| emergency |
| ED visit level 1 | CPT | 99281 | 24 | $412.5 | $412.5 | $17.01 | $116.67 | $350.63 |
| ED visit level 5 | CPT | 99285 | 7 | $2,818.09 | $2,818.09 | $1,972.66 | $2,113.57 | $2,395.38 |
| imaging |
| CT head without contrast | CPT | 70450 | 26 | $3,565.8 | $3,565.8 | $63.12 | $134.15 | $3,030.93 |
| CT head with contrast | CPT | 70460 | 26 | $5,509.35 | $5,509.35 | $91.4 | $206.95 | $4,682.95 |
| CT head with and without contrast | CPT | 70470 | 26 | $6,136.8 | $6,136.8 | $109.64 | $206.95 | $5,216.28 |
| CT neck with contrast | CPT | 70491 | 26 | $5,509.35 | $5,509.35 | $115.42 | $206.95 | $4,682.95 |
| MRI brain without contrast | CPT | 70551 | 26 | $6,305.1 | $6,305.1 | $160 | $276 | $5,359.34 |
| MRI brain with contrast | CPT | 70552 | 26 | $4,023.2 | $4,023.2 | $160 | $433.16 | $3,419.72 |
| MRI brain with and without contrast | CPT | 70553 | 26 | $9,794.35 | $9,794.35 | $160 | $433.16 | $8,325.2 |
| Chest X-ray single view | CPT | 71045 | 26 | $308.5 | $308.5 | $11.54 | $106.62 | $262.23 |
| Chest X-ray 2 views | CPT | 71046 | 26 | $549.75 | $549.75 | $15.65 | $106.62 | $467.29 |
| Chest X-ray 3 views | CPT | 71047 | 26 | $203.5 | $203.5 | $19.98 | $106.62 | $172.98 |
| CT chest without contrast | CPT | 71250 | 26 | $3,565.8 | $3,565.8 | $77.39 | $134.15 | $3,030.93 |
| CT chest with contrast | CPT | 71260 | 26 | $5,509.35 | $5,509.35 | $107.52 | $206.95 | $4,682.95 |
| CT chest with and without contrast | CPT | 71270 | 26 | $6,136.8 | $6,136.8 | $129.34 | $206.95 | $5,216.28 |
| MRI chest without contrast | CPT | 71550 | 26 | $6,305.1 | $6,305.1 | $160 | $298.99 | $5,359.34 |
| MRI chest with contrast | CPT | 71551 | 2 | — | — | $392.6 | $392.6 | $392.6 |
| MRI chest with and without contrast | CPT | 71552 | 26 | $9,794.35 | $9,794.35 | $160 | $469.26 | $8,325.2 |
| Lumbosacral spine X-ray | CPT | 72100 | 26 | $497.55 | $497.55 | $19.75 | $128.99 | $422.92 |
| CT cervical spine without contrast | CPT | 72125 | 26 | $3,565.8 | $3,565.8 | $77.39 | $134.15 | $3,030.93 |
| CT thoracic spine without contrast | CPT | 72128 | 26 | $3,565.8 | $3,565.8 | $77.39 | $134.15 | $3,030.93 |
| CT lumbar spine without contrast | CPT | 72131 | 26 | $3,565.8 | $3,565.8 | $77.39 | $134.15 | $3,030.93 |
| MRI cervical spine without contrast | CPT | 72141 | 26 | $6,305.1 | $6,305.1 | $160 | $276 | $5,359.34 |
| MRI thoracic spine without contrast | CPT | 72146 | 26 | $6,305.1 | $6,305.1 | $160 | $276 | $5,359.34 |
| MRI lumbar spine without contrast | CPT | 72148 | 26 | $6,305.1 | $6,305.1 | $160 | $276 | $5,359.34 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 26 | $6,305.1 | $6,305.1 | $160 | $433.16 | $5,359.34 |
| MRI cervical spine with and without contrast | CPT | 72156 | 26 | $9,794.35 | $9,794.35 | $160 | $433.16 | $8,325.2 |
| MRI lumbar spine with contrast | CPT | 72158 | 26 | $9,794.35 | $9,794.35 | $160 | $433.16 | $8,325.2 |
| CT pelvis without contrast | CPT | 72192 | 26 | $3,565.8 | $3,565.8 | $77.39 | $134.15 | $3,030.93 |
| CT pelvis with contrast | CPT | 72193 | 26 | $5,509.35 | $5,509.35 | $129.34 | $206.95 | $4,682.95 |
| Shoulder X-ray | CPT | 73030 | 26 | $1,434.24 | $1,434.24 | $17.24 | $315.43 | $1,219.1 |
| Humerus X-ray | CPT | 73060 | 26 | $369.85 | $369.85 | $16.33 | $106.62 | $314.37 |
