| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $15 | $15 | $15 |
| Creatinine urine CPT 82570 • Laboratory | $3 | $3 | $3 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $4 | $6 | $8 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $9 | $9 | $9 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $5 | $5 | $5 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $8 | $8 | $8 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $4 | $4 |
| Complete blood count automated CPT 85027 • Laboratory | $2 | $2 | $2 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $6 | $8 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $9 | $9 | $9 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $9 | $9 | $9 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $26 | $26 | $26 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $11 | $13 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $931 | $964 | $997 |
| Postpartum care only CPT 59430 • Maternity | $208 | $208 | $208 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $39 | $39 | $39 |
| Interactive complexity add-on CPT 90785 • Mental Health | $10 | $10 | $10 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $106 | $106 | $106 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $164 | $164 | $164 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $59 | $59 | $59 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $54 | $54 | $54 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $76 | $76 | $76 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $68 | $68 | $68 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $113 | $113 | $113 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $81 | $81 | $81 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $3 | $4 | $4 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $350 | $350 | $350 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $53 | $55 | $56 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $82 | $85 | $88 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $87 | $144 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $225 | $225 | $225 |
| Office visit established patient minimal CPT 99211 • Office Visits | $21 | $26 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $40 | $50 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $54 | $77 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $80 | $129 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $184 | $184 | $184 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $161 | $161 | $161 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $43 | $43 | $43 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $68 | $68 | $68 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $60 | $60 | $60 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $137 | $137 | $137 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $10 | $10 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $22 | $22 | $22 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $20 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $75 | $75 | $75 |