| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $30 | $30 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $30 | $30 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $30 | $30 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $30 | $30 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $30 | $30 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $30 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $30 | $30 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $30 | $30 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $206 | $206 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $30 | $30 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $30 | $30 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $313 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $351 | $351 | $351 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $30 | $30 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $110 | $110 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $112 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $391 | $391 |
| 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 | $10 | $11 |
| 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 | $3 | $3 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $13 | $13 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $24 | $24 | $24 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $11 | $11 | $11 |
| Iron serum CPT 83540 • Laboratory | $1 | $1 | $1 |
| Iron binding capacity CPT 83550 • Laboratory | $7 | $7 | $7 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $3 | $3 | $3 |
| Complete blood count with differential CPT 85025 • Laboratory | $6 | $6 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $1 | $1 | $1 |
| 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 | $1 | $1 | $1 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $26 | $27 | $28 |
| 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 | $7 | $7 | $7 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Fetal non-stress test CPT 59025 • Maternity | $46 | $46 | $46 |
| 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 | $30 | $30 | $30 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |