| Urine culture bacterial colony count CPT 87086 • Laboratory | $2 | $2 | $2 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $14 | $14 | $14 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $14 | $14 | $14 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $49 | $49 | $49 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $102 | $102 | $102 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $20 | $20 | $20 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $50 | $50 | $50 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $138 | $138 | $138 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $177 | $177 | $177 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $151 | $151 | $151 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $52 | $52 | $52 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $67 | $67 | $67 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $134 | $134 | $134 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $158 | $158 | $158 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $172 | $172 | $172 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $44 | $44 | $44 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $77 | $77 | $77 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $78 | $78 | $78 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $170 | $170 | $170 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $116 | $116 | $116 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $155 | $155 | $155 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $47 | $47 | $47 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $70 | $70 | $70 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $143 | $143 | $143 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $63 | $63 | $63 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $141 | $141 | $141 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $121 | $121 | $121 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $113 | $113 | $113 |
| Fundus photography CPT 92250 • Ophthalmology | $35 | $35 | $35 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $18 | $18 | $18 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $12 | $12 | $12 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $33 | $33 | $33 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $35 | $35 | $35 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $25 | $25 | $25 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $28 | $28 | $28 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $75 | $75 | $75 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $26 | $26 |
| Immunization admin injection single CPT 90471 • Preventive Care | $16 | $16 | $16 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $15 | $15 | $15 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $251 | $251 | $251 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $36 | $36 | $36 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $106 | $106 | $106 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $109 | $109 | $109 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $118 | $118 | $118 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $91 | $91 | $91 |