| Heterophile antibodies screen CPT 86308 • Laboratory | $9 | $9 | $9 |
| TB skin test intradermal CPT 86580 • Laboratory | $15 | $15 | $15 |
| Blood typing ABO CPT 86900 • Laboratory | $4 | $4 | $4 |
| Blood typing Rh CPT 86901 • Laboratory | $4 | $4 | $4 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $11 | $11 | $11 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $46 | $46 | $46 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $46 | $46 | $46 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $68 | $68 | $68 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $27 | $27 | $27 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $27 | $27 | $27 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $5,822 | $5,822 | $5,822 |
| Vaginal delivery only CPT 59409 • Maternity | $1,952 | $1,952 | $1,952 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $2,578 | $2,578 | $2,578 |
| External cephalic version CPT 59412 • Maternity | $248 | $248 | $248 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $2,482 | $2,482 | $2,482 |
| Postpartum care only CPT 59430 • Maternity | $645 | $645 | $645 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $6,420 | $6,420 | $6,420 |
| Cesarean delivery only CPT 59514 • Maternity | $2,203 | $2,203 | $2,203 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $3,169 | $3,169 | $3,169 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $6,079 | $6,079 | $6,079 |
| Interactive complexity add-on CPT 90785 • Mental Health | $6 | $6 | $6 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $125 | $125 | $125 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $109 | $109 | $109 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $65 | $65 | $65 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $38 | $38 | $38 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $75 | $75 | $75 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $51 | $51 | $51 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $76 | $76 | $76 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $67 | $67 | $67 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $95 | $95 | $95 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $5 | $5 | $5 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $109 | $109 | $109 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $60 | $60 | $60 |
| Group psychotherapy CPT 90853 • Mental Health | $40 | $52 | $63 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $407 | $407 | $407 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $35 | $100 | $165 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $43 | $149 | $255 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $77 | $193 | $310 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $90 | $297 | $505 |
| Office visit established patient minimal CPT 99211 • Office Visits | $41 | $46 | $52 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $47 | $87 | $128 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $47 | $127 | $207 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $62 | $177 | $292 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $102 | $257 | $412 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $32 | $130 | $228 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $81 | $194 | $307 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $171 | $311 | $451 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $49 | $69 | $88 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $59 | $110 | $162 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $91 | $162 | $233 |