| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $18 | $18 | $18 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $18 | $18 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $26 | $26 | $26 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Fetal non-stress test CPT 59025 • Maternity | $29 | $29 | $29 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,988 | $1,988 | $1,988 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $610 | $610 | $610 |
| Postpartum care only CPT 59430 • Maternity | $168 | $168 | $168 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $85 | $85 | $85 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $98 | $98 | $98 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $31 | $31 | $31 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $22 | $22 | $22 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $95 | $95 | $95 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $160 | $160 | $160 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $46 | $46 | $46 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $63 | $63 | $63 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $102 | $102 | $102 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $102 | $102 | $102 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $76 | $76 | $76 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| EMG needle each extremity complete CPT 95886 • Neurology | $80 | $80 | $80 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $94 | $94 | $94 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $148 | $148 | $148 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $53 | $53 | $53 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $103 | $103 | $103 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $169 | $169 | $169 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $175 | $175 | $175 |
| Office visit established patient minimal CPT 99211 • Office Visits | $20 | $20 | $20 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $56 | $56 | $56 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $91 | $91 | $91 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $129 | $129 | $129 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $128 | $128 | $128 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $76 | $76 | $76 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $96 | $96 | $96 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $128 | $128 | $128 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $43 | $43 | $43 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $58 | $58 | $58 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $93 | $93 | $93 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $75 | $75 | $75 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $106 | $106 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $680 | $680 | $680 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $323 | $323 | $323 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $103 | $103 | $103 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $309 | $309 | $309 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $63 | $63 | $63 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $133 | $133 | $133 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $75 | $75 | $75 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $113 | $113 | $113 |