| emergency |
| ED visit level 1 | CPT | 99281 | 12 | $742.5 | $74.25 | $129.05 | $348.98 | $643.01 |
| ED visit level 2 | CPT | 99282 | 12 | $1,298 | $129.8 | $225.59 | $610.06 | $1,124.07 |
| ED visit level 3 | CPT | 99283 | 13 | $1,851.3 | $185.13 | $321.76 | $870.11 | $1,603.23 |
| ED visit level 4 | CPT | 99284 | 13 | $3,426.5 | $342.65 | $595.53 | $1,610.46 | $2,967.35 |
| ED visit level 5 | CPT | 99285 | 13 | $5,463.7 | $546.37 | $949.59 | $2,567.94 | $4,731.56 |
| Critical care, first hour | CPT | 99291 | 13 | $4,207.2 | $420.72 | $731.21 | $1,977.38 | $3,643.44 |
| imaging |
| CT head without contrast | CPT | 70450 | 14 | $2,258 | $225.8 | $406.44 | $880.62 | $2,420.58 |
| CT head with contrast | CPT | 70460 | 14 | $2,420 | $242 | $435.6 | $943.8 | $2,594.24 |
| CT head with and without contrast | CPT | 70470 | 14 | $2,698 | $269.8 | $485.64 | $1,052.22 | $2,892.26 |
| CT neck with contrast | CPT | 70491 | 14 | $1,694 | $169.4 | $304.92 | $660.66 | $1,815.97 |
| MRI brain without contrast | CPT | 70551 | 14 | $1,846.6 | $184.66 | $332.39 | $720.17 | $1,979.56 |
| MRI brain with contrast | CPT | 70552 | 12 | $2,903 | $290.3 | $522.54 | $1,132.17 | $3,112.02 |
| MRI brain with and without contrast | CPT | 70553 | 14 | $2,873.5 | $287.35 | $517.23 | $1,120.67 | $3,080.39 |
| Chest X-ray single view | CPT | 71045 | 14 | $419 | $41.9 | $75.42 | $190.65 | $449.17 |
| Chest X-ray 2 views | CPT | 71046 | 15 | $460 | $46 | $82.8 | $213.44 | $493.12 |
| Chest X-ray 3 views | CPT | 71047 | 13 | $507 | $50.7 | $91.26 | $239.81 | $543.5 |
| CT chest without contrast | CPT | 71250 | 14 | $3,317 | $331.7 | $597.06 | $1,293.63 | $3,555.82 |
| CT chest with contrast | CPT | 71260 | 14 | $3,611 | $361.1 | $649.98 | $1,408.29 | $3,870.99 |
| CT chest with and without contrast | CPT | 71270 | 14 | $4,016 | $401.6 | $722.88 | $1,566.24 | $4,305.15 |
| MRI chest without contrast | CPT | 71550 | 14 | $1,849.4 | $184.94 | $332.89 | $721.27 | $1,982.56 |
| MRI chest with contrast | CPT | 71551 | 12 | $3,401 | $340.1 | $612.18 | $1,326.39 | $3,645.87 |
| MRI chest with and without contrast | CPT | 71552 | 14 | $5,417 | $541.7 | $975.06 | $2,112.63 | $5,807.02 |
| Lumbosacral spine X-ray | CPT | 72100 | 14 | $832.5 | $83.25 | $149.85 | $324.68 | $892.44 |
| CT cervical spine without contrast | CPT | 72125 | 14 | $2,822.5 | $282.25 | $508.05 | $1,100.78 | $3,025.72 |
| CT thoracic spine without contrast | CPT | 72128 | 14 | $4,146.25 | $414.62 | $746.33 | $1,617.04 | $4,444.78 |
| CT lumbar spine without contrast | CPT | 72131 | 14 | $4,146.25 | $414.62 | $746.33 | $1,617.04 | $4,444.78 |
| MRI cervical spine without contrast | CPT | 72141 | 14 | $2,641 | $264.1 | $475.38 | $1,029.99 | $2,831.15 |
| MRI thoracic spine without contrast | CPT | 72146 | 14 | $3,434 | $343.4 | $618.12 | $1,339.26 | $3,681.25 |
| MRI lumbar spine without contrast | CPT | 72148 | 14 | $2,403.8 | $240.38 | $432.68 | $937.48 | $2,576.87 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 12 | $3,770 | $377 | $678.6 | $1,470.3 | $4,041.44 |
| MRI cervical spine with and without contrast | CPT | 72156 | 14 | $2,916.9 | $291.69 | $525.04 | $1,137.59 | $3,126.92 |
| MRI lumbar spine with contrast | CPT | 72158 | 14 | $5,417 | $541.7 | $975.06 | $2,112.63 | $5,807.02 |
