| MRI cervical spine without contrast CPT 72141 • Imaging | $52 | $52 | $52 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $52 | $52 | $52 |
| X-ray shoulder complete CPT 73030 • Imaging | $27 | $27 | $27 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $48 | $48 | $48 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $26 | $26 | $26 |
| X-ray ankle complete CPT 73610 • Imaging | $22 | $22 | $22 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $48 | $48 |
| CT abdomen without contrast CPT 74150 • Imaging | $42 | $42 | $42 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $77 | $77 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $65 | $65 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $71 | $71 | $71 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $29 | $29 | $29 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $80 | $80 | $80 |
| Ultrasound transvaginal CPT 76830 • Imaging | $86 | $86 | $86 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $24 | $24 | $24 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $91 | $91 | $91 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $115 | $115 |
| Screening mammography bilateral CPT 77067 • Imaging | $95 | $95 | $95 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $321 | $321 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $5 | $5 | $5 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $8 | $8 | $8 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $3 | $3 |
| Lipid panel CPT 80061 • Laboratory | $4 | $4 | $4 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $4 | $4 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $1 | $1 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $96 | $96 | $96 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $7 | $7 | $7 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $8 | $8 | $8 |
| Creatinine urine CPT 82570 • Laboratory | $3 | $3 | $3 |
| Ferritin CPT 82728 • Laboratory | $4 | $4 | $4 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $3 | $3 | $3 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $9 | $9 | $9 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $2 | $2 | $2 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $8 | $8 | $8 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $4 | $4 |
| Complete blood count automated CPT 85027 • Laboratory | $3 | $3 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $2 | $2 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $5 | $5 | $5 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $15 | $15 | $15 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $18 | $18 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $28 | $28 | $28 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $27 | $27 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,861 | $1,861 | $1,861 |
| Vaginal delivery only CPT 59409 • Maternity | $649 | $649 | $649 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $931 | $931 | $931 |