| CT chest without then with contrast CPT 71270 • Imaging | $48 | $48 | $48 |
| CT angiography chest CPT 71275 • Imaging | $48 | $48 | $48 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $48 | $48 | $48 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $340 | $340 | $340 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $48 | $48 | $48 |
| CT pelvis with contrast CPT 72193 • Imaging | $48 | $48 | $48 |
| X-ray shoulder complete CPT 73030 • Imaging | $31 | $40 | $48 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $85 | $85 | $85 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $48 | $48 | $48 |
| X-ray ankle complete CPT 73610 • Imaging | $24 | $29 | $33 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $425 | $425 | $425 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $48 | $48 |
| CT abdomen without contrast CPT 74150 • Imaging | $48 | $48 | $48 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $275 | $275 | $275 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $275 | $275 | $275 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $275 | $275 | $275 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $48 | $48 | $48 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $48 | $48 | $48 |
| Ultrasound transvaginal CPT 76830 • Imaging | $48 | $48 | $48 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $100 | $100 | $100 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $79 | $98 | $118 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $148 | $148 | $148 |
| Screening mammography bilateral CPT 77067 • Imaging | $120 | $120 | $120 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $74 | $74 | $74 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $10 | $10 | $10 |
| Lipid panel CPT 80061 • Laboratory | $12 | $12 | $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 | $5 | $5 | $6 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $12 | $12 | $12 |
| TB skin test intradermal CPT 86580 • Laboratory | $9 | $9 | $9 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $33 | $33 | $33 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $33 | $33 | $33 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $16 | $16 | $16 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $48 | $48 | $48 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $196 | $196 | $197 |
| Chorionic villus sampling CPT 59015 • Maternity | $150 | $150 | $150 |
| Fetal non-stress test CPT 59025 • Maternity | $17 | $32 | $47 |
| Insertion cervical dilator CPT 59200 • Maternity | $43 | $43 | $43 |
| Vaginal delivery only CPT 59409 • Maternity | $48 | $48 | $48 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,037 | $1,037 | $1,037 |
| External cephalic version CPT 59412 • Maternity | $48 | $48 | $48 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,559 | $2,559 | $2,559 |
| Cesarean delivery only CPT 59514 • Maternity | $48 | $48 | $48 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,423 | $2,423 | $2,423 |