| emergency |
| ED visit level 1 | CPT | 99281 | 12 | $301 | $30.1 | $75.25 | $75.25 | $192.64 |
| ED visit level 2 | CPT | 99282 | 12 | $508 | $50.8 | $127 | $127 | $325.12 |
| ED visit level 3 | CPT | 99283 | 12 | $1,473 | $147.3 | $368.25 | $368.25 | $942.72 |
| ED visit level 4 | CPT | 99284 | 12 | $2,786 | $278.6 | $696.5 | $696.5 | $1,783.04 |
| ED visit level 5 | CPT | 99285 | 17 | $3,389 | $338.9 | $292.81 | $1,030.69 | $2,168.96 |
| Critical care, first hour | CPT | 99291 | 17 | $5,037 | $503.7 | $435.2 | $1,531.89 | $3,223.68 |
| imaging |
| CT head without contrast | CPT | 70450 | 7 | $5,476 | $547.6 | $1,369 | $1,369 | $1,369 |
| CT head with contrast | CPT | 70460 | 7 | $7,153 | $715.3 | $1,788.25 | $1,788.25 | $1,788.25 |
| CT head with and without contrast | CPT | 70470 | 7 | $8,112 | $811.2 | $2,028 | $2,028 | $2,028 |
| CT neck with contrast | CPT | 70491 | 7 | $7,153 | $715.3 | $1,788.25 | $1,788.25 | $1,788.25 |
| MRI brain without contrast | CPT | 70551 | 7 | $7,832 | $783.2 | $1,958 | $1,958 | $1,958 |
| MRI brain with contrast | CPT | 70552 | 7 | $9,320 | $932 | $2,330 | $2,330 | $2,330 |
| MRI brain with and without contrast | CPT | 70553 | 7 | $10,595 | $1,059.5 | $2,648.75 | $2,648.75 | $2,648.75 |
| Chest X-ray single view | CPT | 71045 | 14 | $1,090 | $109 | $272.5 | $608.22 | $697.6 |
| Chest X-ray 2 views | CPT | 71046 | 14 | $896 | $89.6 | $224 | $499.97 | $573.44 |
| Chest X-ray 3 views | CPT | 71047 | 14 | $289 | $28.9 | $72.25 | $161.26 | $184.96 |
| CT chest without contrast | CPT | 71250 | 7 | $5,578 | $557.8 | $1,394.5 | $1,394.5 | $1,394.5 |
| CT chest with contrast | CPT | 71260 | 7 | $7,288 | $728.8 | $1,822 | $1,822 | $1,822 |
| CT chest with and without contrast | CPT | 71270 | 7 | $8,264 | $826.4 | $2,066 | $2,066 | $2,066 |
| MRI chest without contrast | CPT | 71550 | 7 | $7,465 | $746.5 | $1,866.25 | $1,866.25 | $1,866.25 |
| MRI chest with contrast | CPT | 71551 | 12 | $7,465 | $746.5 | $1,866.25 | $1,866.25 | $4,777.6 |
| MRI chest with and without contrast | CPT | 71552 | 7 | $7,465 | $746.5 | $1,866.25 | $1,866.25 | $1,866.25 |
| Lumbosacral spine X-ray | CPT | 72100 | 14 | $977 | $97.7 | $244.25 | $545.17 | $625.28 |
| CT cervical spine without contrast | CPT | 72125 | 7 | $5,476 | $547.6 | $1,369 | $1,369 | $1,369 |
| CT thoracic spine without contrast | CPT | 72128 | 7 | $5,578 | $557.8 | $1,394.5 | $1,394.5 | $1,394.5 |
| CT lumbar spine without contrast | CPT | 72131 | 7 | $5,578 | $557.8 | $1,394.5 | $1,394.5 | $1,394.5 |
| MRI cervical spine without contrast | CPT | 72141 | 7 | $7,832 | $783.2 | $1,958 | $1,958 | $1,958 |
| MRI thoracic spine without contrast | CPT | 72146 | 7 | $7,465 | $746.5 | $1,866.25 | $1,866.25 | $1,866.25 |
| MRI lumbar spine without contrast | CPT | 72148 | 7 | $7,465 | $746.5 | $1,866.25 | $1,866.25 | $1,866.25 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 7 | $8,883 | $888.3 | $2,220.75 | $2,220.75 | $2,220.75 |
| MRI cervical spine with and without contrast | CPT | 72156 | 7 | $10,595 | $1,059.5 | $2,648.75 | $2,648.75 | $2,648.75 |
