| Chest X-ray 2 views CPT 71046 • Imaging | $18 | $19 | $20 |
| X-ray shoulder complete CPT 73030 • Imaging | $22 | $26 | $30 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $29 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $26 | $28 | $30 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $66 | $66 | $66 |
| Ultrasound transvaginal CPT 76830 • Imaging | $76 | $76 | $76 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $62 | $62 | $62 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $65 | $65 | $65 |
| Screening mammography bilateral CPT 77067 • Imaging | $81 | $81 | $81 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $101 | $101 | $101 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $2 | $5 | $7 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $11 | $12 | $13 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $7 | $7 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $49 | $96 |
| Hemoglobin A1c CPT 83036 • Laboratory | $7 | $7 | $7 |
| Complete blood count with differential CPT 85025 • Laboratory | $5 | $5 | $5 |
| Complete blood count automated CPT 85027 • Laboratory | $5 | $5 | $5 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $3 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $5 | $5 | $5 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $28 | $28 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $11 | $11 | $11 |
| Fetal non-stress test CPT 59025 • Maternity | $43 | $43 | $43 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $3,583 | $3,583 | $3,583 |
| Vaginal delivery only CPT 59409 • Maternity | $1,181 | $1,181 | $1,181 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $3,964 | $3,964 | $3,964 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,841 | $1,841 | $1,841 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $154 | $154 | $154 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $79 | $79 | $79 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $45 | $45 | $45 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $51 | $51 | $51 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $106 | $106 | $106 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $263 | $263 | $263 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $51 | $51 | $51 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $79 | $79 | $79 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $102 | $102 | $102 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $94 | $94 | $94 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $133 | $133 | $133 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $91 | $91 | $91 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $96 | $96 | $96 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $76 | $76 | $76 |
| Group psychotherapy CPT 90853 • Mental Health | $21 | $21 | $21 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $387 | $387 | $387 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $52 | $52 | $52 |
| EMG needle each extremity complete CPT 95886 • Neurology | $86 | $86 | $86 |