| CT pelvis without contrast | CPT | 72192 | 14 | $3,317 | $331.7 | $597.06 | $1,293.63 | $3,555.82 |
| CT pelvis with contrast | CPT | 72193 | 14 | $2,527.7 | $252.77 | $454.99 | $985.8 | $2,709.69 |
| Shoulder X-ray | CPT | 73030 | 14 | $999.38 | $99.94 | $119.93 | $389.76 | $1,071.34 |
| Humerus X-ray | CPT | 73060 | 14 | $999.38 | $99.94 | $119.93 | $389.76 | $1,071.34 |
| Hand X-ray 3 views | CPT | 73130 | 14 | $799.5 | $79.95 | $95.94 | $311.81 | $857.06 |
| MRI upper extremity joint without contrast | CPT | 73221 | 14 | $5,146.5 | $514.65 | $617.58 | $2,007.14 | $5,517.05 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 14 | $5,417 | $541.7 | $975.06 | $2,112.63 | $5,807.02 |
| Knee X-ray 1-2 views | CPT | 73560 | 14 | $999.38 | $99.94 | $119.93 | $389.76 | $1,071.34 |
| Ankle X-ray 3 views | CPT | 73610 | 14 | $799.5 | $79.95 | $95.94 | $311.81 | $857.06 |
| MRI lower extremity joint without contrast | CPT | 73721 | 14 | $5,151 | $515.1 | $618.12 | $2,008.89 | $5,521.87 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 14 | $3,791.9 | $379.19 | $682.54 | $1,478.84 | $4,064.92 |
| CT abdomen without contrast | CPT | 74150 | 14 | $3,317 | $331.7 | $597.06 | $1,293.63 | $3,555.82 |
| CT abdomen with contrast | CPT | 74160 | 14 | $3,611 | $361.1 | $649.98 | $1,408.29 | $3,870.99 |
| CT abdomen with and without contrast | CPT | 74170 | 14 | $4,016 | $401.6 | $722.88 | $1,566.24 | $4,305.15 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 14 | $4,869 | $486.9 | $876.42 | $1,898.91 | $5,219.57 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 14 | $7,185.28 | $718.53 | $1,293.35 | $2,802.26 | $7,702.62 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 14 | $7,673 | $767.3 | $1,381.14 | $2,992.47 | $8,225.46 |
| MRI abdomen without contrast | CPT | 74181 | 14 | $3,431 | $343.1 | $617.58 | $1,338.09 | $3,678.03 |
| MRI abdomen with and without contrast | CPT | 74183 | 14 | $5,417 | $541.7 | $975.06 | $2,112.63 | $5,807.02 |
| Abdominal ultrasound complete | CPT | 76700 | 14 | $1,272.5 | $127.25 | $229.05 | $496.28 | $1,364.12 |
| Abdominal ultrasound limited | CPT | 76705 | 14 | $1,018 | $101.8 | $183.24 | $397.02 | $1,091.3 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 14 | $1,018 | $101.8 | $183.24 | $397.02 | $1,091.3 |
| Obstetric ultrasound first trimester | CPT | 76801 | 14 | $1,018 | $101.8 | $183.24 | $397.02 | $1,091.3 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 12 | $712.6 | $71.26 | $128.27 | $277.91 | $763.91 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 12 | $1,608 | $160.8 | $289.44 | $627.12 | $1,723.78 |
| Transvaginal ultrasound | CPT | 76830 | 14 | $1,018 | $101.8 | $183.24 | $397.02 | $1,091.3 |
| Pelvic ultrasound complete | CPT | 76856 | 14 | $1,018 | $101.8 | $183.24 | $397.02 | $1,091.3 |
| Scrotal ultrasound | CPT | 76870 | 14 | $1,272.5 | $127.25 | $229.05 | $496.28 | $1,364.12 |
| Diagnostic mammography unilateral | CPT | 77065 | 16 | $767 | $76.7 | $52.49 | $299.13 | $822.22 |
| Diagnostic mammography bilateral | CPT | 77066 | 16 | $827 | $82.7 | $56.6 | $322.53 | $886.54 |
| Screening mammography bilateral | CPT | 77067 | 16 | $697 | $69.7 | $47.7 | $271.83 | $747.18 |
| EKG tracing only | CPT | 93005 | 19 | $349 | $34.9 | $23.89 | $160.54 | $374.13 |