| MRI lumbar spine with contrast | CPT | 72158 | 7 | $10,098 | $1,009.8 | $2,524.5 | $2,524.5 | $2,524.5 |
| CT pelvis without contrast | CPT | 72192 | 7 | $5,578 | $557.8 | $1,394.5 | $1,394.5 | $1,394.5 |
| CT pelvis with contrast | CPT | 72193 | 7 | $7,288 | $728.8 | $1,822 | $1,822 | $1,822 |
| Shoulder X-ray | CPT | 73030 | 14 | $1,465.5 | $146.55 | $244.25 | $579.37 | $937.92 |
| Humerus X-ray | CPT | 73060 | 14 | $1,465.5 | $146.55 | $244.25 | $579.37 | $937.92 |
| Hand X-ray 3 views | CPT | 73130 | 14 | $1,623 | $162.3 | $270.5 | $641.63 | $1,038.72 |
| MRI upper extremity joint without contrast | CPT | 73221 | 7 | $11,198 | $1,119.75 | $1,866.25 | $2,332.82 | $2,799.38 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 7 | $10,098 | $1,009.8 | $2,524.5 | $2,524.5 | $2,524.5 |
| Knee X-ray 1-2 views | CPT | 73560 | 14 | $1,284 | $128.4 | $214 | $507.61 | $821.76 |
| Ankle X-ray 3 views | CPT | 73610 | 14 | $1,623 | $162.3 | $270.5 | $641.63 | $1,038.72 |
| MRI lower extremity joint without contrast | CPT | 73721 | 7 | $11,198 | $1,119.75 | $1,866.25 | $2,332.82 | $2,799.38 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 7 | $10,098 | $1,009.8 | $2,524.5 | $2,524.5 | $2,524.5 |
| CT abdomen without contrast | CPT | 74150 | 7 | $5,578 | $557.8 | $1,394.5 | $1,394.5 | $1,394.5 |
| CT abdomen with contrast | CPT | 74160 | 7 | $7,288 | $728.8 | $1,822 | $1,822 | $1,822 |
| CT abdomen with and without contrast | CPT | 74170 | 7 | $8,264 | $826.4 | $2,066 | $2,066 | $2,066 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 7 | $11,154 | $1,115.4 | $2,788.5 | $2,788.5 | $2,788.5 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 7 | $14,573 | $1,457.3 | $3,643.25 | $3,643.25 | $3,643.25 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 7 | $16,525 | $1,652.5 | $4,131.25 | $4,131.25 | $4,131.25 |
| MRI abdomen without contrast | CPT | 74181 | 7 | $7,465 | $746.5 | $1,866.25 | $1,866.25 | $1,866.25 |
| MRI abdomen with and without contrast | CPT | 74183 | 7 | $10,098 | $1,009.8 | $2,524.5 | $2,524.5 | $2,524.5 |
| Abdominal ultrasound complete | CPT | 76700 | 10 | $2,179 | $217.9 | $544.75 | $544.75 | $1,368.41 |
| Abdominal ultrasound limited | CPT | 76705 | 10 | $1,980 | $198 | $495 | $495 | $1,243.44 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 10 | $1,783 | $178.3 | $445.75 | $445.75 | $1,119.72 |
| Obstetric ultrasound first trimester | CPT | 76801 | 14 | $1,682 | $168.2 | $420.5 | $938.56 | $1,076.48 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 14 | $1,771 | $177.1 | $442.75 | $988.22 | $1,133.44 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 14 | $854 | $85.4 | $213.5 | $476.53 | $546.56 |
| Transvaginal ultrasound | CPT | 76830 | 14 | $1,814 | $181.4 | $453.5 | $1,012.21 | $1,160.96 |
| Pelvic ultrasound complete | CPT | 76856 | 10 | $1,814 | $181.4 | $453.5 | $453.5 | $1,139.19 |
| Scrotal ultrasound | CPT | 76870 | 10 | $1,428 | $142.8 | $357 | $357 | $896.78 |
| Diagnostic mammography unilateral | CPT | 77065 | 17 | $829 | $82.9 | $71.63 | $252.12 | $530.56 |
