| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $97 | $97 | $97 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $119 | $119 | $119 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $153 | $153 | $153 |
| Screening mammography bilateral CPT 77067 • Imaging | $126 | $126 | $126 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fetal non-stress test CPT 59025 • Maternity | $63 | $63 | $63 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $3,069 | $3,069 | $3,069 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $110 | $110 | $110 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $127 | $127 | $127 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $131 | $131 | $131 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $190 | $190 | $190 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $64 | $64 | $64 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $84 | $84 | $84 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $127 | $127 | $127 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $7 | $7 | $7 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $90 | $90 | $90 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $66 | $66 | $66 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $102 | $102 | $102 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $172 | $172 | $172 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $224 | $224 | $224 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $34 | $34 | $34 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $67 | $67 | $67 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $104 | $104 | $104 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $148 | $148 | $148 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $135 | $135 | $135 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $182 | $182 | $182 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $269 | $269 | $269 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $52 | $52 | $52 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $96 | $96 | $96 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $138 | $138 | $138 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $97 | $97 | $97 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $142 | $142 | $142 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $61 | $61 | $61 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $15 | $15 | $15 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $38 | $38 | $38 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $44 | $44 | $44 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $34 | $34 | $34 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $35 | $35 | $35 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $106 | $106 | $106 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $106 | $106 | $106 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $106 | $106 | $106 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $72 | $72 | $72 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $46 | $46 | $46 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $46 | $46 | $46 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $43 | $43 | $43 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $45 | $45 | $45 |
| Immunization admin injection single CPT 90471 • Preventive Care | $33 | $33 | $33 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $174 | $174 | $174 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $201 | $201 | $201 |