| CT soft tissue neck with contrast CPT 70491 • Imaging | $45 | $45 | $45 |
| MRI brain without contrast CPT 70551 • Imaging | $45 | $45 | $45 |
| Chest X-ray single view CPT 71045 • Imaging | $21 | $21 | $21 |
| Chest X-ray 2 views CPT 71046 • Imaging | $25 | $25 | $25 |
| CT chest without contrast CPT 71250 • Imaging | $45 | $45 | $45 |
| CT chest without then with contrast CPT 71270 • Imaging | $45 | $45 | $45 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $45 | $45 | $45 |
| CT pelvis with contrast CPT 72193 • Imaging | $45 | $45 | $45 |
| X-ray shoulder complete CPT 73030 • Imaging | $24 | $35 | $45 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $27 | $27 | $27 |
| X-ray ankle complete CPT 73610 • Imaging | $24 | $34 | $45 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $45 | $45 | $45 |
| 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 transvaginal CPT 76830 • Imaging | $149 | $149 | $149 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $107 | $107 | $107 |
| Screening mammography bilateral CPT 77067 • Imaging | $109 | $109 | $109 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $546 | $546 | $546 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $5 | $5 | $5 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $12 | $12 | $12 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $96 | $96 | $96 |
| 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 |
| Hemoglobin A1c CPT 83036 • Laboratory | $8 | $8 | $8 |
| Iron binding capacity CPT 83550 • Laboratory | $8 | $8 | $8 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $3 | $3 | $3 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $4 | $4 |
| Complete blood count automated CPT 85027 • Laboratory | $5 | $5 | $5 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $6 | $6 | $6 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $5 | $7 | $8 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $11 | $15 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $171 | $171 | $171 |
| Fetal non-stress test CPT 59025 • Maternity | $40 | $42 | $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 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $902 | $902 | $902 |
| 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 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,108 | $2,108 | $2,108 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $154 | $154 | $154 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $170 | $170 | $170 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $40 | $81 | $122 |