| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $219 | $27.85 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $403 | $34.9 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $704 | $53.39 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $1,108 | $101.28 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $1,589 | $175.86 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $2,099 | $27.85 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $1,308 | $27.85 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $1,964 | $27.85 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $2,276 | $27.85 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $1,648 | $27.85 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $251 | $27.85 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $251 | $27.85 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $290 | $27.85 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $1,653 | $27.85 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $2,387 | $27.85 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $2,934 | $27.85 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $353 | $27.85 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $1,519 | $5.82 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $1,519 | $27.85 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $1,519 | $22.33 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $1,308 | $27.85 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $1,456 | $27.85 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $468 | $27.85 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $363 | $27.85 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $325 | $27.85 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $363 | $27.85 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $1,865 | $27.85 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $2,511 | $27.85 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $2,848 | $27.85 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $1,203 | $27.85 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $3,045 | $27.85 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $2,253 | $27.85 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $462 | $27.85 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $439 | $27.85 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $437 | $27.85 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $426 | $27.85 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $414 | $27.85 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $462 | $27.85 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $401 | $27.85 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $439 | $27.85 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $202 | $4.04 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $2,730 | $27.85 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $734 | $27.85 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $164 | $7.81 | — | — | — |
| General health panel | CPT | 80050 | 0 | $276 | $27.85 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $153 | $15.07 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $202 | $6.83 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $140 | $13.29 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $202 | $8.59 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $164 | $7.58 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $44 | — | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $65 | $3.93 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $115 | $9.01 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $140 | $15.68 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $91 | $5.79 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $53 | $17.35 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $102 | $6.78 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $156 | $27.85 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $523 | $27.85 | — | — | — |
| office |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $91 | $3.75 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $2,475 | $27.85 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $2,475 | $27.85 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $2,406 | $27.85 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $2,406 | $27.85 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $2,406 | $27.85 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $3,163 | $27.85 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $3,163 | $27.85 | — | — | — |
| surgery |
| Open appendectomy | CPT | 44950 | 0 | $9,795 | $27.85 | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $15,227 | $27.85 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $15,227 | $27.85 | — | — | — |
| Open umbilical hernia repair | CPT | 49560 | 0 | $9,795 | $27.85 | — | — | — |
| Umbilical hernia repair age 5+ | CPT | 49585 | 0 | $9,795 | $27.85 | — | — | — |
| Total abdominal hysterectomy | CPT | 58150 | 0 | $3,260 | $27.85 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $15,227 | $27.85 | — | — | — |
