| CT soft tissue neck with contrast CPT 70491 • Imaging | $170 | $170 | $170 |
| MRI brain without contrast CPT 70551 • Imaging | $248 | $248 | $248 |
| Chest X-ray single view CPT 71045 • Imaging | $21 | $21 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $24 | $24 | $24 |
| CT chest without then with contrast CPT 71270 • Imaging | $182 | $182 | $182 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $243 | $243 | $243 |
| CT pelvis with contrast CPT 72193 • Imaging | $49 | $49 | $49 |
| X-ray shoulder complete CPT 73030 • Imaging | $8 | $8 | $8 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $30 | $30 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $256 | $256 | $256 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $285 | $285 | $285 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $319 | $319 | $319 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $104 | $104 | $104 |
| Screening mammography bilateral CPT 77067 • Imaging | $106 | $106 | $106 |
| Lipid panel CPT 80061 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $0 | $0 | $0 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $2 | $2 | $2 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $4 | $4 | $4 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $1 | $1 | $1 |
| Ferritin CPT 82728 • Laboratory | $8 | $8 | $8 |
| Iron binding capacity CPT 83550 • Laboratory | $5 | $5 | $5 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $1 | $1 | $1 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $10 | $10 | $10 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $31 | $31 | $31 |
| Fetal non-stress test CPT 59025 • Maternity | $8 | $8 | $8 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $824 | $824 | $824 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $42 | $42 | $42 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $15 | $15 | $15 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $177 | $177 | $177 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $177 | $177 | $177 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $158 | $158 | $158 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $105 | $105 | $105 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $152 | $152 | $152 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $105 | $105 | $105 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $65 | $65 | $65 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $160 | $160 | $160 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $12 | $12 | $12 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $210 | $210 | $210 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $83 | $83 | $83 |
| Consultation office low complexity CPT 99243 • Office Visits | $38 | $38 | $38 |
| Consultation office high complexity CPT 99245 • Office Visits | $18 | $18 | $18 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $560 | $560 | $560 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $378 | $378 | $378 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $898 | $898 | $898 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $46 | $46 | $46 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,839 | $1,839 | $1,839 |
| Total knee replacement CPT 27447 • Orthopedics | $1,296 | $1,296 | $1,296 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $592 | $592 | $592 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $919 | $919 | $919 |