| emergency |
| ED visit level 1 | CPT | 99281 | 1 | $250 | $250 | $82 | $82 | $82 |
| ED visit level 2 | CPT | 99282 | 1 | $250 | $250 | $152 | $152 | $152 |
| ED visit level 3 | CPT | 99283 | 1 | $250 | $250 | $264 | $264 | $264 |
| ED visit level 4 | CPT | 99284 | 1 | $250 | $250 | $410 | $410 | $410 |
| ED visit level 5 | CPT | 99285 | 1 | $250 | $250 | $595 | $595 | $595 |
| imaging |
| CT head without contrast | CPT | 70450 | 7 | $250 | $250 | $102 | $275 | $300 |
| CT head with contrast | CPT | 70460 | 7 | $250 | $250 | $170 | $280 | $325 |
| CT head with and without contrast | CPT | 70470 | 7 | $250 | $250 | $170 | $280 | $325 |
| CT neck with contrast | CPT | 70491 | 7 | $250 | $250 | $138 | $280 | $325 |
| MRI brain without contrast | CPT | 70551 | 7 | $400 | $400 | $227 | $625 | $650 |
| MRI brain with contrast | CPT | 70552 | 7 | $425 | $425 | $356 | $647 | $730 |
| MRI brain with and without contrast | CPT | 70553 | 7 | $425 | $425 | $356 | $650 | $750 |
| Chest X-ray single view | CPT | 71045 | 7 | $16 | $16 | $10 | $20 | $84 |
| Chest X-ray 2 views | CPT | 71046 | 6 | $32 | $32 | $16 | $28.5 | $84 |
| Chest X-ray 3 views | CPT | 71047 | 7 | $37 | $37 | $19 | $30 | $84 |
| CT chest without contrast | CPT | 71250 | 7 | $250 | $250 | $102 | $275 | $300 |
| CT chest with contrast | CPT | 71260 | 7 | $250 | $250 | $170 | $285 | $325 |
| CT chest with and without contrast | CPT | 71270 | 7 | $250 | $250 | $170 | $292 | $325 |
| MRI chest without contrast | CPT | 71550 | 7 | $400 | $400 | $227 | $625 | $650 |
| MRI chest with contrast | CPT | 71551 | 7 | $425 | $425 | $439 | $650 | $742 |
| MRI chest with and without contrast | CPT | 71552 | 7 | $425 | $425 | $356 | $625 | $650 |
| Lumbosacral spine X-ray | CPT | 72100 | 7 | $32 | $32 | $32 | $44 | $102 |
| CT cervical spine without contrast | CPT | 72125 | 7 | $250 | $250 | $102 | $275 | $300 |
| CT thoracic spine without contrast | CPT | 72128 | 7 | $250 | $250 | $102 | $285 | $300 |
| CT lumbar spine without contrast | CPT | 72131 | 7 | $250 | $250 | $102 | $275 | $300 |
| MRI cervical spine without contrast | CPT | 72141 | 7 | $400 | $400 | $227 | $635 | $650 |
| MRI thoracic spine without contrast | CPT | 72146 | 7 | $400 | $400 | $227 | $635 | $650 |
| MRI lumbar spine without contrast | CPT | 72148 | 7 | $400 | $400 | $227 | $625 | $650 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 7 | $425 | $425 | $356 | $650 | $730 |
| MRI cervical spine with and without contrast | CPT | 72156 | 7 | $425 | $425 | $356 | $647 | $730 |
| MRI lumbar spine with contrast | CPT | 72158 | 7 | $425 | $425 | $356 | $647 | $730 |
| CT pelvis without contrast | CPT | 72192 | 7 | $150 | $150 | $102 | $275 | $325 |
| CT pelvis with contrast | CPT | 72193 | 7 | $250 | $250 | $170 | $300 | $428 |
| Shoulder X-ray | CPT | 73030 | 7 | $24 | $24 | $24 | $39 | $84 |
| Humerus X-ray | CPT | 73060 | 7 | $32 | $32 | $24 | $36 | $84 |
| Hand X-ray 3 views | CPT | 73130 | 7 | $25 | $25 | $28 | $41 | $84 |
| MRI upper extremity joint without contrast | CPT | 73221 | 7 | $400 | $400 | $227 | $625 | $650 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 7 | $425 | $425 | $356 | $625 | $710 |
| Knee X-ray 1-2 views | CPT | 73560 | 7 | $27 | $27 | $24 | $36 | $84 |
| Ankle X-ray 3 views | CPT | 73610 | 7 | $27 | $27 | $28 | $42 | $84 |
| MRI lower extremity joint without contrast | CPT | 73721 | 7 | $400 | $400 | $227 | $625 | $650 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 7 | $425 | $425 | $330 | $620 | $650 |
| CT abdomen without contrast | CPT | 74150 | 7 | $250 | $250 | $102 | $275 | $300 |
| CT abdomen with contrast | CPT | 74160 | 7 | $250 | $250 | $170 | $285 | $325 |
| CT abdomen with and without contrast | CPT | 74170 | 7 | $250 | $250 | $170 | $285 | $325 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 7 | $275 | $275 | $227 | $300 | $450 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 7 | $275 | $275 | $275 | $383 | $450 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 7 | $275 | $275 | $275 | $378 | $450 |
| MRI abdomen without contrast | CPT | 74181 | 7 | $400 | $400 | $227 | $625 | $650 |
| MRI abdomen with and without contrast | CPT | 74183 | 7 | $425 | $425 | $356 | $625 | $650 |
| Abdominal ultrasound complete | CPT | 76700 | 7 | $93 | $93 | $70 | $100 | $102 |
