| X-ray ankle complete CPT 73610 • Imaging | $36 | $36 | $36 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $400 | $400 | $400 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $306 | $306 | $306 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $342 | $342 | $342 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $120 | $120 | $120 |
| Screening mammography bilateral CPT 77067 • Imaging | $123 | $123 | $123 |
| Lipid panel CPT 80061 • Laboratory | $10 | $10 | $10 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $12 | $12 | $12 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $22 | $22 | $22 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $5 | $5 | $5 |
| Iron binding capacity CPT 83550 • Laboratory | $3 | $3 | $3 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $6 | $6 | $6 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $1 | $1 | $1 |
| TB skin test intradermal CPT 86580 • Laboratory | $9 | $9 | $9 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $12 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $197 | $197 | $197 |
| Fetal non-stress test CPT 59025 • Maternity | $10 | $10 | $10 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,041 | $1,041 | $1,041 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,350 | $2,350 | $2,350 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $89 | $89 | $89 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $161 | $161 | $161 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $182 | $182 | $182 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $143 | $143 | $143 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $111 | $111 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $159 | $159 | $159 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $109 | $109 | $109 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $165 | $165 | $165 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $212 | $212 | $212 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $108 | $108 | $108 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $164 | $164 | $164 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $109 | $109 | $109 |
| Consultation office low complexity CPT 99243 • Office Visits | $129 | $129 | $129 |
| Consultation office high complexity CPT 99245 • Office Visits | $238 | $238 | $238 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $648 | $648 | $648 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $432 | $432 | $432 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,039 | $1,039 | $1,039 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $68 | $68 | $68 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,884 | $1,884 | $1,884 |
| Total knee replacement CPT 27447 • Orthopedics | $1,328 | $1,328 | $1,328 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $611 | $611 | $611 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $937 | $937 | $937 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $571 | $571 | $571 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $173 | $173 | $173 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $468 | $468 | $468 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $260 | $260 | $260 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $260 | $260 | $260 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $55 | $55 | $55 |