| X-ray shoulder complete CPT 73030 • Imaging | $12 | $12 | $12 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $18 | $18 | $18 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $215 | $215 | $215 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $105 | $109 | $113 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $116 | $116 | $116 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $128 | $206 | $285 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $45 | $45 | $45 |
| Ultrasound transvaginal CPT 76830 • Imaging | $32 | $47 | $61 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $45 | $53 | $61 |
| Screening mammography bilateral CPT 77067 • Imaging | $124 | $124 | $124 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $426 | $426 | $426 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $9 | $9 | $9 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $3 | $3 | $3 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $18 | $18 | $18 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Glucose quantitative blood CPT 82947 • Laboratory | $4 | $4 | $4 |
| Hemoglobin A1c CPT 83036 • Laboratory | $13 | $13 | $13 |
| Complete blood count with differential CPT 85025 • Laboratory | $10 | $10 | $10 |
| TB skin test intradermal CPT 86580 • Laboratory | $10 | $10 | $10 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $18 | $18 | $18 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $116 | $116 | $116 |
| Fetal non-stress test CPT 59025 • Maternity | $32 | $32 | $32 |
| Insertion cervical dilator CPT 59200 • Maternity | $64 | $64 | $64 |
| Vaginal delivery only CPT 59409 • Maternity | $934 | $934 | $934 |
| Cesarean delivery only CPT 59514 • Maternity | $933 | $933 | $933 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $61 | $61 | $61 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $91 | $91 | $91 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $31 | $31 | $31 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $40 | $40 | $40 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $169 | $169 | $169 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $198 | $198 | $198 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $105 | $105 | $105 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $109 | $109 | $109 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $65 | $65 | $65 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $134 | $134 | $134 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $88 | $88 | $88 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $72 | $72 | $72 |
| EMG needle each extremity complete CPT 95886 • Neurology | $118 | $118 | $118 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $86 | $86 | $86 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $168 | $168 | $168 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $241 | $241 | $241 |
| Office visit established patient minimal CPT 99211 • Office Visits | $23 | $23 | $23 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $56 | $56 | $56 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $118 | $118 | $118 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $136 | $136 | $136 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $180 | $180 | $180 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $83 | $83 | $83 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $158 | $158 | $158 |