| behavioral |
| Psychiatric diagnostic evaluation | CPT | 90791 | 15 | — | — | $63.73 | $224.61 | 1.3× | $702.57 |
| Psychiatric eval with medical services | CPT | 90792 | 15 | — | — | $63.73 | $224.61 | 1.3× | $702.57 |
| Psychotherapy 30 minutes | CPT | 90832 | 15 | — | — | $32.45 | $114.38 | 0.77× | $357.78 |
| Psychotherapy 45 minutes | CPT | 90834 | 15 | — | — | $42.02 | $148.11 | 0.92× | $463.28 |
| Psychotherapy 60 minutes | CPT | 90837 | 15 | — | — | $38.53 | $135.8 | 0.71× | $425.09 |
| Crisis psychotherapy 60 minutes | CPT | 90839 | 15 | — | — | $52.66 | $185.6 | 1.2× | $580.54 |
| emergency |
| ED visit level 1 | CPT | 99281 | 14 | — | — | $80.23 | $152.63 | 1.1× | $493.32 |
| ED visit level 2 | CPT | 99282 | 14 | — | — | $153.7 | $244.2 | 1.0× | $791.98 |
| ED visit level 3 | CPT | 99283 | 14 | — | — | $277.29 | $405.91 | 1.0× | $1,269.68 |
| ED visit level 4 | CPT | 99284 | 14 | — | — | $361.34 | $656.29 | 0.98× | $2,052.85 |
| ED visit level 5 | CPT | 99285 | 14 | — | — | $719.74 | $1,154.26 | 1.1× | $3,246.35 |
| Critical care, first hour | CPT | 99291 | 14 | — | — | $931.35 | $1,493.64 | 1.4× | $4,200.85 |
| imaging |
| CT head without contrast | CPT | 70450 | 14 | — | — | $297.79 | $477.57 | 2.3× | $1,343.17 |
| CT head with contrast | CPT | 70460 | 14 | — | — | $379 | $546.52 | 2.3× | $1,709.49 |
| CT head with and without contrast | CPT | 70470 | 14 | — | — | $460.22 | $738.06 | 2.8× | $2,075.81 |
| CT neck with contrast | CPT | 70491 | 14 | — | — | $2.84 | $630.85 | 2.3× | $1,663.98 |
| MRI brain without contrast | CPT | 70551 | 14 | — | — | $442.48 | $769.11 | 1.9× | $2,405.74 |
| MRI brain with contrast | CPT | 70552 | 14 | — | — | $601.37 | $965.36 | 2.0× | $3,019.6 |
| MRI brain with and without contrast | CPT | 70553 | 14 | — | — | $464.09 | $1,097.5 | 1.9× | $3,432.92 |
| Chest X-ray single view | CPT | 71045 | 14 | — | — | $92.94 | $149.04 | 1.6× | $419.18 |
| Chest X-ray 2 views | CPT | 71046 | 14 | — | — | $98.44 | $141.95 | 1.4× | $444.01 |
| Chest X-ray 3 views | CPT | 71047 | 14 | — | — | $148.85 | $238.71 | 2.5× | $671.37 |
| CT chest without contrast | CPT | 71250 | 14 | — | — | $339 | $852.45 | 4.0× | $1,992.56 |
| CT chest with contrast | CPT | 71260 | 14 | — | — | $349.9 | $925.85 | 3.3× | $2,896.03 |
| CT chest with and without contrast | CPT | 71270 | 14 | — | — | $714.62 | $1,030.47 | 3.5× | $3,223.27 |
| MRI chest without contrast | CPT | 71550 | 14 | — | — | $50.83 | $1,034.78 | 2.4× | $3,236.73 |
| MRI chest with contrast | CPT | 71551 | 14 | — | — | $791.48 | $1,205.31 | 1.5× | $3,569.94 |
| MRI chest with and without contrast | CPT | 71552 | 14 | — | — | $33.79 | $1,346.13 | 2.2× | $4,304.01 |
| Lumbosacral spine X-ray | CPT | 72100 | 14 | — | — | $77.69 | $152.52 | 1.5× | $543.15 |
| CT cervical spine without contrast | CPT | 72125 | 14 | — | — | $516.05 | $744.14 | 3.7× | $2,327.64 |
| CT thoracic spine without contrast | CPT | 72128 | 14 | — | — | $420.89 | $656.29 | 3.3× | $1,898.41 |
| CT lumbar spine without contrast | CPT | 72131 | 14 | — | — | $535.88 | $859.4 | 4.2× | $2,417.08 |
| MRI cervical spine without contrast | CPT | 72141 | 14 | — | — | $681.16 | $902.36 | 2.3× | $3,258.54 |
| MRI thoracic spine without contrast | CPT | 72146 | 14 | — | — | $722.44 | $876.49 | 2.4× | $3,258.54 |
