| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $25 | $25 | $25 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $6 |
| Ferritin CPT 82728 • Laboratory | $11 | $11 | $12 |
| Iron binding capacity CPT 83550 • Laboratory | $7 | $7 | $7 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $15 | $15 | $15 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $11 | $11 | $11 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $15 | $15 | $15 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing ABO CPT 86900 • Laboratory | $2 | $2 | $2 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $29 | $29 | $29 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $29 | $29 | $29 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $14 | $14 | $14 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $154 | $154 | $154 |
| Chorionic villus sampling CPT 59015 • Maternity | $120 | $120 | $120 |
| Fetal non-stress test CPT 59025 • Maternity | $15 | $26 | $37 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,836 | $1,836 | $1,836 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $812 | $812 | $813 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,031 | $2,031 | $2,031 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,923 | $1,923 | $1,923 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $43 | $43 | $43 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $49 | $65 | $81 |
| Interactive complexity add-on CPT 90785 • Mental Health | $5 | $9 | $14 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $113 | $177 | $234 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $88 | $131 | $152 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $37 | $63 | $76 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $32 | $45 | $51 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $99 | $105 | $116 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $79 | $90 | $110 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $136 | $155 | $174 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $133 | $138 | $146 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $101 | $102 | $103 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $9 | $31 | $53 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $95 | $124 | $154 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $73 | $87 | $100 |
| Group psychotherapy CPT 90853 • Mental Health | $38 | $40 | $41 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $113 | $113 | $113 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $116 | $116 | $116 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $166 | $166 | $166 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $115 | $115 | $115 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $81 | $81 | $81 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $33 | $33 | $33 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $41 | $41 | $41 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $45 | $114 | $163 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $45 | $95 | $154 |
| Office visit established patient minimal CPT 99211 • Office Visits | $4 | $31 | $60 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $33 | $33 | $33 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $32 | $33 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $54 | $89 |