| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $225.93 | $27.63 | — | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $373.36 | $28.48 | — | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $595.77 | $28.48 | — | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $948.47 | $28.48 | — | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $1,401.35 | $28.48 | — | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $1,786 | $270.68 | — | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $2,080 | $316.3 | — | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $2,653 | $316.3 | — | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $2,095 | $316.3 | — | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $4,272 | $316.3 | — | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $4,961 | $393.4 | — | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $6,534 | $393.4 | — | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $407 | $270.68 | — | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $548 | $270.68 | — | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $2,539 | $291.92 | — | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $2,842 | $316.3 | — | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $3,605 | $316.3 | — | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $5,396 | $316.3 | — | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $5,964 | $410.55 | — | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $8,326 | $393.4 | — | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $655 | $2,608.25 | — | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $2,645 | $291.92 | — | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $2,639 | $291.92 | — | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $2,628 | $291.92 | — | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $4,972 | $316.3 | — | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $5,401 | $316.3 | — | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $5,181 | $316.3 | — | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $5,829 | $393.4 | — | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $7,236 | $393.4 | — | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $7,581 | $393.4 | — | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $2,339 | $291.92 | — | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $2,723 | $316.3 | — | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $611 | $631.9 | — | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $568 | $631.9 | — | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $502 | $1,167.38 | — | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $2,652 | $316.3 | — | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $3,947 | $393.4 | — | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $490 | $1,300.87 | — | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $521 | $1,462.78 | — | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $3,168 | $331.82 | — | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $4,546 | $393.4 | — | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $2,989 | $291.92 | — | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $3,560 | $316.3 | — | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $4,379 | $316.3 | — | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $6,242 | $331.82 | — | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $9,150 | $393.4 | — | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $1,216 | $299.82 | — | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $869 | $299.82 | — | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $1,197 | $299.82 | — | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $1,027 | $1,401.67 | — | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $1,027 | $1,401.67 | — | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $1,684 | $168.46 | — | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $1,179 | $1,401.67 | — | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $1,031 | $316.3 | — | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $912 | $24.15 | — | — | — | — |
| EKG complete | CPT | 93000 | 0 | $555 | — | — | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $356 | $190.03 | — | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $4,364 | $237.59 | — | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $2,818 | $168.46 | — | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $3,089 | $237.59 | — | — | — | — |
| inpatient |
| Initial hospital care, low complexity | CPT | 99221 | 0 | $50 | — | — | — | — | — |
| Initial hospital care, moderate complexity | CPT | 99222 | 0 | $50 | — | — | — | — | — |
| Initial hospital care, high complexity | CPT | 99223 | 0 | $50 | — | — | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $301 | — | — | — | — | — |
| General health panel | CPT | 80050 | 0 | $689 | — | — | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $251 | — | — | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $351 | — | — | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $401 | — | — | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $376 | — | — | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $313 | — | — | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $45 | — | — | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $47 | — | — | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $88 | — | — | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $182 | — | — | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $270 | — | — | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $133 | — | — | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $125 | — | — | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $151 | — | — | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $145 | — | — | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $499 | $307.26 | — | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $437.67 | $10,218 | — | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $5,742.47 | $10,218 | — | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $174 | — | — | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $250 | — | — | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $385 | — | — | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $490 | — | — | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $90 | — | — | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $164 | — | — | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $255 | — | — | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $378 | — | — | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $480 | — | — | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $5,696 | $10,218 | — | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $5,944 | $10,218 | — | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $1,654.31 | $10,218 | — | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $1,654.31 | $10,218 | — | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $5,781 | $10,218 | — | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $5,781 | $10,218 | — | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $5,781 | $10,218 | — | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | $20,000 | $13,979 | — | — | — | — |
| Hip hemiarthroplasty | CPT | 27125 | 0 | $35,212 | $10,218 | — | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | $48,383 | $17,820 | — | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | $38,314 | $18,569 | — | — | — | — |
| Knee revision arthroplasty single component | CPT | 27486 | 0 | $20,798 | $6,712.14 | — | — | — | — |
| Knee revision arthroplasty all components | CPT | 27487 | 0 | $24,578 | $14,215 | — | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $23,037 | $8,712.34 | — | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | $21,281 | $8,712.34 | — | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $20,720 | $10,218 | — | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | $31,105 | $10,218 | — | — | — | — |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 0 | $10,591 | $8,946.98 | — | — | — | — |
| Open appendectomy | CPT | 44950 | 0 | $7,788 | $3,771.94 | — | — | — | — |
| Laparoscopic appendectomy | CPT | 44970 | 0 | $13,419 | $10,218 | — | — | — | — |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 0 | $27,930 | — | — | — | — | — |
| Major joint replacement w MCC | MS-DRG | 469 | 0 | $28,396 | $17,712 | — | — | — | — |
| Major joint replacement w/o MCC | MS-DRG | 470 | 0 | $122,851 | $10,218 | — | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $18,480 | $10,218 | — | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $13,419 | $7,342.92 | — | — | — | — |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 0 | $4,153 | $11,244 | — | — | — | — |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 0 | $17,159 | $8,596.9 | — | — | — | — |
| Open umbilical hernia repair | CPT | 49560 | 0 | $21,039 | $10,218 | — | — | — | — |
| Umbilical hernia repair age 5+ | CPT | 49585 | 0 | $15,780 | $10,218 | — | — | — | — |
| Lap inguinal hernia repair | CPT | 49650 | 0 | $15,029 | $10,218 | — | — | — | — |
| Lap incisional hernia repair | CPT | 49652 | 0 | $25,748 | $10,218 | — | — | — | — |
| Total abdominal hysterectomy | CPT | 58150 | 0 | $13,406 | $6,495.37 | — | — | — | — |
| Vaginal hysterectomy | CPT | 58260 | 0 | $30,015 | $10,218 | — | — | — | — |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 0 | $25,753 | $10,218 | — | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | $25,753 | $10,618 | — | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $20,603 | $10,218 | — | — | — | — |
| Complex cataract surgery | CPT | 66982 | 0 | $10,024 | $10,218 | — | — | — | — |
| Cataract surgery with lens implant | CPT | 66984 | 0 | $9,240 | $10,218 | — | — | — | — |
| Intravitreal injection | CPT | 67028 | 0 | $6,227 | $10,218 | — | — | — | — |
| Vitrectomy mechanical | CPT | 67042 | 0 | $18,680 | $10,218 | — | — | — | — |