| X-ray ankle complete CPT 73610 • Imaging | $34 | $34 | $34 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $332 | $332 | $332 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $227 | $227 | $227 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $227 | $227 | $227 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $104 | $104 | $104 |
| Screening mammography bilateral CPT 77067 • Imaging | $124 | $124 | $124 |
| Lipid panel CPT 80061 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $1 | $1 | $1 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $13 | $13 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $22 | $22 | $22 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $10 | $10 | $10 |
| Iron binding capacity CPT 83550 • Laboratory | $7 | $7 | $7 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $1 | $1 | $1 |
| TB skin test intradermal CPT 86580 • Laboratory | $7 | $7 | $7 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $6 | $6 | $6 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $176 | $176 | $176 |
| Fetal non-stress test CPT 59025 • Maternity | $43 | $43 | $43 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $936 | $936 | $936 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $40 | $40 | $40 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $92 | $92 | $92 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $147 | $147 | $147 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $129 | $129 | $129 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $91 | $91 | $91 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $166 | $166 | $166 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $223 | $223 | $223 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $175 | $175 | $175 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $226 | $226 | $226 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $161 | $161 | $161 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $243 | $243 | $243 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $106 | $106 | $106 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $242 | $242 | $242 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $128 | $128 | $128 |
| Consultation office low complexity CPT 99243 • Office Visits | $144 | $144 | $144 |
| Consultation office high complexity CPT 99245 • Office Visits | $263 | $263 | $263 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $673 | $673 | $673 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $457 | $457 | $457 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,072 | $1,072 | $1,072 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $75 | $75 | $75 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,133 | $2,133 | $2,133 |
| Total knee replacement CPT 27447 • Orthopedics | $1,509 | $1,509 | $1,509 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $679 | $679 | $679 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $805 | $805 | $805 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $638 | $638 | $638 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $196 | $196 | $196 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $336 | $336 | $336 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $526 | $526 | $526 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $217 | $217 | $217 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $198 | $198 | $198 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |