| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $3 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $5 | $6 | $7 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $19 | $26 | $32 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $23 | $28 | $32 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $27 | $38 | $52 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $12 | $18 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $8 | $10 | $11 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $51 | $51 | $51 |
| Fetal non-stress test CPT 59025 • Maternity | $56 | $56 | $56 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,153 | $1,153 | $1,153 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $51 | $51 | $51 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $115 | $115 | $115 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $147 | $147 | $147 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $165 | $165 | $165 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $77 | $77 | $77 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $51 | $51 | $51 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $163 | $163 | $163 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $235 | $235 | $235 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $162 | $162 | $162 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $30 | $30 | $30 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $53 | $100 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $104 | $119 | $126 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $30 | $30 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $30 | $30 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $42 | $48 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $30 | $30 | $30 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $51 | $51 | $51 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $46 | $46 | $46 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $67 | $67 | $67 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $144 | $144 | $144 |
| Consultation office low complexity CPT 99243 • Office Visits | $0 | $25 | $51 |
| Consultation office high complexity CPT 99245 • Office Visits | $0 | $134 | $268 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $773 | $773 | $773 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $452 | $452 | $452 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $102 | $116 | $130 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $517 | $517 | $517 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $51 | $51 | $51 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $51 | $51 | $51 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,307 | $2,307 | $2,307 |
| Total knee replacement CPT 27447 • Orthopedics | $51 | $51 | $51 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $746 | $746 | $746 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $51 | $51 | $51 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $51 | $51 | $51 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $51 | $51 | $51 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $363 | $363 | $363 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $560 | $560 | $560 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $236 | $236 | $236 |
| Cytopathology concentration technique CPT 88108 • Pathology | $13 | $26 | $55 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $30 | $47 | $55 |