| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $174 | $69.6 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $300 | $120 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $602 | $240.8 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $932 | $372.8 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $1,310 | $524 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $1,945 | $778 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $1,654 | $661.6 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $1,738 | $695.2 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $1,819 | $727.6 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $1,738 | $695.2 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $3,209 | $1,283.6 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $3,927 | $1,570.8 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $4,320 | $1,728 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $316 | $126.4 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $343 | $137.2 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $378 | $151.2 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $1,737 | $694.8 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $2,126 | $850.4 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $2,881 | $1,152.4 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $2,167 | $866.8 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $3,510 | $1,404 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $581 | $232.4 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $2,453 | $981.2 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $2,453 | $981.2 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $1,852 | $740.8 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $3,435 | $1,374 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $3,445 | $1,378 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $3,424 | $1,369.6 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $3,596 | $1,438.4 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $4,288 | $1,715.2 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $4,247 | $1,698.8 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $1,786 | $714.4 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $2,174 | $869.6 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $527 | $210.8 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $358 | $143.2 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $428 | $171.2 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $2,167 | $866.8 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $3,528 | $1,411.2 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $255 | $102 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $304 | $121.6 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $2,167 | $866.8 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $3,528 | $1,411.2 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $1,955 | $782 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $2,162 | $864.8 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $2,705 | $1,082 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $3,738 | $1,495.2 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $4,331 | $1,732.4 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $5,093 | $2,037.2 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $2,257 | $902.8 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $3,532 | $1,412.8 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $875 | $350 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $637 | $254.8 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $785 | $314 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $535 | $214 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $527 | $210.8 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $1,189 | $475.6 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $576 | $230.4 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $919 | $367.6 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $669 | $267.6 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $518 | $207.2 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $542 | $216.8 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $542 | $216.8 | — | — | — |
| EKG complete | CPT | 93000 | 0 | $342 | $136.8 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $292 | $116.8 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $2,416 | $966.4 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $1,686 | $674.4 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $655 | $262 | — | — | — |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 0 | $22,112 | $8,844.86 | — | — | — |
| COPD w MCC | MS-DRG | 190 | 0 | $12,417 | $4,966.98 | — | — | — |
| COPD w CC | MS-DRG | 191 | 0 | $13,083 | $5,233.37 | — | — | — |
| COPD w/o CC/MCC | MS-DRG | 192 | 0 | $14,077 | $5,630.92 | — | — | — |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 0 | $19,094 | $7,637.55 | — | — | — |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 0 | $11,577 | $4,630.87 | — | — | — |
| AMI discharged alive w MCC | MS-DRG | 280 | 0 | $12,764 | $5,105.5 | — | — | — |
| AMI discharged alive w CC | MS-DRG | 281 | 0 | $14,669 | $5,867.45 | — | — | — |
| Heart failure & shock w MCC | MS-DRG | 291 | 0 | $35,958 | $14,383 | — | — | — |
| Heart failure & shock w CC | MS-DRG | 292 | 0 | $22,360 | $8,943.86 | — | — | — |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 0 | $11,180 | $4,472.09 | — | — | — |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 0 | $15,164 | $6,065.77 | — | — | — |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 0 | $25,753 | $10,301 | — | — | — |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 0 | $9,837.77 | $3,935.11 | — | — | — |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 0 | $3,967.22 | $1,586.89 | — | — | — |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 0 | $12,159 | $4,863.55 | — | — | — |
| Kidney/UTI w MCC | MS-DRG | 689 | 0 | $13,074 | $5,229.4 | — | — | — |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 0 | $28,334 | $11,333 | — | — | — |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 0 | $14,340 | $5,736.07 | — | — | — |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 0 | $13,179 | $5,271.49 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $188 | $75.2 | — | — | — |
| General health panel | CPT | 80050 | 0 | $754 | $301.6 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $108 | $43.2 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $490 | $196 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $112 | $44.8 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $338 | $135.2 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $347 | $138.8 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $28 | $11.2 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $48 | $19.2 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $75 | $30 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $107 | $42.8 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $75 | $30 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $73 | $29.2 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $62 | $24.8 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $69 | $27.6 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $437 | $174.8 | — | — | — |
| maternity |
| Vaginal delivery only | CPT | 59409 | 0 | $4,792 | $1,916.8 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $238 | $95.2 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $286 | $114.4 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $380 | $152 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $453 | $181.2 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $130 | $52 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $136 | $54.4 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $167 | $66.8 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $188 | $75.2 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $220 | $88 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $2,758 | $1,103.2 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $2,792.2 | $1,116.88 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $2,687 | $1,074.8 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $2,990.63 | $1,196.25 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $2,766.9 | $1,106.76 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $2,999.06 | $1,199.62 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $2,958.04 | $1,183.22 | — | — | — |
| surgery |
| Total knee replacement | CPT | 27447 | 0 | $40,290 | $16,116 | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $9,760.39 | $3,904.16 | — | — | — |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 0 | $238,015 | $95,206 | — | — | — |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 0 | $132,762 | $53,105 | — | — | — |
| Cataract surgery with lens implant | CPT | 66984 | 0 | $9,451.37 | $3,780.55 | — | — | — |
