| X-ray ankle complete CPT 73610 • Imaging | $31 | $31 | $31 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $303 | $303 | $303 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $220 | $220 | $220 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $220 | $220 | $220 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $110 | $110 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $112 | $112 |
| Lipid panel CPT 80061 • Laboratory | $12 | $12 | $12 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| 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 binding capacity CPT 83550 • Laboratory | $4 | $4 | $4 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $15 | $15 | $15 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $178 | $178 | $178 |
| Fetal non-stress test CPT 59025 • Maternity | $44 | $44 | $44 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $946 | $946 | $946 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,235 | $2,235 | $2,235 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $83 | $83 | $83 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $118 | $118 | $118 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $129 | $129 | $129 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $181 | $181 | $181 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $144 | $144 | $144 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $209 | $209 | $209 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $146 | $146 | $146 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $164 | $164 | $164 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $245 | $245 | $245 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $127 | $127 | $127 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $245 | $245 | $245 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $130 | $130 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $146 | $146 | $146 |
| Consultation office high complexity CPT 99245 • Office Visits | $267 | $267 | $267 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $631 | $631 | $631 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $428 | $428 | $428 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,004 | $1,004 | $1,004 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $98 | $98 | $98 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,793 | $2,793 | $2,793 |
| Total knee replacement CPT 27447 • Orthopedics | $1,976 | $1,976 | $1,976 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $889 | $889 | $889 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $1,413 | $1,413 | $1,413 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $835 | $835 | $835 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $257 | $257 | $257 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $574 | $574 | $574 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $237 | $237 | $237 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $235 | $235 | $235 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $45 | $45 | $45 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $21 | $21 | $21 |