| emergency |
| ED visit level 1 | CPT | 99281 | 7 | $200 | $200 | $82 | $215 | 1.5× | $300 |
| ED visit level 2 | CPT | 99282 | 7 | $336 | $336 | $152 | $215 | 0.91× | $300 |
| ED visit level 3 | CPT | 99283 | 7 | $101 | $101 | $182 | $250 | 0.62× | $300 |
| ED visit level 4 | CPT | 99284 | 7 | $100 | $100 | $182 | $250 | 0.37× | $410 |
| ED visit level 5 | CPT | 99285 | 7 | $109 | $109 | $182 | $250 | 0.24× | $595 |
| imaging |
| CT head without contrast | CPT | 70450 | 7 | $1,189 | $1,189 | $102 | $275 | 1.3× | $303 |
| CT head with contrast | CPT | 70460 | 7 | $728 | $728 | $170 | $285 | 1.2× | $325 |
| CT head with and without contrast | CPT | 70470 | 7 | $728 | $728 | $170 | $300 | 1.1× | $325 |
| CT neck with contrast | CPT | 70491 | 7 | $750 | $750 | $170 | $285 | 1.0× | $325 |
| MRI brain without contrast | CPT | 70551 | 7 | $300 | $300 | $227 | $625 | 1.5× | $715 |
| MRI brain with contrast | CPT | 70552 | 7 | $135 | $135 | $356 | $625 | 1.3× | $730 |
| MRI brain with and without contrast | CPT | 70553 | 7 | $930 | $930 | $356 | $625 | 1.1× | $750 |
| Chest X-ray single view | CPT | 71045 | 6 | $160 | $160 | $20 | $31 | 0.33× | $84 |
| Chest X-ray 2 views | CPT | 71046 | 6 | $130 | $130 | $31 | $41 | 0.42× | $84 |
| Chest X-ray 3 views | CPT | 71047 | 5 | $440 | $440 | $40 | $42 | 0.44× | $84 |
| CT chest without contrast | CPT | 71250 | 7 | $534 | $534 | $102 | $275 | 1.3× | $330 |
| CT chest with contrast | CPT | 71260 | 7 | $112 | $112 | $170 | $285 | 1.0× | $330 |
| CT chest with and without contrast | CPT | 71270 | 7 | $150 | $150 | $170 | $292 | 1.0× | $330 |
| MRI chest without contrast | CPT | 71550 | 7 | $93 | $93 | $227 | $625 | 1.5× | $715 |
| MRI chest with contrast | CPT | 71551 | 7 | $117 | $117 | $439 | $650 | 0.80× | $742 |
| MRI chest with and without contrast | CPT | 71552 | 7 | $124 | $124 | $356 | $625 | 1.0× | $715 |
| Lumbosacral spine X-ray | CPT | 72100 | 7 | $175 | $175 | $32 | $44 | 0.43× | $102 |
| CT cervical spine without contrast | CPT | 72125 | 7 | $750 | $750 | $102 | $275 | 1.4× | $303 |
| CT thoracic spine without contrast | CPT | 72128 | 7 | $150 | $150 | $102 | $285 | 1.4× | $330 |
| CT lumbar spine without contrast | CPT | 72131 | 7 | $210 | $210 | $102 | $275 | 1.4× | $303 |
| MRI cervical spine without contrast | CPT | 72141 | 7 | $2,500 | $2,500 | $227 | $625 | 1.6× | $715 |
| MRI thoracic spine without contrast | CPT | 72146 | 7 | $2,100 | $2,100 | $227 | $625 | 1.7× | $715 |
| MRI lumbar spine without contrast | CPT | 72148 | 7 | $2,300 | $2,300 | $227 | $625 | 1.7× | $715 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 7 | $4,050 | $4,050 | $356 | $625 | 1.4× | $730 |
| MRI cervical spine with and without contrast | CPT | 72156 | 7 | $4,600 | $4,600 | $356 | $625 | 1.2× | $730 |
| MRI lumbar spine with contrast | CPT | 72158 | 7 | $25 | $25 | $356 | $625 | 1.1× | $730 |
| CT pelvis without contrast | CPT | 72192 | 7 | $1,413 | $1,413 | $102 | $275 | 1.4× | $330 |
| CT pelvis with contrast | CPT | 72193 | 7 | $375 | $375 | $170 | $285 | 1.0× | $330 |
| Shoulder X-ray | CPT | 73030 | 7 | $175 | $175 | $24 | $39 | 0.42× | $84 |
| Humerus X-ray | CPT | 73060 | 7 | $125 | $125 | $24 | $36 | 0.40× | $84 |
| Hand X-ray 3 views | CPT | 73130 | 7 | $125 | $125 | $30 | $41 | 0.44× | $84 |
| MRI upper extremity joint without contrast | CPT | 73221 | 7 | $74 | $74 | $227 | $625 | 1.5× | $715 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 7 | $96 | $96 | $356 | $625 | 1.0× | $715 |
| Knee X-ray 1-2 views | CPT | 73560 | 7 | $74 | $74 | $24 | $36 | 0.39× | $84 |
| Ankle X-ray 3 views | CPT | 73610 | 7 | $100 | $100 | $31 | $42 | 0.46× | $84 |
