| X-ray ankle complete CPT 73610 • Imaging | $30 | $30 | $30 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $525 | $525 | $525 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $320 | $320 | $320 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $361 | $361 | $361 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $119 | $119 | $119 |
| Screening mammography bilateral CPT 77067 • Imaging | $122 | $122 | $122 |
| Lipid panel CPT 80061 • Laboratory | $13 | $13 | $13 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $15 | $15 | $15 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $28 | $28 | $28 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $6 | $6 | $6 |
| Ferritin CPT 82728 • Laboratory | $13 | $13 | $13 |
| Iron binding capacity CPT 83550 • Laboratory | $8 | $8 | $8 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $6 | $6 | $6 |
| TB skin test intradermal CPT 86580 • Laboratory | $7 | $7 | $7 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $14 | $14 | $14 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $227 | $227 | $227 |
| Fetal non-stress test CPT 59025 • Maternity | $53 | $53 | $53 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,167 | $1,167 | $1,167 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,090 | $2,090 | $2,090 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $87 | $87 | $87 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $174 | $174 | $174 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $195 | $195 | $195 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $150 | $150 | $150 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $128 | $128 | $128 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $183 | $183 | $183 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $132 | $132 | $132 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $16 | $16 | $16 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $204 | $204 | $204 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $107 | $107 | $107 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $200 | $200 | $200 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $106 | $106 |
| Consultation office low complexity CPT 99243 • Office Visits | $115 | $115 | $115 |
| Consultation office high complexity CPT 99245 • Office Visits | $209 | $209 | $209 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $554 | $554 | $554 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $295 | $295 | $295 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $664 | $664 | $664 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $67 | $67 | $67 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,095 | $2,095 | $2,095 |
| Total knee replacement CPT 27447 • Orthopedics | $1,526 | $1,526 | $1,526 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $649 | $649 | $649 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $1,031 | $1,031 | $1,031 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $608 | $608 | $608 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $179 | $179 | $179 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $461 | $461 | $461 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $190 | $190 | $190 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $230 | $230 | $230 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $38 | $38 | $38 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $22 | $22 | $22 |