| emergency |
| ED visit level 1 | CPT | 99281 | 33 | — | $178.47 | $41.06 | $196.32 | $593.96 |
| ED visit level 2 | CPT | 99282 | 33 | — | $273.78 | $41.06 | $301.16 | $593.96 |
| ED visit level 3 | CPT | 99283 | 33 | — | $505.08 | $41.06 | $555.59 | $890.98 |
| ED visit level 4 | CPT | 99284 | 33 | — | $1,002.48 | $41.06 | $1,102.73 | $1,670.8 |
| ED visit level 5 | CPT | 99285 | 33 | — | $1,142.28 | $41.06 | $1,256.51 | $1,903.8 |
| Critical care, first hour | CPT | 99291 | 33 | — | $2,286.18 | $41.06 | $2,286.18 | $3,810.3 |
| imaging |
| CT head without contrast | CPT | 70450 | 33 | — | $1,260.63 | $41.06 | $692.22 | $2,101.05 |
| CT head with contrast | CPT | 70460 | 33 | — | $1,494.96 | $41.06 | $829.71 | $2,491.6 |
| CT head with and without contrast | CPT | 70470 | 33 | — | $1,945.35 | $41.06 | $1,035.91 | $3,242.25 |
| CT neck with contrast | CPT | 70491 | 33 | — | $1,028.16 | $41.06 | $771.12 | $1,979.92 |
| MRI brain without contrast | CPT | 70551 | 33 | — | $1,137.81 | $41.06 | $1,137.81 | $2,969.9 |
| MRI brain with and without contrast | CPT | 70553 | 33 | — | $1,753.95 | $41.06 | $1,753.95 | $4,229.48 |
| Chest X-ray single view | CPT | 71045 | 33 | — | $234 | $41.06 | $122.3 | $1,435.46 |
| Chest X-ray 2 views | CPT | 71046 | 33 | — | $283.2 | $41.06 | $122.3 | $1,435.46 |
| Chest X-ray 3 views | CPT | 71047 | 33 | — | $317.4 | $41.06 | $122.3 | $1,435.46 |
| CT chest without contrast | CPT | 71250 | 33 | — | $1,501.32 | $41.06 | $865.44 | $2,502.2 |
| CT chest with contrast | CPT | 71260 | 33 | — | $1,602.75 | $41.06 | $1,035.91 | $2,671.25 |
| CT chest with and without contrast | CPT | 71270 | 33 | — | $2,445.39 | $41.06 | $1,291.89 | $4,075.65 |
| MRI chest without contrast | CPT | 71550 | 33 | — | $869.55 | $41.06 | $869.55 | $2,969.9 |
| Lumbosacral spine X-ray | CPT | 72100 | 33 | — | $367.71 | $41.06 | $164.73 | $1,435.46 |
| CT cervical spine without contrast | CPT | 72125 | 33 | — | $1,975.23 | $41.06 | $1,697.71 | $3,292.05 |
| CT thoracic spine without contrast | CPT | 72128 | 33 | — | $764.73 | $41.06 | $733.36 | $1,979.92 |
| CT lumbar spine without contrast | CPT | 72131 | 33 | — | $1,479.6 | $41.06 | $1,479.6 | $2,466 |
| MRI cervical spine without contrast | CPT | 72141 | 33 | — | $1,706.43 | $41.06 | $1,388.9 | $2,969.9 |
| MRI thoracic spine without contrast | CPT | 72146 | 33 | — | $1,260.84 | $41.06 | $1,260.84 | $2,969.9 |
| MRI lumbar spine without contrast | CPT | 72148 | 33 | — | $1,399.53 | $41.06 | $1,399.53 | $2,969.9 |
| MRI cervical spine with and without contrast | CPT | 72156 | 33 | — | $2,630.52 | $41.06 | $2,630.52 | $4,384.2 |
| MRI lumbar spine with contrast | CPT | 72158 | 33 | — | $2,157.45 | $41.06 | $2,157.45 | $4,229.48 |
| CT pelvis without contrast | CPT | 72192 | 33 | — | $1,141.62 | $41.06 | $856.22 | $1,979.92 |
| CT pelvis with contrast | CPT | 72193 | 33 | — | $1,443.66 | $41.06 | $1,000.83 | $2,406.1 |
| Shoulder X-ray | CPT | 73030 | 33 | — | $335.31 | $41.06 | $122.3 | $1,435.46 |
| Humerus X-ray | CPT | 73060 | 33 | — | $313.62 | $41.06 | $122.3 | $1,435.46 |
| Hand X-ray 3 views | CPT | 73130 | 33 | — | $329.76 | $41.06 | $122.3 | $1,435.46 |
| MRI upper extremity joint without contrast | CPT | 73221 | 33 | — | $1,246.17 | $41.06 | $1,246.17 | $2,969.9 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 33 | — | $2,017.02 | $41.06 | $2,017.02 | $3,808.27 |
| Knee X-ray 1-2 views | CPT | 73560 | 33 | — | $396.6 | $41.06 | $122.3 | $1,435.46 |
| Ankle X-ray 3 views | CPT | 73610 | 33 | — | $343.29 | $41.06 | $122.3 | $1,435.46 |