| Diagnostic mammography bilateral | CPT | 77066 | 17 | $1,082 | $108.2 | $93.48 | $329.07 | $692.48 |
| Screening mammography bilateral | CPT | 77067 | 17 | $922 | $92.2 | $79.66 | $280.41 | $590.08 |
| EKG tracing only | CPT | 93005 | 17 | $758 | $75.8 | $65.49 | $230.53 | $485.12 |
| Transthoracic echocardiogram complete | CPT | 93306 | 17 | $5,377 | $537.7 | $464.57 | $1,635.3 | $3,441.28 |
| Transthoracic echocardiogram | CPT | 93307 | 14 | $1,169 | $116.9 | $292.25 | $652.3 | $748.16 |
| Stress echocardiogram | CPT | 93350 | 14 | $1,882 | $188.2 | $470.5 | $1,050.16 | $1,204.48 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 14 | $449 | $44.9 | $112.25 | $250.54 | $287.36 |
| Electrolyte panel | CPT | 80051 | 14 | $373 | $37.3 | $93.25 | $208.13 | $238.72 |
| Comprehensive metabolic panel | CPT | 80053 | 14 | $562 | $56.2 | $140.5 | $313.6 | $359.68 |
| Lipid panel | CPT | 80061 | 14 | $713 | $71.3 | $178.25 | $397.85 | $456.32 |
| Renal function panel | CPT | 80069 | 14 | $462 | $46.2 | $115.5 | $257.8 | $295.68 |
| Hepatic function panel | CPT | 80076 | 14 | $436 | $43.6 | $109 | $243.29 | $279.04 |
| Urinalysis non-automated | CPT | 81002 | 14 | $155 | $15.5 | $38.75 | $86.49 | $99.2 |
| Urinalysis automated | CPT | 81003 | 14 | $136 | $13.6 | $34 | $75.89 | $87.04 |
| Glucose quantitative | CPT | 82947 | 14 | $154 | $15.4 | $38.5 | $85.93 | $98.56 |
| Hemoglobin A1c | CPT | 83036 | 14 | $377 | $37.7 | $94.25 | $210.37 | $241.28 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 14 | $651 | $65.1 | $162.75 | $363.26 | $416.64 |
| Complete blood count with automated differential | CPT | 85025 | 14 | $371 | $37.1 | $92.75 | $207.02 | $237.44 |
| Complete blood count without differential | CPT | 85027 | 14 | $295 | $29.5 | $73.75 | $164.61 | $188.8 |
| Urine culture bacterial | CPT | 87086 | 14 | $36 | $3.6 | $9 | $20.09 | $23.04 |
| Urine culture identification | CPT | 87088 | 12 | $435 | $43.5 | $108.75 | $108.75 | $278.4 |
| Tissue exam by pathologist level IV | CPT | 88305 | 17 | $762 | $76.2 | $65.84 | $231.75 | $487.68 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 13 | $530 | $53 | $45.79 | $161.19 | $332.84 |
| office |
| Office visit, established patient, 5 min | CPT | 99211 | 22 | $566 | $56.6 | $141.5 | $226.16 | $362.24 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 10 | $2,561 | $256.1 | $640.25 | $640.25 | $1,608.31 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 10 | $3,269 | $326.9 | $817.25 | $817.25 | $2,052.93 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 13 | $1,995 | $199.5 | $498.75 | $606.74 | $1,252.86 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 10 | $3,168 | $316.8 | $792 | $792 | $1,989.5 |
| Colonoscopy diagnostic | CPT | 45378 | 10 | $2,169 | $216.9 | $542.25 | $542.25 | $1,362.13 |
| Colonoscopy with biopsy | CPT | 45380 | 10 | $3,269 | $326.9 | $817.25 | $817.25 | $2,052.93 |
| Colonoscopy with polyp removal | CPT | 45385 | 10 | $3,269 | $326.9 | $817.25 | $817.25 | $2,052.93 |
| surgery |
| Coronary angiography with bypass cath | CPT | 93458 | 17 | $8,993 | $899.3 | $777 | $2,735.02 | $5,755.52 |