI thoracic spine without contrast | CPT | 72146 | 57 | $1,650 | $268.48 | $1 | $352.53 | 0.95× | $1,050 |
| MRI lumbar spine without contrast | CPT | 72148 | 57 | $1,650 | $268.48 | $1 | $233.52 | 0.62× | $1,050 |
| MRI cervical spine with and without contrast | CPT | 72156 | 57 | $2,050 | $439.91 | $1 | $438.47 | 0.81× | $1,050 |
| MRI lumbar spine with contrast | CPT | 72158 | 57 | $2,050 | $439.91 | $1 | $438.47 | 0.80× | $1,050 |
| CT pelvis without contrast | CPT | 72192 | 57 | $798 | $129.12 | $1 | $325.36 | 1.6× | $800 |
| Shoulder X-ray | CPT | 73030 | 57 | $225 | $91.94 | $1 | $704.29 | 7.6× | $1,120 |
| Humerus X-ray | CPT | 73060 | 57 | $178 | $91.94 | $1 | $704.29 | 7.9× | $1,120 |
| Hand X-ray 3 views | CPT | 73130 | 57 | $178 | $91.94 | $1 | $1,301.11 | 14.0× | $1,821.55 |
| MRI upper extremity joint without contrast | CPT | 73221 | 57 | $1,850 | $268.48 | $1 | $352.53 | 0.85× | $1,110 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 57 | $1,650 | $439.91 | $1 | $438.47 | 0.72× | $990 |
| Knee X-ray 1-2 views | CPT | 73560 | 57 | $213 | $91.94 | $1 | $1,449.89 | 15.5× | $2,029.85 |
| Ankle X-ray 3 views | CPT | 73610 | 57 | $178 | $91.94 | $1 | $1,630.35 | 17.7× | $2,282.49 |
| MRI lower extremity joint without contrast | CPT | 73721 | 57 | $1,650 | $268.48 | $1 | $233.52 | 0.50× | $990 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 57 | $2,050 | $439.91 | $1 | $438.47 | 0.69× | $1,230 |
| CT abdomen without contrast | CPT | 74150 | 57 | $1,046 | $129.12 | $1 | $325.36 | 1.7× | $800 |
| CT abdomen with and without contrast | CPT | 74170 | 57 | $1,266 | $209.93 | $1 | $352.53 | 1.1× | $800 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 57 | $582 | $268.48 | $1 | $369.83 | 1.0× | $800 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 57 | $897 | $439.91 | $1 | $438.47 | 0.80× | $800 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 57 | $1,002 | $439.91 | $1 | $438.47 | 0.76× | $800 |
| MRI abdomen with and without contrast | CPT | 74183 | 57 | $2,050 | $439.91 | $1 | $438.47 | 0.77× | $1,050 |
| surgery |
| Total hip replacement | CPT | 27130 | 76 | $9,725 | $15,924 | $1 | $11,844 | 2.7× | $27,806 |
| Total knee replacement | CPT | 27447 | 76 | $22,728 | $15,924 | $1 | $11,844 | 2.8× | $28,975 |
| Shoulder arthroscopy with decompression | CPT | 29826 | 76 | $7,875 | $12,579 | $1 | $9,314.41 | 28.5× | $11,170 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 76 | $7,875 | $12,579 | $1 | $7,761.68 | 2.4× | $11,170 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 76 | $6,025 | $14,970 | $1 | $8,060.75 | 3.9× | $14,525 |
| ACL reconstruction | CPT | 29888 | 76 | $9,725 | $14,970 | $1 | $10,122 | 3.0× | $14,525 |