| Hand X-ray 3 views | CPT | 73130 | 26 | $543.1 | $543.1 | $19.07 | $252.2 | $461.64 |
| MRI upper extremity joint without contrast | CPT | 73221 | 26 | $6,305.1 | $6,305.1 | $160 | $276 | $5,359.34 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 2 | — | — | $368.43 | $368.43 | $368.43 |
| Knee X-ray 1-2 views | CPT | 73560 | 26 | $427.6 | $427.6 | $17.7 | $237.41 | $363.46 |
| Ankle X-ray 3 views | CPT | 73610 | 26 | $203.5 | $203.5 | $19.29 | $106.62 | $172.98 |
| MRI lower extremity joint without contrast | CPT | 73721 | 26 | $6,305.1 | $6,305.1 | $160 | $276 | $5,359.34 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 26 | $6,305.1 | $6,305.1 | $160 | $440.9 | $5,359.34 |
| CT abdomen without contrast | CPT | 74150 | 26 | $3,565.8 | $3,565.8 | $77.39 | $134.15 | $3,030.93 |
| CT abdomen with contrast | CPT | 74160 | 26 | $5,509.35 | $5,509.35 | $129.34 | $206.95 | $4,682.95 |
| CT abdomen with and without contrast | CPT | 74170 | 26 | $6,136.8 | $6,136.8 | $129.34 | $206.95 | $5,216.28 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 26 | $5,348.7 | $5,348.7 | $97.48 | $276 | $4,546.4 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 26 | $8,264 | $8,264 | $160 | $433.16 | $7,024.4 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 26 | $9,205.2 | $9,205.2 | $160 | $433.16 | $7,824.42 |
| MRI abdomen without contrast | CPT | 74181 | 26 | $6,305.1 | $6,305.1 | $160 | $276 | $5,359.34 |
| MRI abdomen with and without contrast | CPT | 74183 | 2 | — | — | $354.51 | $354.51 | $354.51 |
| Abdominal ultrasound complete | CPT | 76700 | 26 | $1,130.75 | $1,130.75 | $54.41 | $128.99 | $961.14 |
| Abdominal ultrasound limited | CPT | 76705 | 26 | $978.85 | $978.85 | $40.96 | $128.99 | $832.02 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 26 | $1,415.51 | $1,415.51 | $50.76 | $740.12 | $1,203.18 |
| Obstetric ultrasound first trimester | CPT | 76801 | 2 | — | — | $106.88 | $106.88 | $106.88 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 2 | — | — | $106.88 | $106.88 | $106.88 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 2 | — | — | $176.09 | $176.09 | $176.09 |
| Transvaginal ultrasound | CPT | 76830 | 26 | $662.2 | $662.2 | $59.89 | $128.99 | $562.87 |
| Pelvic ultrasound complete | CPT | 76856 | 26 | $1,130.75 | $1,130.75 | $50.31 | $128.99 | $961.14 |
| Scrotal ultrasound | CPT | 76870 | 26 | $446.8 | $446.8 | $48.48 | $128.99 | $379.78 |
| EKG tracing only | CPT | 93005 | 24 | $349.05 | $349.05 | $5.01 | $80.38 | $296.69 |
| Transthoracic echocardiogram complete | CPT | 93306 | 24 | $1,063.7 | $1,063.7 | $110.34 | $629.8 | $906.17 |
| Transthoracic echocardiogram | CPT | 93307 | 26 | $1,063.7 | $1,063.7 | $81.07 | $287.5 | $904.15 |
| Stress echocardiogram | CPT | 93350 | 2 | — | — | $185.11 | $185.11 | $185.11 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 26 | $449.25 | $449.25 | $5.92 | $10.58 | $381.86 |
| Electrolyte panel | CPT | 80051 | 26 | $284.75 | $284.75 | $4.91 | $8.76 | $242.04 |
| Comprehensive metabolic panel | CPT | 80053 | 26 | $585.95 | $585.95 | $7.39 | $13.2 | $498.06 |
| Lipid panel | CPT | 80061 | 26 | $234.35 | $234.35 | $9.37 | $16.74 | $199.2 |
| Renal function panel | CPT | 80069 | 26 | $572.45 | $572.45 | $6.08 | $10.85 | $486.58 |
| Hepatic function panel | CPT | 80076 | 26 | $375.25 | $375.25 | $5.72 | $10.21 | $318.96 |
| Urinalysis non-automated | CPT | 81002 | 2 | — | — | $2.92 | $2.92 | $2.92 |
| Urinalysis automated | CPT | 81003 | 26 | $82.75 | $82.75 | $1.58 | $3.94 | $70.34 |
| Glucose quantitative | CPT | 82947 | 26 | $418.55 | $418.55 | $2.75 | $4.92 | $355.77 |
| Hemoglobin A1c | CPT | 83036 | 26 | $147.2 | $147.2 | $6.8 | $12.14 | $125.12 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 26 | $219.8 | $219.8 | $11.76 | $21 | $186.83 |
| Complete blood count with automated differential | CPT | 85025 | 26 | $135.7 | $135.7 | $5.44 | $9.71 | $115.35 |
| Complete blood count without differential | CPT | 85027 | 26 | $139.7 | $139.7 | $4.53 | $8.09 | $118.75 |
| Urine culture bacterial | CPT | 87086 | 26 | $231.05 | $231.05 | $5.65 | $10.09 | $196.39 |
| Urine culture identification | CPT | 87088 | 26 | $1,197.45 | $1,197.45 | $5.66 | $10.12 | $1,017.83 |
| Tissue exam by pathologist level IV | CPT | 88305 | 24 | $490.75 | $490.75 | $23.04 | $71.21 | $417.14 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 2 | — | — | $15.78 | $15.78 | $15.78 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 26 | $4,122.3 | $4,122.3 | $112.76 | $1,063.55 | $3,503.96 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 26 | $2,503.44 | $2,503.44 | $127.08 | $1,021.01 | $2,127.92 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 26 | $1,155 | $1,155 | $51.39 | $857.85 | $1,501.24 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 26 | $1,155 | $1,155 | $65.84 | $857.85 | $1,501.24 |
| Colonoscopy diagnostic | CPT | 45378 | 26 | $3,926.05 | $3,926.05 | $169.49 | $1,072.32 | $3,337.14 |
| Colonoscopy with biopsy | CPT | 45380 | 26 | $1,650 | $1,650 | $184.25 | $1,155 | $1,938.35 |
| Colonoscopy with polyp removal | CPT | 45385 | 2 | — | — | $429.26 | $429.26 | $429.26 |
| surgery |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 2 | — | — | $2,398.52 | $2,398.52 | $2,398.52 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 2 | — | — | $1,088.27 | $1,088.27 | $1,088.27 |
| ACL reconstruction | CPT | 29888 | 2 | — | — | $3,300.05 | $3,300.05 | $3,300.05 |
| Laparoscopic cholecystectomy | CPT | 47562 | 2 | — | — | $1,888.85 | $1,888.85 | $1,888.85 |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 2 | — | — | $1,888.85 | $1,888.85 | $1,888.85 |
| Lap inguinal hernia repair | CPT | 49650 | 2 | — | — | $1,888.85 | $1,888.85 | $1,888.85 |
| Vaginal hysterectomy | CPT | 58260 | 2 | — | — | $1,526.99 | $1,526.99 | $1,526.99 |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 2 | — | — | $1,888.85 | $1,888.85 | $1,888.85 |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 2 | — | — | $3,110.01 | $3,110.01 | $3,110.01 |
| Lap salpingo-oophorectomy | CPT | 58661 | 2 | — | — | $1,888.85 | $1,888.85 | $1,888.85 |
| Complex cataract surgery | CPT | 66982 | 2 | — | — | $849.94 | $849.94 | $849.94 |
| Cataract surgery with lens implant | CPT | 66984 | 2 | — | — | $849.94 | $849.94 | $849.94 |
| Intravitreal injection | CPT | 67028 | 2 | — | — | $48.45 | $48.45 | $48.45 |
| Vitrectomy mechanical | CPT | 67042 | 2 | — | — | $1,533.49 | $1,533.49 | $1,533.49 |