| X-ray ankle complete CPT 73610 • Imaging | $35 | $35 | $35 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $45 | $45 | $45 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $231 | $231 | $231 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $260 | $260 | $260 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $135 | $135 | $135 |
| Screening mammography bilateral CPT 77067 • Imaging | $138 | $138 | $138 |
| Lipid panel CPT 80061 • Laboratory | $9 | $9 | $9 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $11 | $11 | $11 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $4 | $4 | $4 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $10 | $10 | $10 |
| Iron binding capacity CPT 83550 • Laboratory | $6 | $6 | $6 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $12 | $12 | $12 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $6 | $6 | $6 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $12 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $45 | $45 | $45 |
| Fetal non-stress test CPT 59025 • Maternity | $47 | $47 | $47 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,009 | $1,009 | $1,009 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $45 | $45 | $45 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $97 | $97 | $97 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $143 | $143 | $143 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $159 | $159 | $159 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $45 | $45 | $45 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $122 | $122 | $122 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $174 | $174 | $174 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $123 | $123 | $123 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $45 | $45 | $45 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $45 | $45 | $45 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $45 | $45 | $45 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $201 | $201 | $201 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $107 | $107 | $107 |
| Consultation office low complexity CPT 99243 • Office Visits | $45 | $45 | $45 |
| Consultation office high complexity CPT 99245 • Office Visits | $224 | $224 | $224 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $506 | $506 | $506 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $343 | $343 | $343 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $45 | $45 | $45 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $45 | $45 | $45 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,790 | $1,790 | $1,790 |
| Total knee replacement CPT 27447 • Orthopedics | $45 | $45 | $45 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $572 | $572 | $572 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $45 | $45 | $45 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $45 | $45 | $45 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $263 | $263 | $263 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $420 | $420 | $420 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $174 | $174 | $174 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $196 | $196 | $196 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $6 | $6 | $6 |