| Blood typing ABO CPT 86900 • Laboratory | $2 | $2 | $2 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $29 | $29 | $29 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $29 | $29 | $29 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $14 | $14 | $14 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $154 | $154 | $154 |
| Chorionic villus sampling CPT 59015 • Maternity | $120 | $120 | $120 |
| Fetal non-stress test CPT 59025 • Maternity | $22 | $30 | $37 |
| Insertion cervical dilator CPT 59200 • Maternity | $33 | $33 | $33 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,836 | $1,836 | $1,836 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $812 | $812 | $813 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,031 | $2,031 | $2,031 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $999 | $999 | $999 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,923 | $1,923 | $1,923 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $43 | $43 | $43 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $49 | $65 | $81 |
| Interactive complexity add-on CPT 90785 • Mental Health | $4 | $9 | $14 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $151 | $167 | $183 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $152 | $174 | $196 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $75 | $84 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $69 | $87 | $106 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $88 | $105 | $121 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $66 | $92 | $119 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $110 | $110 | $110 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $116 | $151 | $185 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $141 | $141 | $141 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $70 | $74 | $79 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $71 | $98 | $125 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $100 | $129 | $157 |
| Group psychotherapy CPT 90853 • Mental Health | $19 | $19 | $19 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $113 | $113 | $113 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $351 | $351 | $351 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $116 | $116 | $116 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $166 | $166 | $166 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $115 | $115 | $115 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $57 | $57 | $57 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $75 | $75 | $75 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $70 | $117 | $163 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $154 | $200 | $246 |
| Office visit established patient minimal CPT 99211 • Office Visits | $4 | $10 | $17 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $55 | $55 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $65 | $65 | $65 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $125 | $142 | $160 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $122 | $122 | $122 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $69 | $69 | $69 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $100 | $100 | $100 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $80 | $80 | $80 |
| Consultation office low complexity CPT 99243 • Office Visits | $65 | $88 | $111 |
| Consultation office high complexity CPT 99245 • Office Visits | $207 | $207 | $207 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $518 | $518 | $518 |