| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $14 | $14 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $30 | $30 | $30 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $30 | $30 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $30 | $30 | $30 |
| Auto-added CPT 10120 • General | $30 | $30 | $30 |
| Auto-added CPT 81025 • General | $7 | $7 | $7 |
| Auto-added CPT 82962 • General | $3 | $3 | $3 |
| Auto-added CPT 85018 • General | $2 | $2 | $2 |
| Auto-added CPT 87807 • General | $10 | $10 | $10 |
| Auto-added CPT 99495 • General | $140 | $140 | $140 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $13 | $13 | $13 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $13 | $13 | $13 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $53 | $53 | $53 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $30 | $30 | $30 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $30 | $30 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $183 | $183 | $183 |
| Office visit established patient minimal CPT 99211 • Office Visits | $30 | $30 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $30 | $30 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $30 | $30 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $30 | $30 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $30 | $30 | $30 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $106 | $106 | $106 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $96 | $96 | $96 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $102 | $102 | $102 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $102 | $102 | $102 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $94 | $94 | $94 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $30 | $30 | $30 |