| Chest X-ray 2 views CPT 71046 • Imaging | $7 | $7 | $7 |
| CT chest without contrast CPT 71250 • Imaging | $86 | $86 | $86 |
| CT chest with contrast CPT 71260 • Imaging | $51 | $51 | $51 |
| CT chest without then with contrast CPT 71270 • Imaging | $86 | $86 | $86 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $187 | $187 | $188 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $187 | $187 | $187 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $187 | $187 | $187 |
| CT pelvis with contrast CPT 72193 • Imaging | $120 | $120 | $120 |
| X-ray shoulder complete CPT 73030 • Imaging | $16 | $16 | $16 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $187 | $187 | $187 |
| X-ray ankle complete CPT 73610 • Imaging | $12 | $12 | $12 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $187 | $187 | $187 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $187 | $187 | $188 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $171 | $171 | $171 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $120 | $145 | $171 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $120 | $145 | $171 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $59 | $73 | $87 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $109 | $109 | $109 |
| Screening mammography bilateral CPT 77067 • Imaging | $88 | $88 | $88 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $250 | $250 | $250 |
| Lipid panel CPT 80061 • Laboratory | $12 | $12 | $12 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $7 | $7 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| 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 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $17 | $17 | $17 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $6 | $6 | $6 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $12 | $12 | $12 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $4 | $4 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $11 | $11 | $11 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $179 | $179 | $179 |
| Fetal non-stress test CPT 59025 • Maternity | $39 | $39 | $39 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $40 | $40 | $40 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $788 | $788 | $788 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $40 | $40 | $40 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $954 | $954 | $954 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,100 | $2,100 | $2,100 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $60 | $60 | $60 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $32 | $32 | $32 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $24 | $27 | $31 |
| Interactive complexity add-on CPT 90785 • Mental Health | $4 | $4 | $4 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $124 | $124 | $124 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $124 | $124 | $124 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $91 | $91 | $91 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $91 | $91 | $91 |