| Hemoglobin A1c CPT 83036 • Laboratory | $4 | $11 | $17 |
| Iron serum CPT 83540 • Laboratory | $3 | $7 | $12 |
| Iron binding capacity CPT 83550 • Laboratory | $4 | $12 | $16 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $9 | $21 | $33 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $4 | $10 | $16 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $7 | $19 | $30 |
| Complete blood count with differential CPT 85025 • Laboratory | $3 | $8 | $14 |
| Complete blood count automated CPT 85027 • Laboratory | $3 | $3 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $5 | $7 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $5 | $5 | $5 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $9 | $9 | $9 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $9 | $11 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $15 | $15 | $15 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $18 | $40 | $63 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $40 | $63 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $22 | $44 | $67 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $17 | $27 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $6 | $13 | $16 |
| Fetal non-stress test CPT 59025 • Maternity | $26 | $26 | $26 |
| Postpartum care only CPT 59430 • Maternity | $168 | $168 | $168 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $49 | $49 | $49 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $98 | $98 | $98 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $24 | $24 | $24 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $22 | $78 | $151 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $110 | $110 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $160 | $160 | $160 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $52 | $52 | $52 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $71 | $71 | $71 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $102 | $102 | $102 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $7 | $9 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $72 | $73 | $74 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $103 | $104 | $104 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $124 | $141 | $150 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $188 | $193 | $205 |
| Office visit established patient minimal CPT 99211 • Office Visits | $21 | $32 | $43 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $43 | $48 | $52 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $55 | $73 | $90 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $85 | $91 | $101 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $128 | $156 | $184 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $76 | $76 | $76 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $113 | $113 | $113 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $161 | $161 | $161 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $61 | $61 | $61 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $73 | $73 | $73 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $93 | $93 | $93 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $75 | $75 | $75 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $106 | $106 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $461 | $461 | $461 |