| Screening mammography bilateral CPT 77067 • Imaging | $36 | $36 | $36 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $77 | $77 | $77 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $6 | $6 | $6 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $10 | $10 | $10 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $9 | $9 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $20 | $20 | $20 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $4 | $4 | $4 |
| Creatinine urine CPT 82570 • Laboratory | $3 | $3 | $3 |
| Ferritin CPT 82728 • Laboratory | $9 | $9 | $9 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $6 | $6 | $6 |
| Iron serum CPT 83540 • Laboratory | $4 | $4 | $4 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $11 | $11 | $11 |
| Complete blood count with differential CPT 85025 • Laboratory | $5 | $5 | $5 |
| Complete blood count automated CPT 85027 • Laboratory | $4 | $4 | $4 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $2 | $2 | $2 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $8 | $8 | $8 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $4 | $4 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $4 | $4 | $4 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $15 | $15 | $15 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $15 | $15 | $15 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $35 | $35 | $35 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Fetal non-stress test CPT 59025 • Maternity | $35 | $35 | $35 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $2,748 | $2,748 | $2,748 |
| Vaginal delivery only CPT 59409 • Maternity | $825 | $825 | $825 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $118 | $118 | $118 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $49 | $49 | $49 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $174 | $174 | $174 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $31 | $31 | $31 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $102 | $102 | $102 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $117 | $117 | $117 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $68 | $68 | $68 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $134 | $134 | $134 |
| Group psychotherapy CPT 90853 • Mental Health | $25 | $25 | $25 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $54 | $54 | $54 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $158 | $158 | $158 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $50 | $50 | $50 |
| EMG needle each extremity complete CPT 95886 • Neurology | $47 | $47 | $47 |