| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $171 | $171 | $171 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $171 | $171 | $171 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $30 | $30 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $134 | $134 | $134 |
| Screening mammography bilateral CPT 77067 • Imaging | $134 | $134 | $134 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $300 | $300 | $300 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $10 | $11 | $12 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $7 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $14 | $14 | $14 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $26 | $26 | $26 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $6 | $6 | $6 |
| Ferritin CPT 82728 • Laboratory | $12 | $12 | $12 |
| Iron serum CPT 83540 • Laboratory | $6 | $6 | $6 |
| Iron binding capacity CPT 83550 • Laboratory | $8 | $8 | $8 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $3 | $3 | $3 |
| Complete blood count with differential CPT 85025 • Laboratory | $7 | $7 | $7 |
| Complete blood count automated CPT 85027 • Laboratory | $6 | $6 | $6 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $11 | $11 | $11 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $16 | $16 | $16 |
| TB skin test intradermal CPT 86580 • Laboratory | $6 | $6 | $6 |
| Blood typing Rh CPT 86901 • Laboratory | $3 | $3 | $3 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $26 | $28 | $30 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $26 | $26 | $26 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $12 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Fetal non-stress test CPT 59025 • Maternity | $43 | $43 | $43 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $952 | $952 | $952 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $45 | $45 | $45 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $104 | $104 | $104 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $113 | $113 | $113 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $30 | $30 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $31 | $31 | $31 |
| Interactive complexity add-on CPT 90785 • Mental Health | $3 | $5 | $6 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $150 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $118 | $135 | $151 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $68 | $75 | $82 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $72 | $89 | $106 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $81 | $105 | $130 |