| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $4 | $4 | $4 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $19 | $19 | $19 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $35 | $35 | $35 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $7 | $7 | $8 |
| Ferritin CPT 82728 • Laboratory | $16 | $16 | $16 |
| Iron binding capacity CPT 83550 • Laboratory | $10 | $10 | $10 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $21 | $21 | $21 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $7 | $7 | $7 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $15 | $15 | $15 |
| TB skin test intradermal CPT 86580 • Laboratory | $10 | $10 | $10 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $20 | $20 | $20 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $273 | $273 | $274 |
| Chorionic villus sampling CPT 59015 • Maternity | $177 | $177 | $177 |
| Fetal non-stress test CPT 59025 • Maternity | $61 | $61 | $61 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,408 | $1,408 | $1,409 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,086 | $1,086 | $1,086 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $48 | $48 | $48 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,600 | $2,600 | $2,600 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $87 | $87 | $87 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $38 | $38 | $38 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $21 | $41 | $61 |
| Interactive complexity add-on CPT 90785 • Mental Health | $15 | $15 | $15 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $142 | $142 | $142 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $157 | $157 | $157 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $71 | $71 | $71 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $78 | $78 | $78 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $73 | $73 | $73 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $138 | $138 | $138 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $118 | $118 | $118 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $144 | $144 | $144 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $59 | $59 | $59 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $87 | $87 | $87 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $106 | $106 | $106 |
| Group psychotherapy CPT 90853 • Mental Health | $41 | $41 | $41 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $208 | $208 | $208 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $149 | $149 | $149 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $214 | $214 | $214 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $152 | $152 | $152 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $76 | $76 | $76 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $187 | $187 | $187 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $233 | $233 | $233 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $121 | $121 | $121 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $234 | $234 | $234 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $122 | $122 | $122 |
| Consultation office low complexity CPT 99243 • Office Visits | $109 | $119 | $129 |
| Consultation office high complexity CPT 99245 • Office Visits | $235 | $235 | $235 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $862 | $862 | $862 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $947 | $947 | $947 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $2,087 | $2,087 | $2,087 |