| Complete blood count automated CPT 85027 • Laboratory | $9 | $9 | $9 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $5 | $6 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $4 | $4 | $4 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $8 | $8 | $8 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $18 | $18 | $18 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $14 | $14 | $14 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $7 | $7 | $7 |
| Blood typing ABO CPT 86900 • Laboratory | $4 | $4 | $4 |
| Blood typing Rh CPT 86901 • Laboratory | $4 | $4 | $4 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $11 | $11 | $11 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $49 | $49 | $49 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $49 | $49 | $49 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $62 | $72 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $23 | $23 | $23 |
| Fetal non-stress test CPT 59025 • Maternity | $64 | $64 | $64 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $3,517 | $3,517 | $3,517 |
| Cesarean delivery only CPT 59514 • Maternity | $885 | $1,033 | $1,181 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $156 | $156 | $156 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $180 | $180 | $180 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $237 | $237 | $237 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $107 | $107 | $107 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $123 | $123 | $123 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $123 | $158 | $192 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $518 | $518 | $518 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $596 | $596 | $596 |
| EMG needle each extremity complete CPT 95886 • Neurology | $53 | $90 | $128 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $97 | $97 | $97 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $149 | $149 | $149 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $224 | $224 | $224 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $180 | $238 | $296 |
| Office visit established patient minimal CPT 99211 • Office Visits | $31 | $31 | $31 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $76 | $76 | $76 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $122 | $122 | $122 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $172 | $172 | $172 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $243 | $243 | $243 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $829 | $829 | $829 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,564 | $1,564 | $1,564 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $715 | $851 | $987 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $720 | $720 | $720 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $604 | $604 | $604 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $52 | $62 | $72 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $73 | $73 | $73 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $86 | $86 | $86 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,223 | $2,223 | $2,223 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,911 | $1,911 | $1,911 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $465 | $465 | $465 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $778 | $778 | $778 |
| Total hip replacement CPT 27130 • Orthopedics | $1,698 | $1,698 | $1,698 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $2,205 | $2,205 | $2,205 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,624 | $1,624 | $1,624 |