| behavioral |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $720.35 | $45.61 | — | — | — |
| Psychiatric eval with medical services | CPT | 90792 | 0 | $798.3 | $151.68 | — | — | — |
| Psychotherapy 30 minutes | CPT | 90832 | 0 | $1,047 | $22.8 | — | — | — |
| Psychotherapy 45 minutes | CPT | 90834 | 0 | $1,446.08 | $261.67 | — | — | — |
| Psychotherapy 60 minutes | CPT | 90837 | 0 | $2,051.75 | $389.83 | — | — | — |
| Crisis psychotherapy 60 minutes | CPT | 90839 | 0 | $574.35 | $109.13 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $3,390.83 | $644.26 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $3,896.94 | $740.42 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $5,571.43 | $1,058.57 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $4,985.25 | $947.2 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $5,904.1 | $1,121.78 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $10,713 | $2,035.47 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $3,297.4 | $626.51 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $4,616.65 | $877.16 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $5,440.29 | $1,033.66 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $5,193.9 | $986.84 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $5,488.42 | $1,042.8 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $8,185.27 | $1,555.2 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $9,301.39 | $1,767.26 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $197.43 | $37.51 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $244.52 | $46.46 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $298.26 | $56.67 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $4,226.65 | $803.06 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $8,495.54 | $1,614.15 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $9,510.66 | $1,807.03 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $5,775.13 | $1,097.27 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $6,300 | $1,197 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $9,789.05 | $1,859.92 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $338.71 | $64.35 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $3,869.03 | $735.12 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $3,869.03 | $735.12 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $3,985.88 | $757.32 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $5,043 | $958.17 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $4,696.13 | $892.26 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $5,967.13 | $1,133.75 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $8,890.53 | $1,689.2 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $8,523.18 | $1,619.4 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $10,085 | $1,916.1 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $2,707.47 | $514.42 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $5,414.96 | $1,028.84 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $694.31 | $131.92 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $319.99 | $60.8 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $868.19 | $164.96 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $6,325.51 | $1,201.85 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $10,690 | $2,031.13 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $365.88 | $69.52 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $396.06 | $75.25 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $6,325.51 | $1,201.85 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $10,690 | $2,031.13 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $3,960.55 | $752.5 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $6,106.25 | $1,160.19 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $6,931.31 | $1,316.95 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $5,281.19 | $1,003.43 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $8,251.96 | $1,567.87 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $9,324.81 | $1,771.71 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $5,758.49 | $1,094.11 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $9,760.9 | $1,854.57 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $1,971.12 | $374.51 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $1,616.48 | $307.13 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $1,894.09 | $359.88 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $2,891.6 | $549.4 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $3,323.29 | $631.43 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $902.26 | $171.43 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $2,139.81 | $406.56 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $2,102.62 | $399.5 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $1,855.57 | $352.56 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $1,426.83 | $271.1 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $1,719.05 | $326.62 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $1,490.01 | $283.1 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $515.81 | $98 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $3,309.95 | $628.89 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $1,039.31 | $197.47 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $2,680.22 | $509.24 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $178.89 | $10.15 | — | — | — |
| General health panel | CPT | 80050 | 0 | $338.84 | $64.38 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $61.5 | $8.41 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $325.51 | $12.67 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $148.35 | $16.07 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $92.56 | $10.42 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $74.17 | $9.8 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $21.3 | $4.18 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $104.51 | $2.7 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $32.97 | $4.72 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $99.85 | $11.65 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $161.03 | $20.16 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $138.61 | $9.32 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $67.68 | $7.76 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $130.56 | $9.68 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $77.34 | $9.71 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $1,642.38 | $312.05 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $7,193 | $1,366.67 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | — | — | — | — | — |
| C-section delivery only | CPT | 59514 | 0 | $1,080.62 | $205.32 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $1,569.75 | $298.25 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $1,569.75 | $298.25 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $3,344.09 | $635.38 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $1,464.39 | $278.23 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $3,054.21 | $580.3 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $3,054.21 | $580.3 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $1,851.1 | $351.71 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $2,206.1 | $419.16 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $2,625.26 | $498.8 | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | — | — | — | — | — |
| Hip hemiarthroplasty | CPT | 27125 | 0 | — | — | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | — | — | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | — | — | — | — | — |
| Knee revision arthroplasty single component | CPT | 27486 | 0 | — | — | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | — | — | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | — | — | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | — | — | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | — | — | — | — | — |
| Open appendectomy | CPT | 44950 | 0 | — | — | — | — | — |
| Laparoscopic appendectomy | CPT | 44970 | 0 | $15,941 | $3,028.72 | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $10,373 | $1,970.92 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | — | — | — | — | — |
| Lap inguinal hernia repair | CPT | 49650 | 0 | — | — | — | — | — |
| Total abdominal hysterectomy | CPT | 58150 | 0 | — | — | — | — | — |
| Vaginal hysterectomy | CPT | 58260 | 0 | — | — | — | — | — |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 0 | — | — | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | — | — | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $15,182 | $2,884.49 | — | — | — |
| Complex cataract surgery | CPT | 66982 | 0 | — | — | — | — | — |
| Cataract surgery with lens implant | CPT | 66984 | 0 | — | — | — | — | — |
| Intravitreal injection | CPT | 67028 | 0 | $1,063.88 | $202.14 | — | — | — |
| Vitrectomy mechanical | CPT | 67042 | 0 | — | — | — | — | — |
| PCI single major coronary artery | CPT | 92920 | 0 | $15,412 | $2,928.26 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $22,336 | $4,243.92 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $22,336 | $4,243.92 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $28,720 | $5,456.71 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $24,247 | $4,606.86 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $26,108 | $4,960.6 | — | — | — |