| MRI lumbar spine without contrast | CPT | 72148 | 14 | — | — | $578.92 | $915.05 | 2.4× | $3,258.54 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 14 | — | — | $830.62 | $1,039.79 | 2.3× | $3,746.5 |
| MRI cervical spine with and without contrast | CPT | 72156 | 14 | — | — | $1,162.16 | $1,675.82 | 3.1× | $5,241.9 |
| MRI lumbar spine with contrast | CPT | 72158 | 14 | — | — | $1,162.16 | $1,675.82 | 3.1× | $5,241.9 |
| CT pelvis without contrast | CPT | 72192 | 14 | — | — | $240.22 | $578.14 | 2.9× | $2,058.8 |
| CT pelvis with contrast | CPT | 72193 | 14 | — | — | $633.98 | $914.2 | 3.2× | $2,859.56 |
| Shoulder X-ray | CPT | 73030 | 14 | — | — | $44.88 | $97.96 | 1.1× | $306.42 |
| Humerus X-ray | CPT | 73060 | 14 | — | — | $51.92 | $118.78 | 1.3× | $371.54 |
| Hand X-ray 3 views | CPT | 73130 | 14 | — | — | $72.5 | $139.96 | 1.5× | $437.79 |
| MRI upper extremity joint without contrast | CPT | 73221 | 14 | — | — | $73.89 | $959.59 | 2.3× | $3,001.55 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 14 | — | — | $822.51 | $1,252.57 | 2.0× | $3,709.93 |
| Knee X-ray 1-2 views | CPT | 73560 | 14 | — | — | $49.14 | $82.63 | 0.89× | $258.46 |
| Ankle X-ray 3 views | CPT | 73610 | 14 | — | — | $74 | $128.34 | 1.4× | $401.45 |
| MRI lower extremity joint without contrast | CPT | 73721 | 14 | — | — | $55.22 | $604.86 | 1.3× | $2,153.93 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 14 | — | — | $23.61 | $1,146.4 | 1.8× | $3,585.89 |
| CT abdomen without contrast | CPT | 74150 | 14 | — | — | $358.16 | $516.47 | 2.7× | $1,615.49 |
| CT abdomen with contrast | CPT | 74160 | 14 | — | — | $379.01 | $645.58 | 2.3× | $2,019.36 |
| CT abdomen with and without contrast | CPT | 74170 | 14 | — | — | $564.11 | $832.67 | 2.5× | $2,544.42 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 14 | — | — | $372.47 | $738.28 | 2.0× | $2,309.3 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 14 | — | — | $615.46 | $1,008.8 | 1.8× | $3,155.47 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 14 | — | — | $783.14 | $1,129.28 | 2.0× | $3,532.35 |
| MRI abdomen without contrast | CPT | 74181 | 14 | — | — | $507.39 | $805.2 | 2.1× | $2,288.57 |
| MRI abdomen with and without contrast | CPT | 74183 | 14 | — | — | $381.63 | $1,183.56 | 2.1× | $3,702.12 |
| Abdominal ultrasound complete | CPT | 76700 | 14 | — | — | $94.92 | $235.29 | 1.6× | $735.97 |
| Abdominal ultrasound limited | CPT | 76705 | 14 | — | — | $95.67 | $156.29 | 1.1× | $488.86 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 14 | — | — | $161.18 | $232.42 | 1.6× | $726.99 |
| Obstetric ultrasound first trimester | CPT | 76801 | 14 | — | — | $25.54 | $274.04 | 1.9× | $857.19 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 14 | — | — | $191.98 | $276.83 | 1.8× | $865.93 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 14 | — | — | $190.04 | $304.78 | 1.3× | $857.19 |
| Transvaginal ultrasound | CPT | 76830 | 14 | — | — | $153.52 | $246.2 | 1.7× | $692.43 |
| Pelvic ultrasound complete | CPT | 76856 | 14 | — | — | $190.04 | $274.04 | 1.9× | $857.19 |
| Scrotal ultrasound | CPT | 76870 | 14 | — | — | $159.22 | $229.59 | 1.8× | $718.15 |
| Diagnostic mammography unilateral | CPT | 77065 | 14 | — | — | $115.74 | $178.54 | 1.2× | $558.46 |
