| MRI joint upper extremity without contrast CPT 73221 • Imaging | $180 | $180 | $180 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $50 | $50 | $50 |
| X-ray ankle complete CPT 73610 • Imaging | $50 | $50 | $50 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $600 | $600 | $600 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $235 | $235 | $235 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $371 | $371 | $372 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $471 | $471 | $471 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $135 | $135 | $135 |
| Ultrasound transvaginal CPT 76830 • Imaging | $125 | $125 | $125 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $132 | $132 | $132 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $167 | $167 | $167 |
| Screening mammography bilateral CPT 77067 • Imaging | $36 | $86 | $136 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $402 | $402 | $402 |
| Lipid panel CPT 80061 • Laboratory | $14 | $14 | $14 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $3 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $16 | $16 | $16 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $31 | $31 | $31 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $7 | $7 | $7 |
| Ferritin CPT 82728 • Laboratory | $14 | $14 | $14 |
| Iron binding capacity CPT 83550 • Laboratory | $9 | $9 | $9 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $19 | $19 | $19 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $6 | $6 | $6 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $13 | $13 | $13 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $6 | $6 | $6 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $12 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $254 | $254 | $254 |
| Fetal non-stress test CPT 59025 • Maternity | $58 | $58 | $58 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $50 | $602 | $1,155 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,350 | $2,350 | $2,350 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $50 | $50 | $50 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $99 | $99 | $99 |
| Interactive complexity add-on CPT 90785 • Mental Health | $18 | $18 | $18 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $173 | $173 | $173 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $194 | $194 | $195 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $84 | $84 | $84 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $87 | $87 | $87 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $84 | $84 | $84 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $83 | $83 | $83 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $143 | $143 | $143 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $146 | $146 | $146 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $176 | $176 | $176 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $63 | $63 | $63 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $115 | $115 | $115 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $141 | $141 | $141 |
| Group psychotherapy CPT 90853 • Mental Health | $45 | $45 | $45 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $207 | $207 | $207 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $114 | $114 | $114 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $165 | $165 | $165 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $146 | $146 | $146 |