| MRI lower extremity joint without contrast | CPT | 73721 | 33 | — | $1,023.69 | $41.06 | $1,023.69 | $2,969.9 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 33 | — | $1,932.24 | $41.06 | $1,932.24 | $3,808.27 |
| CT abdomen without contrast | CPT | 74150 | 33 | — | $1,719.27 | $41.06 | $829.71 | $2,865.45 |
| CT abdomen with contrast | CPT | 74160 | 33 | — | $1,877.04 | $41.06 | $1,000.83 | $3,128.4 |
| CT abdomen with and without contrast | CPT | 74170 | 33 | — | $2,952.42 | $41.06 | $1,240 | $4,920.7 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 33 | — | $2,039.01 | $41.06 | $1,529.26 | $3,398.35 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 33 | — | $2,308.86 | $41.06 | $1,731.65 | $3,848.1 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 33 | — | $3,538.26 | $41.06 | $2,101.5 | $5,897.1 |
| MRI abdomen without contrast | CPT | 74181 | 33 | — | $1,421.64 | $41.06 | $1,388.9 | $2,969.9 |
| MRI abdomen with and without contrast | CPT | 74183 | 33 | — | $2,191.35 | $41.06 | $2,191.35 | $3,808.27 |
| Abdominal ultrasound complete | CPT | 76700 | 33 | — | $790.59 | $41.06 | $288.95 | $1,317.65 |
| Abdominal ultrasound limited | CPT | 76705 | 33 | — | $602.82 | $41.06 | $208.31 | $1,004.7 |
| Obstetric ultrasound first trimester | CPT | 76801 | 33 | — | $172.02 | $41.06 | $189.22 | $791.98 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 33 | — | $390.09 | $41.06 | $292.57 | $791.98 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 33 | — | $294.72 | $41.06 | $343.84 | $791.98 |
| Transvaginal ultrasound | CPT | 76830 | 33 | — | $604.74 | $41.06 | $224.42 | $1,007.9 |
| Pelvic ultrasound complete | CPT | 76856 | 33 | — | $556.2 | $41.06 | $224.42 | $927 |
| EKG tracing only | CPT | 93005 | 33 | — | $203.67 | $41.06 | $152.75 | $1,336.45 |
| Transthoracic echocardiogram complete | CPT | 93306 | 33 | — | $1,438.83 | $41.06 | $1,558.73 | $2,398.05 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 33 | — | $178.71 | $4.8 | $192.63 | $297.85 |
| Electrolyte panel | CPT | 80051 | 33 | — | $82.2 | $3.9 | $34.01 | $137 |
| Comprehensive metabolic panel | CPT | 80053 | 33 | — | $217.32 | $6 | $234.46 | $362.2 |
| Lipid panel | CPT | 80061 | 22 | — | $127.23 | $5.6 | $148.44 | $212.05 |
| Renal function panel | CPT | 80069 | 33 | — | $78.45 | $4.8 | $78.45 | $130.75 |
| Hepatic function panel | CPT | 80076 | 33 | — | $144.69 | $4.5 | $155.77 | $241.15 |
| Urinalysis automated | CPT | 81003 | 33 | — | $26.34 | $1.6 | $11.16 | $43.9 |
| Glucose quantitative | CPT | 82947 | 22 | — | $20.07 | $2.4 | $19.65 | $33.45 |
| Hemoglobin A1c | CPT | 83036 | 33 | — | $78.63 | $6 | $48.37 | $131.05 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 33 | — | $71.64 | $10.8 | $81.48 | $121.58 |
| Complete blood count with automated differential | CPT | 85025 | 33 | — | $57.87 | $4.8 | $61.21 | $96.45 |
| Complete blood count without differential | CPT | 85027 | 33 | — | $58.02 | $3.6 | $61.37 | $96.7 |
| Urine culture bacterial | CPT | 87086 | 33 | — | $75.33 | $4.8 | $40.22 | $125.55 |
| Urine culture identification | CPT | 87088 | 33 | — | $75.33 | $4.8 | $40.29 | $125.55 |
| Tissue exam by pathologist level IV | CPT | 88305 | 33 | — | $181.83 | $15.85 | $145.64 | $453.9 |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 21 | — | $139.62 | $104.72 | $193.14 | $232.7 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 21 | — | $193.2 | $144.9 | $267.26 | $322 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 21 | — | $242.16 | $181.62 | $334.99 | $403.6 |
| Office visit, established patient, 5 min | CPT | 99211 | 22 | — | $188.31 | $41.06 | $194.5 | $313.85 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 21 | — | $139.62 | $104.72 | $193.14 | $232.7 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 21 | — | $166.47 | $124.85 | $230.28 | $277.45 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 21 | — | $193.2 | $144.9 | $267.26 | $322 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 21 | — | $242.16 | $181.62 | $334.99 | $403.6 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 33 | — | $334.86 | $41.06 | $778.83 | $6,066.08 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 33 | — | $294.55 | $41.06 | $778.83 | $7,925.66 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 33 | — | $1,591 | $41.06 | $778.03 | $4,518.19 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 33 | — | $449.3 | $41.06 | $763.48 | $4,240.1 |
| Colonoscopy diagnostic | CPT | 45378 | 33 | — | $333.57 | $41.06 | $763.48 | $4,126.19 |
| Colonoscopy with biopsy | CPT | 45380 | 33 | — | $332.72 | $41.06 | $997.54 | $4,126.19 |
| Colonoscopy with polyp removal | CPT | 45385 | 33 | — | $365.03 | $41.06 | $997.54 | $4,126.19 |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 29 | — | $4,479.94 | $3,359.95 | $11,283 | $22,565 |
| Total hip replacement | CPT | 27130 | 33 | — | $5,703.67 | $41.06 | $11,734 | $34,462 |
| Total knee replacement | CPT | 27447 | 33 | — | $5,605.64 | $41.06 | $11,734 | $35,435 |
| Knee revision arthroplasty single component | CPT | 27486 | 29 | — | $5,131.8 | $3,848.85 | $11,283 | $22,565 |
| Knee revision arthroplasty all components | CPT | 27487 | 29 | — | $7,010.82 | $5,258.12 | $11,685 | $22,565 |
| Shoulder arthroscopy with decompression | CPT | 29826 | 17 | — | $994.62 | $745.97 | $1,375.89 | $5,100 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 29 | — | $1,123.91 | $842.93 | $5,739.82 | $13,246 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 33 | — | $3,012.75 | $41.06 | $3,314.03 | $10,129 |
| ACL reconstruction | CPT | 29888 | 29 | — | $1,560.85 | $1,170.64 | $5,739.82 | $13,246 |
| Laparoscopic appendectomy | CPT | 44970 | 33 | — | $3,043.12 | $41.06 | $4,821.72 | $26,706 |
| Laparoscopic cholecystectomy | CPT | 47562 | 33 | — | $2,983.95 | $41.06 | $4,868.09 | $18,124 |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 33 | — | $3,783.23 | $41.06 | $4,960.81 | $20,901 |
| Open umbilical hernia repair | CPT | 49560 | 33 | — | $2,163.94 | $41.06 | $3,062.41 | $11,781 |
| Umbilical hernia repair age 5+ | CPT | 49585 | 33 | — | $2,300.91 | $41.06 | $3,062.41 | $10,720 |
| Lap inguinal hernia repair | CPT | 49650 | 33 | — | $3,189.38 | $41.06 | $4,868.09 | $17,805 |
| Lap incisional hernia repair | CPT | 49652 | 33 | — | $2,852.44 | $41.06 | $4,821.72 | $18,644 |
| Vaginal hysterectomy | CPT | 58260 | 33 | — | $2,206.19 | $41.06 | $4,201.53 | $15,120 |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 29 | — | $5,094.86 | $3,821.14 | $5,179.93 | $13,246 |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 33 | — | $4,821.74 | $41.06 | $8,487.46 | $20,072 |
| Lap salpingo-oophorectomy | CPT | 58661 | 33 | — | $3,754.99 | $41.06 | $4,868.09 | $17,342 |
| PCI single major coronary artery | CPT | 92920 | 33 | — | $8,532.12 | $41.06 | $9,243.13 | $14,220 |
| PCI with drug-eluting stent | CPT | 92928 | 33 | — | $9,317.46 | $41.06 | $10,870 | $18,402 |
| PCI bypass graft | CPT | 92937 | 33 | — | $9,317.46 | $41.06 | $10,870 | $18,402 |
| Coronary angiography with cath | CPT | 93455 | 33 | — | $2,527.5 | $41.06 | $2,841.95 | $10,117 |
| Coronary angiography with bypass cath | CPT | 93458 | 33 | — | $4,710.63 | $41.06 | $5,181.69 | $10,117 |