| Diagnostic mammography bilateral | CPT | 77066 | 14 | — | — | $39.21 | $200.61 | 1.1× | $714.39 |
| Screening mammography bilateral | CPT | 77067 | 14 | — | — | $2.01 | $167.43 | 1.1× | $649.24 |
| EKG tracing only | CPT | 93005 | 14 | — | — | $61.54 | $98.7 | 0.84× | $277.59 |
| Transthoracic echocardiogram complete | CPT | 93306 | 14 | — | — | $397.16 | $636.94 | 1.1× | $1,791.41 |
| Transthoracic echocardiogram | CPT | 93307 | 14 | — | — | $187.38 | $353.45 | 1.4× | $1,258.64 |
| Stress echocardiogram | CPT | 93350 | 14 | — | — | $336.52 | $519.43 | 1.0× | $1,517.86 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 15 | — | — | $15.8 | $55.69 | 1.7× | $174.19 |
| Electrolyte panel | CPT | 80051 | 14 | — | — | $9.35 | $19.42 | 0.82× | $69.16 |
| Comprehensive metabolic panel | CPT | 80053 | 15 | — | — | $17.62 | $62.09 | 1.4× | $194.21 |
| Lipid panel | CPT | 80061 | 15 | — | — | $9.06 | $31.93 | 0.84× | $99.89 |
| Renal function panel | CPT | 80069 | 14 | — | — | $41.66 | $60.07 | 2.2× | $187.9 |
| Hepatic function panel | CPT | 80076 | 15 | — | — | $21.25 | $74.89 | 2.8× | $234.24 |
| Urinalysis non-automated | CPT | 81002 | 15 | — | — | $2.35 | $7.66 | 1.1× | $25.93 |
| Urinalysis automated | CPT | 81003 | 14 | — | — | $9.98 | $19.09 | 1.4× | $67.82 |
| Glucose quantitative | CPT | 82947 | 15 | — | — | $3.89 | $13.71 | 0.78× | $42.88 |
| Hemoglobin A1c | CPT | 83036 | 15 | — | — | $14.54 | $51.25 | 1.9× | $160.3 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 15 | — | — | $16.47 | $58.06 | 1.2× | $181.61 |
| Complete blood count with automated differential | CPT | 85025 | 15 | — | — | $8.03 | $28.32 | 1.1× | $88.57 |
| Complete blood count without differential | CPT | 85027 | 15 | — | — | $9.32 | $32.86 | 1.5× | $102.8 |
| Urine culture bacterial | CPT | 87086 | 15 | — | — | $8.66 | $30.51 | 1.3× | $95.44 |
| Tissue exam by pathologist level IV | CPT | 88305 | 14 | — | — | $62.25 | $140.14 | 1.4× | $523.59 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 14 | — | — | $145.12 | $209.26 | 1.1× | $654.56 |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 15 | — | — | $20.01 | $63.43 | 0.74× | $233.08 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 15 | — | — | $22.8 | $70.59 | 0.58× | $251.36 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 15 | — | — | $27.32 | $82.41 | 0.47× | $301.19 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 15 | — | — | $29.73 | $100.63 | 0.46× | $358.36 |
| Office visit, established patient, 5 min | CPT | 99211 | 15 | — | — | $8.23 | $105.72 | 1.6× | $462.95 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 15 | — | — | $15.97 | $49.45 | 0.62× | $177.89 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 15 | — | — | $19.9 | $61.62 | 0.54× | $219.43 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 15 | — | — | $24.3 | $75.22 | 0.49× | $267.86 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 15 | — | — | $27.62 | $85.52 | 0.45× | $304.54 |
| preventive |
| Sigmoidoscopy diagnostic | CPT | 45330 | 14 | — | — | $662.16 | $1,025.3 | 1.2× | $3,221.87 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 14 | — | — | $662.16 | $954.83 | 1.1× | $3,221.84 |
| surgery |
| Intravitreal injection | CPT | 67028 | 14 | — | — | $266.48 | $476.95 | 1.4× | $1,413.84 |