| MRI lower extremity joint without contrast | CPT | 73721 | 7 | $300 | $300 | $227 | $625 | 1.3× | $715 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 7 | $300 | $300 | $330 | $620 | 0.98× | $715 |
| CT abdomen without contrast | CPT | 74150 | 7 | $4,200 | $4,200 | $102 | $275 | 1.5× | $330 |
| CT abdomen with contrast | CPT | 74160 | 7 | $3,200 | $3,200 | $170 | $285 | 0.99× | $330 |
| CT abdomen with and without contrast | CPT | 74170 | 7 | $390 | $390 | $170 | $285 | 0.85× | $330 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 7 | $225 | $225 | $227 | $300 | 0.82× | $495 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 7 | $150 | $150 | $275 | $381 | 0.69× | $495 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 7 | $415 | $415 | $275 | $378 | 0.66× | $495 |
| MRI abdomen without contrast | CPT | 74181 | 7 | $300 | $300 | $227 | $625 | 1.6× | $715 |
| MRI abdomen with and without contrast | CPT | 74183 | 7 | $800 | $800 | $356 | $625 | 1.1× | $715 |
| Abdominal ultrasound complete | CPT | 76700 | 7 | $858 | $858 | $70 | $100 | 0.67× | $110 |
| Abdominal ultrasound limited | CPT | 76705 | 7 | $400 | $400 | $35 | $80 | 0.55× | $110 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 7 | $300 | $300 | $70 | $91 | 0.63× | $110 |
| Obstetric ultrasound first trimester | CPT | 76801 | 7 | $300 | $300 | $40 | $77 | 0.54× | $102 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 7 | $300 | $300 | $40 | $80 | 0.52× | $106 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 7 | $650 | $650 | $75 | $138 | 0.59× | $227 |
| Transvaginal ultrasound | CPT | 76830 | 7 | $900 | $900 | $40 | $100 | 0.68× | $125 |
| Pelvic ultrasound complete | CPT | 76856 | 7 | $600 | $600 | $40 | $75 | 0.52× | $102 |
| Scrotal ultrasound | CPT | 76870 | 7 | $600 | $600 | $60 | $75 | 0.57× | $125 |
| Diagnostic mammography unilateral | CPT | 77065 | 4 | $600 | $600 | $45 | $80.5 | 0.54× | $99 |
| Diagnostic mammography bilateral | CPT | 77066 | 5 | $600 | $600 | $71 | $108 | 0.57× | $140 |
| Screening mammography bilateral | CPT | 77067 | 5 | $300 | $300 | $52 | $101 | 0.64× | $118 |
| EKG complete | CPT | 93000 | 3 | $650 | $650 | $30 | $30 | 1.2× | $30 |
| EKG tracing only | CPT | 93005 | 4 | $509 | $509 | $10 | $16 | 0.14× | $57 |
| EKG interpretation only | CPT | 93010 | 4 | $652 | $652 | $15 | $15.5 | 0.86× | $20 |
| Transthoracic echocardiogram complete | CPT | 93306 | 5 | $250 | $250 | $175 | $400 | 0.67× | $511 |
| Transthoracic echocardiogram | CPT | 93307 | 4 | $300 | $300 | $160 | $248.5 | 1.0× | $328 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 6 | $22 | $22 | $12 | $13.5 | 0.42× | $40 |
| Electrolyte panel | CPT | 80051 | 6 | $120 | $120 | $10 | $12.5 | 0.53× | $18 |
| Comprehensive metabolic panel | CPT | 80053 | 6 | $120 | $120 | $18 | $20 | 0.45× | $55 |
| Lipid panel | CPT | 80061 | 6 | $132 | $132 | $22 | $27 | 0.71× | $40 |
| Renal function panel | CPT | 80069 | 6 | $383 | $383 | $12 | $18 | 0.66× | $53 |
| Hepatic function panel | CPT | 80076 | 6 | $168 | $168 | $11 | $15 | 0.56× | $35 |
| Urinalysis non-automated | CPT | 81002 | 6 | $24 | $24 | $3 | $3.5 | 0.50× | $7 |
| Urinalysis automated | CPT | 81003 | 6 | $24 | $24 | $2 | $3 | 0.22× | $8 |
| Glucose quantitative | CPT | 82947 | 6 | $60 | $60 | $6 | $6 | 0.34× | $8 |
| Hemoglobin A1c | CPT | 83036 | 6 | $139 | $139 | $14 | $16 | 0.59× | $25 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 6 | $187 | $187 | $20 | $28.5 | 0.60× | $40 |
| Complete blood count with automated differential | CPT | 85025 | 6 | $29 | $29 | $8 | $9 | 0.34× | $11 |
| Complete blood count without differential | CPT | 85027 | 6 | $22 | $22 | $6 | $7 | 0.32× | $10 |
| Urine culture bacterial | CPT | 87086 | 6 | $87 | $87 | $3 | $7 | 0.30× | $30 |
| Urine culture identification | CPT | 87088 | 6 | $72 | $72 | $20 | $23 | 1.0× | $30 |