| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $6 | $6 | $6 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $9 | $9 | $9 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $13 | $13 | $13 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing ABO CPT 86900 • Laboratory | $2 | $2 | $2 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $25 | $25 | $25 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $13 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $159 | $159 | $159 |
| Chorionic villus sampling CPT 59015 • Maternity | $120 | $120 | $120 |
| Fetal non-stress test CPT 59025 • Maternity | $39 | $39 | $39 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $49 | $49 | $49 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $846 | $846 | $847 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $49 | $49 | $49 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,926 | $1,926 | $1,926 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $42 | $42 | $42 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $39 | $59 | $78 |
| Interactive complexity add-on CPT 90785 • Mental Health | $18 | $18 | $18 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $177 | $179 | $180 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $151 | $165 | $180 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $76 | $76 | $76 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $78 | $78 | $78 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $79 | $79 | $79 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $118 | $118 | $118 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $109 | $109 | $109 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $136 | $136 | $136 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $177 | $177 | $177 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $66 | $66 | $66 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $117 | $117 | $117 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $122 | $122 | $122 |
| Group psychotherapy CPT 90853 • Mental Health | $53 | $53 | $53 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $137 | $137 | $137 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $105 | $105 | $105 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $152 | $152 | $152 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $105 | $105 | $105 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $127 | $127 | $127 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $172 | $199 | $226 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $84 | $84 | $84 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $221 | $221 | $221 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $117 | $117 | $117 |
| Consultation office low complexity CPT 99243 • Office Visits | $64 | $64 | $64 |
| Consultation office high complexity CPT 99245 • Office Visits | $246 | $246 | $246 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $546 | $546 | $546 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $761 | $761 | $761 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $368 | $368 | $368 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $603 | $740 | $877 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $70 | $70 | $70 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $56 | $56 | $56 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $11 | $11 | $11 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $60 | $60 | $60 |