| Transthoracic echocardiogram complete | CPT | 93306 | 17 | $2,768.5 | $276.85 | $189.48 | $1,079.72 | $2,967.83 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 15 | $115 | $11.5 | $20.7 | $44.85 | $123.28 |
| General health panel | CPT | 80050 | 12 | $487 | $48.7 | $84.64 | $189.93 | $522.06 |
| Electrolyte panel | CPT | 80051 | 15 | $95 | $9.5 | $17.1 | $37.05 | $101.84 |
| Comprehensive metabolic panel | CPT | 80053 | 15 | $558.75 | $55.87 | $100.58 | $217.91 | $598.98 |
| Lipid panel | CPT | 80061 | 15 | $267.8 | $26.78 | $48.2 | $104.44 | $287.08 |
| Renal function panel | CPT | 80069 | 15 | $165.2 | $16.52 | $29.74 | $64.43 | $177.09 |
| Hepatic function panel | CPT | 80076 | 15 | $168 | $16.8 | $30.24 | $65.52 | $180.1 |
| Urinalysis non-automated | CPT | 81002 | 15 | $7 | — | $1.26 | $2.73 | $7.5 |
| Urinalysis automated | CPT | 81003 | 15 | $69 | $6.9 | $12.42 | $26.91 | $73.97 |
| Glucose quantitative | CPT | 82947 | 15 | $57 | $5.7 | $10.26 | $22.23 | $61.1 |
| Hemoglobin A1c | CPT | 83036 | 15 | $302.9 | $30.29 | $54.52 | $118.13 | $324.71 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 15 | $517.4 | $51.74 | $93.13 | $201.79 | $554.65 |
| Complete blood count with automated differential | CPT | 85025 | 15 | $515 | $51.5 | $92.7 | $200.85 | $552.08 |
| Complete blood count without differential | CPT | 85027 | 15 | $145 | $14.5 | $26.1 | $56.55 | $155.44 |
| Urine culture bacterial | CPT | 87086 | 15 | $139 | $13.9 | $25.02 | $54.21 | $149.01 |
| Urine culture identification | CPT | 87088 | 12 | $95 | $9.5 | $17.1 | $37.05 | $101.84 |
| Tissue exam by pathologist level IV | CPT | 88305 | 15 | $413.5 | $41.35 | $28.3 | $161.27 | $443.27 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 21 | $574 | $57.4 | $39.28 | $271.5 | $615.33 |
| office |
| Office visit, established patient, 5 min | CPT | 99211 | 21 | $657 | $65.7 | $78.84 | $256.23 | $568.96 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 14 | $1,983.8 | $198.38 | $267.42 | $773.68 | $1,717.97 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 14 | $3,188.25 | $318.82 | $286.52 | $1,024.5 | $2,761.02 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 15 | $2,840 | $284 | $382.83 | $1,107.6 | $2,459.44 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 14 | $2,888 | $288.8 | $389.3 | $1,126.32 | $2,501.01 |
| Colonoscopy diagnostic | CPT | 45378 | 14 | $1,988 | $198.8 | $267.98 | $775.32 | $1,721.61 |
| Colonoscopy with biopsy | CPT | 45380 | 14 | $2,614.5 | $261.45 | $352.43 | $1,019.66 | $2,264.16 |
| Colonoscopy with polyp removal | CPT | 45385 | 14 | $2,651.85 | $265.18 | $357.47 | $1,034.22 | $2,296.5 |
| surgery |
| PCI single major coronary artery | CPT | 92920 | 15 | $13,575 | $1,357.51 | $929.08 | $5,294.29 | $14,553 |
| PCI with drug-eluting stent | CPT | 92928 | 13 | $18,694 | $1,869.4 | $3,249.02 | $7,290.66 | $20,040 |
| PCI bypass graft | CPT | 92937 | 13 | $18,694 | $1,869.4 | $3,249.02 | $7,290.66 | $20,040 |
| Left heart catheterization | CPT | 93452 | 13 | $16,080 | $1,608 | $2,794.7 | $6,271.2 | $17,238 |
| Coronary angiography with cath | CPT | 93455 | 13 | $11,274 | $1,127.42 | $1,959.46 | $4,396.94 | $12,086 |
| Coronary angiography with bypass cath | CPT | 93458 | 15 | $13,346 | $1,334.64 | $913.43 | $5,205.1 | $14,307 |