| behavioral |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $400 | $320 | — | — | — |
| Psychotherapy 45 minutes | CPT | 90834 | 0 | $200 | $160 | — | — | — |
| Psychotherapy 60 minutes | CPT | 90837 | 0 | $300 | $240 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $450 | $360 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $650 | $520 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $850 | $680 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $1,250 | $1,000 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $1,850 | $1,480 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $925 | $740 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $1,450 | $1,160 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $2,500 | $2,000 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $3,200 | $2,560 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $225 | $180 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $350 | $280 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $1,125 | $900 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $2,850 | $2,280 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $2,850 | $2,280 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $2,750 | $2,200 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $275 | $220 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $2,750 | $2,200 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $2,200 | $1,760 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $525 | $420 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $425 | $340 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $575 | $460 | — | — | — |
| EKG complete | CPT | 93000 | 0 | $125 | $100 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $1,850 | $1,480 | — | — | — |
| lab |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $185 | $148 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $125 | $100 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $55 | $44 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $85 | $68 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $125 | $100 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $75 | $60 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $85 | $68 | — | — | — |
| maternity |
| Routine obstetric care including vaginal delivery | CPT | 59400 | 0 | $5,500 | $4,400 | — | — | — |
| Routine obstetric care with C-section | CPT | 59510 | 0 | $7,500 | $6,000 | — | — | — |
| office |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $250 | $200 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $375 | $300 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $500 | $400 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $150 | $120 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $225 | $180 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $325 | $260 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $2,800 | $2,240 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $3,200 | $2,560 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $3,500 | $2,800 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $3,800 | $3,040 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $4,200 | $3,360 | — | — | — |
| surgery |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $8,500 | $6,800 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $8,200 | $6,560 | — | — | — |
| Cataract surgery with lens implant | CPT | 66984 | 0 | $3,500 | $2,800 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $8,500 | $6,800 | — | — | — |
