| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $12 | $12 | $12 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $16 | $16 | $16 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $4 | $4 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $27 | $27 | $27 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $27 | $27 | $27 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $11 | $11 | $11 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $179 | $179 | $179 |
| Chorionic villus sampling CPT 59015 • Maternity | $133 | $133 | $133 |
| Fetal non-stress test CPT 59025 • Maternity | $26 | $32 | $39 |
| Insertion cervical dilator CPT 59200 • Maternity | $39 | $39 | $39 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $40 | $40 | $40 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $788 | $788 | $788 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $954 | $954 | $954 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,100 | $2,100 | $2,100 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $113 | $113 | $113 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $24 | $27 | $31 |
| Interactive complexity add-on CPT 90785 • Mental Health | $4 | $4 | $4 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $124 | $124 | $124 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $124 | $124 | $124 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $78 | $78 | $78 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $91 | $91 | $91 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $105 | $105 | $105 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $105 | $105 | $105 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $124 | $124 | $124 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $62 | $62 | $62 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $68 | $68 | $68 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $91 | $91 | $91 |
| Group psychotherapy CPT 90853 • Mental Health | $48 | $48 | $48 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $140 | $140 | $140 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $68 | $68 | $68 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $99 | $99 | $99 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $98 | $98 | $98 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $140 | $153 | $165 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $40 | $122 | $204 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $104 | $104 | $104 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $146 | $146 | $146 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $90 | $90 | $90 |
| Consultation office low complexity CPT 99243 • Office Visits | $124 | $124 | $124 |
| Consultation office high complexity CPT 99245 • Office Visits | $206 | $206 | $206 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $374 | $374 | $374 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $40 | $40 | $40 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $40 | $40 | $40 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $254 | $254 | $254 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $596 | $596 | $596 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $40 | $40 | $40 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $94 | $94 | $94 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $11 | $11 | $11 |