| X-ray ankle complete CPT 73610 • Imaging | $34 | $34 | $34 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $374 | $374 | $374 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $365 | $365 | $365 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $408 | $408 | $408 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $132 | $132 | $132 |
| Screening mammography bilateral CPT 77067 • Imaging | $136 | $136 | $136 |
| Lipid panel CPT 80061 • Laboratory | $15 | $15 | $15 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $18 | $18 | $18 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $5 | $5 | $5 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $7 | $7 | $7 |
| Ferritin CPT 82728 • Laboratory | $16 | $16 | $16 |
| Iron binding capacity CPT 83550 • Laboratory | $10 | $10 | $10 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| TB skin test intradermal CPT 86580 • Laboratory | $11 | $11 | $11 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $19 | $19 | $19 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $184 | $184 | $184 |
| Fetal non-stress test CPT 59025 • Maternity | $45 | $45 | $45 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $994 | $994 | $994 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,836 | $1,836 | $1,836 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $98 | $98 | $98 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $178 | $178 | $178 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $185 | $185 | $185 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $134 | $134 | $134 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $136 | $136 | $136 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $195 | $195 | $195 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $135 | $135 | $135 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $132 | $132 | $132 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $174 | $174 | $174 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $101 | $101 | $101 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $147 | $147 | $147 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $97 | $97 | $97 |
| Consultation office low complexity CPT 99243 • Office Visits | $136 | $136 | $136 |
| Consultation office high complexity CPT 99245 • Office Visits | $243 | $243 | $243 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $607 | $607 | $607 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $377 | $377 | $377 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $964 | $964 | $964 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $72 | $72 | $72 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,015 | $2,015 | $2,015 |
| Total knee replacement CPT 27447 • Orthopedics | $1,426 | $1,426 | $1,426 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $600 | $600 | $600 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $975 | $975 | $975 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $606 | $606 | $606 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $180 | $180 | $180 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $421 | $421 | $421 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $225 | $225 | $225 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $229 | $229 | $229 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $50 | $50 | $50 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $23 | $23 | $23 |