| MRI joint lower extremity without contrast CPT 73721 • Imaging | $208 | $208 | $208 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $301 | $301 | $301 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $337 | $337 | $337 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $110 | $110 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $112 | $112 |
| Lipid panel CPT 80061 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $3 | $3 | $3 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $5 | $5 | $5 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $1 | $1 | $1 |
| Ferritin CPT 82728 • Laboratory | $6 | $6 | $6 |
| Iron binding capacity CPT 83550 • Laboratory | $4 | $4 | $4 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $1 | $1 | $1 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $3 | $3 | $3 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $164 | $164 | $164 |
| Fetal non-stress test CPT 59025 • Maternity | $39 | $39 | $39 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $872 | $872 | $872 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,056 | $2,056 | $2,056 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $82 | $82 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $154 | $154 | $154 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $171 | $171 | $171 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $116 | $116 | $116 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $109 | $109 | $109 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $157 | $157 | $157 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $109 | $109 | $109 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $107 | $107 | $107 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $180 | $180 | $180 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $110 | $110 | $110 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $16 | $16 | $16 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $110 | $110 | $110 |
| Consultation office low complexity CPT 99243 • Office Visits | $131 | $131 | $131 |
| Consultation office high complexity CPT 99245 • Office Visits | $21 | $21 | $21 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $482 | $482 | $482 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $326 | $326 | $326 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $771 | $771 | $771 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $58 | $58 | $58 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,663 | $1,663 | $1,663 |
| Total knee replacement CPT 27447 • Orthopedics | $1,154 | $1,154 | $1,154 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $523 | $523 | $523 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $795 | $795 | $795 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $488 | $488 | $488 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $146 | $146 | $146 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $384 | $384 | $384 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $211 | $211 | $211 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $45 | $45 | $45 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $48 | $48 | $48 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $22 | $22 | $22 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |