| MRI brain without contrast then with contrast CPT 70553 • Imaging | $243 | $243 | $243 |
| Chest X-ray single view CPT 71045 • Imaging | $21 | $21 | $21 |
| Chest X-ray 2 views CPT 71046 • Imaging | $28 | $28 | $28 |
| CT chest without contrast CPT 71250 • Imaging | $71 | $71 | $71 |
| CT chest with contrast CPT 71260 • Imaging | $122 | $122 | $122 |
| CT angiography chest CPT 71275 • Imaging | $122 | $122 | $122 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $150 | $150 | $150 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $151 | $151 | $151 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $151 | $151 | $151 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $164 | $164 | $164 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $164 | $164 | $164 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $127 | $127 | $127 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $243 | $243 | $243 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $243 | $243 | $243 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $71 | $71 | $71 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $71 | $71 | $71 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $14 | $14 | $14 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $14 | $14 | $14 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $76 | $4,767 | $13,476 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $57 | $337 | $750 |
| Chorionic villus sampling CPT 59015 • Maternity | $57 | $295 | $750 |
| Fetal non-stress test CPT 59025 • Maternity | $24 | $53 | $77 |
| Insertion cervical dilator CPT 59200 • Maternity | $57 | $302 | $750 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $57 | $1,938 | $3,819 |
| Vaginal delivery only CPT 59409 • Maternity | $57 | $403 | $750 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $57 | $403 | $750 |
| External cephalic version CPT 59412 • Maternity | $57 | $776 | $2,108 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $57 | $847 | $1,637 |
| Postpartum care only CPT 59430 • Maternity | $57 | $403 | $750 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $57 | $2,135 | $4,214 |
| Cesarean delivery only CPT 59514 • Maternity | $57 | $749 | $1,441 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $57 | $403 | $750 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $57 | $2,022 | $3,988 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $71 | $71 | $71 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $71 | $71 | $71 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $107 | $107 | $107 |
| Interactive complexity add-on CPT 90785 • Mental Health | $26 | $26 | $26 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $303 | $303 | $303 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $339 | $339 | $339 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $131 | $131 | $131 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $120 | $120 | $120 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $173 | $173 | $173 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $152 | $152 | $152 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $255 | $255 | $255 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $201 | $201 | $201 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $244 | $244 | $244 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $121 | $121 | $121 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $167 | $167 | $167 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $174 | $174 | $174 |
| Group psychotherapy CPT 90853 • Mental Health | $46 | $46 | $46 |