| Abdominal ultrasound limited | CPT | 76705 | 7 | $58 | $58 | $35 | $80 | $102 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 7 | $79 | $79 | $70 | $100 | $102 |
| Obstetric ultrasound first trimester | CPT | 76801 | 3 | $68 | $68 | $75 | $75 | $102 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 7 | $68 | $68 | $75 | $75 | $106 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 5 | $188 | $188 | $75 | $75 | $227 |
| Transvaginal ultrasound | CPT | 76830 | 7 | $50 | $50 | $40 | $100 | $125 |
| Pelvic ultrasound complete | CPT | 76856 | 7 | $66 | $66 | $40 | $75 | $113 |
| Scrotal ultrasound | CPT | 76870 | 7 | $63 | $63 | $70 | $75 | $102 |
| Diagnostic mammography unilateral | CPT | 77065 | 2 | $95 | $95 | $33 | $60 | $87 |
| Diagnostic mammography bilateral | CPT | 77066 | 6 | $120 | $120 | $41 | $80 | $108 |
| Screening mammography bilateral | CPT | 77067 | 4 | $100 | $100 | $59 | $72.5 | $101 |
| EKG complete | CPT | 93000 | 4 | $63 | $63 | $15 | $30 | $30 |
| EKG tracing only | CPT | 93005 | 1 | $63 | $63 | $57 | $57 | $57 |
| EKG interpretation only | CPT | 93010 | 3 | $15 | $15 | $15 | $15 | $15 |
| Transthoracic echocardiogram complete | CPT | 93306 | 7 | $350 | $350 | $175 | $373 | $511 |
| Transthoracic echocardiogram | CPT | 93307 | 7 | $430 | $430 | $135 | $160 | $227 |
| Stress echocardiogram | CPT | 93350 | 7 | $125 | $125 | $150 | $233 | $511 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 6 | $50 | $50 | $12 | $13.5 | $40 |
| General health panel | CPT | 80050 | 4 | $108 | $108 | $43 | $64.5 | $90 |
| Electrolyte panel | CPT | 80051 | 6 | $30 | $30 | $10 | $12.5 | $18 |
| Comprehensive metabolic panel | CPT | 80053 | 6 | $50 | $50 | $18 | $20 | $55 |
| Lipid panel | CPT | 80061 | 6 | $76 | $76 | $22 | $27 | $40 |
| Renal function panel | CPT | 80069 | 6 | $45 | $45 | $12 | $18 | $53 |
| Hepatic function panel | CPT | 80076 | 6 | $42 | $42 | $11 | $15 | $35 |
| Urinalysis non-automated | CPT | 81002 | 2 | $12 | $12 | $3 | $5 | $7 |
| Urinalysis automated | CPT | 81003 | 2 | $24 | $24 | $6 | $7 | $8 |
| Glucose quantitative | CPT | 82947 | 6 | $15 | $15 | $6 | $6 | $8 |
| Hemoglobin A1c | CPT | 83036 | 6 | $66 | $66 | $14 | $16 | $25 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 6 | $54 | $54 | $20 | $28.5 | $40 |
| Complete blood count with automated differential | CPT | 85025 | 6 | $17 | $17 | $8 | $9 | $11 |
| Complete blood count without differential | CPT | 85027 | 6 | $20 | $20 | $6 | $7 | $10 |
| Urine culture bacterial | CPT | 87086 | 6 | $30 | $30 | $3 | $7 | $30 |
| Urine culture identification | CPT | 87088 | 6 | $40 | $40 | $20 | $23 | $30 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 1 | $50 | $50 | $185 | $185 | $185 |
| office |
| Office visit, new patient, 45-59 min | CPT | 99204 | 1 | $200 | $200 | $30 | $30 | $30 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 1 | $200 | $200 | $30 | $30 | $30 |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $16 | $16 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 1 | $200 | $200 | $40 | $40 | $40 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 5 | $110 | $110 | $22 | $100 | $100 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 1 | $200 | $200 | $25 | $25 | $25 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 7 | $150 | $150 | $85 | $135 | $840 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 7 | $150 | $150 | $85 | $135 | $840 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 1 | $500 | $500 | $847 | $847 | $847 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 1 | $500 | $500 | $847 | $847 | $847 |
| Colonoscopy diagnostic | CPT | 45378 | 5 | $150 | $150 | $85 | $135 | $847 |
| Colonoscopy with biopsy | CPT | 45380 | 7 | $700 | $700 | $85 | $135 | $1,094 |
| surgery |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $700 | $700 | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 1 | $3,000 | $3,000 | $6,631 | $6,631 | $6,631 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 1 | $150 | $150 | $3,000 | $3,000 | $3,000 |
| Cataract surgery with lens implant | CPT | 66984 | 1 | $125 | $125 | $2,160 | $2,160 | $2,160 |
| Left heart catheterization | CPT | 93452 | 6 | $2,200 | $2,200 | $1,680 | $2,035 | $3,020 |
| Coronary angiography with bypass cath | CPT | 93458 | 6 | $2,200 | $2,200 | $1,680 | $2,035 | $3,020 |
