| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $5 | $5 | $5 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $4 | $4 |
| Complete blood count automated CPT 85027 • Laboratory | $3 | $3 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $2 | $2 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $5 | $5 | $5 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $15 | $15 | $15 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $18 | $18 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $28 | $28 | $28 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $27 | $27 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,861 | $1,861 | $1,861 |
| Vaginal delivery only CPT 59409 • Maternity | $649 | $649 | $649 |
| Postpartum care only CPT 59430 • Maternity | $216 | $216 | $216 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,212 | $2,212 | $2,212 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $95 | $95 | $95 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $110 | $110 | $110 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $170 | $170 | $170 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $66 | $66 | $66 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $70 | $70 | $70 |
| Interactive complexity add-on CPT 90785 • Mental Health | $8 | $8 | $8 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $170 | $170 | $170 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $167 | $167 | $167 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $54 | $54 | $54 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $78 | $78 | $78 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $76 | $76 | $76 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $114 | $114 | $114 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $92 | $92 | $92 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $145 | $145 | $145 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $46 | $46 | $46 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $78 | $78 | $78 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $76 | $76 | $76 |
| Group psychotherapy CPT 90853 • Mental Health | $22 | $22 | $22 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $379 | $379 | $379 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $72 | $72 | $72 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $95 | $95 | $95 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $169 | $169 | $169 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $191 | $191 | $191 |
| Office visit established patient minimal CPT 99211 • Office Visits | $23 | $23 | $23 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $30 | $30 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $47 | $47 | $47 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $70 | $70 | $70 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $168 | $168 | $168 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $65 | $65 | $65 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $121 | $121 | $121 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $137 | $137 | $137 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $43 | $43 | $43 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $62 | $62 | $62 |