| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $642 | $642 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $1,118 | $1,118 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $1,433 | $1,433 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $1,932 | $1,932 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $2,600 | $2,600 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $4,667 | $4,667 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $2,177 | $2,177 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $2,608 | $2,608 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $3,254 | $3,254 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $2,608 | $2,608 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $5,168 | $5,168 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $6,187 | $6,187 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $6,187 | $6,187 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $233 | $233 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $285 | $285 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $342 | $342 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $2,723 | $2,723 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $3,254 | $3,254 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $4,070 | $4,070 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $5,116 | $5,116 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $5,723 | $5,723 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $6,059 | $6,059 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $330 | $330 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $2,723 | $2,723 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $2,723 | $2,723 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $2,621 | $2,621 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $5,162 | $5,162 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $5,723 | $5,723 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $5,723 | $5,723 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $6,187 | $6,187 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $6,187 | $6,187 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $6,187 | $6,187 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $2,255 | $2,255 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $2,450 | $2,450 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $273 | $273 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $273 | $273 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $248 | $248 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $5,088 | $5,088 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $6,033 | $6,033 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $245 | $245 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $248 | $248 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $5,088 | $5,088 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $6,033 | $6,033 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $2,255 | $2,255 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $2,450 | $2,450 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $2,645 | $2,645 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $2,645 | $2,645 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $2,842 | $2,842 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $3,039 | $3,039 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $5,116 | $5,116 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $6,059 | $6,059 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $1,308 | $1,308 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $970 | $970 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $1,308 | $1,308 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $624 | $624 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $1,131 | $1,131 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $1,277 | $1,277 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $618 | $618 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $970 | $970 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $970 | $970 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $433 | $433 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $528 | $528 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $355 | $355 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $347 | $347 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $3,316 | $3,316 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $1,230 | $1,230 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $2,445 | $2,445 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $103 | $103 | — | — | — |
| General health panel | CPT | 80050 | 0 | $264 | $264 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $360 | $360 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $201 | $201 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $65 | $65 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $103 | $103 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $199 | $199 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $53 | $53 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $35 | $35 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $83 | $83 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $340 | $340 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $423 | $423 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $144 | $144 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $121 | $121 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $130 | $130 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $666 | $666 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $699 | $699 | — | — | — |
| Vaginal delivery with postpartum | CPT | 59410 | 0 | $5,829 | $5,829 | — | — | — |
| C-section with postpartum | CPT | 59515 | 0 | $1,122 | $1,122 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $342 | $342 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $342 | $342 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $342 | $342 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $342 | $342 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $483 | $483 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $342 | $342 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $342 | $342 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $342 | $342 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $342 | $342 | — | — | — |
| preventive |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $475 | $475 | — | — | — |