| Diagnostic mammography unilateral CPT 77065 • Imaging | $126 | $126 | $126 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $160 | $160 | $160 |
| Screening mammography bilateral CPT 77067 • Imaging | $58 | $58 | $58 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $58 | $58 | $58 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $4 | $4 | $4 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $8 | $8 | $8 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $86 | $86 | $86 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $6 | $6 | $6 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $4 | $4 | $4 |
| Complete blood count with differential CPT 85025 • 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 | $4 | $4 | $4 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $26 | $26 | $26 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Postpartum care only CPT 59430 • Maternity | $187 | $187 | $187 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $53 | $53 | $53 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $56 | $56 | $56 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $106 | $106 | $106 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $52 | $52 | $52 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $99 | $99 | $99 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $360 | $360 | $360 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $61 | $61 | $61 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $103 | $103 | $103 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $144 | $144 | $144 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $191 | $191 | $191 |
| Office visit established patient minimal CPT 99211 • Office Visits | $16 | $16 | $16 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $25 | $25 | $25 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $69 | $69 | $69 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $119 | $119 | $119 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $141 | $141 | $141 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $113 | $113 | $113 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $161 | $161 | $161 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $73 | $73 | $73 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $103 | $103 | $103 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $689 | $689 | $689 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $284 | $284 | $284 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $680 | $680 | $680 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $411 | $411 | $411 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $109 | $109 | $109 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $486 | $486 | $486 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $63 | $63 | $63 |
| Visual field examination CPT 92083 • Ophthalmology | $56 | $56 | $56 |