| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $7 | $7 | $7 |
| Complete blood count with differential CPT 85025 • Laboratory | $3 | $3 | $3 |
| Complete blood count automated CPT 85027 • Laboratory | $3 | $3 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $6 | $7 |
| 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 | $22 | $22 | $22 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $10 | $12 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $164 | $164 | $164 |
| Fetal non-stress test CPT 59025 • Maternity | $29 | $34 | $39 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $874 | $874 | $874 |
| Postpartum care only CPT 59430 • Maternity | $168 | $168 | $168 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,885 | $1,885 | $1,885 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $49 | $49 | $49 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $98 | $98 | $98 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $24 | $24 | $24 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $37 | $54 | $71 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $128 | $147 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $152 | $156 | $160 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $58 | $58 | $58 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $71 | $71 | $71 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $75 | $83 | $91 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $99 | $99 | $99 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $107 | $107 | $107 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $131 | $131 | $131 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $120 | $120 | $120 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $105 | $105 | $105 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $152 | $152 | $152 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $106 | $106 | $106 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $20 | $20 | $20 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $95 | $95 | $95 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $44 | $100 | $155 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $177 | $201 | $225 |
| Office visit established patient minimal CPT 99211 • Office Visits | $21 | $21 | $21 |
| 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 | $44 | $87 | $129 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $165 | $165 | $165 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $76 | $76 | $76 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $113 | $113 | $113 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $155 | $158 | $161 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $43 | $43 | $43 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $73 | $73 | $73 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $103 | $103 | $103 |
| 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 | $82 | $94 | $106 |