| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $28 | $28 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $41 | $41 | $41 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $13 | $13 | $13 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $13 | $13 | $13 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $72 | $403 | $595 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $35 | $632 | $977 |
| Chorionic villus sampling CPT 59015 • Maternity | $74 | $595 | $977 |
| Fetal non-stress test CPT 59025 • Maternity | $23 | $29 | $35 |
| Insertion cervical dilator CPT 59200 • Maternity | $35 | $330 | $595 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $445 | $445 | $445 |
| Vaginal delivery only CPT 59409 • Maternity | $595 | $735 | $1,016 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $445 | $749 | $977 |
| External cephalic version CPT 59412 • Maternity | $1,016 | $1,507 | $1,999 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $445 | $445 | $445 |
| Postpartum care only CPT 59430 • Maternity | $445 | $545 | $595 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $445 | $445 | $445 |
| Cesarean delivery only CPT 59514 • Maternity | $445 | $445 | $445 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $445 | $800 | $977 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $445 | $445 | $445 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $68 | $68 | $68 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $68 | $68 | $68 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $101 | $101 | $101 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $157 | $205 | $254 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $351 | $514 | $595 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $35 | $459 | $977 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $35 | $327 | $595 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $113 | $113 | $113 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $174 | $174 | $174 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $213 | $251 | $278 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $345 | $353 | $367 |
| Office visit established patient minimal CPT 99211 • Office Visits | $35 | $35 | $35 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $87 | $87 | $87 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $142 | $142 | $142 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $125 | $180 | $214 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $282 | $282 | $282 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $157 | $157 | $157 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $211 | $211 | $211 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $311 | $318 | $331 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $60 | $60 | $60 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $112 | $112 | $112 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $161 | $161 | $161 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $112 | $112 | $112 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $165 | $168 | $175 |
| Consultation office low complexity CPT 99243 • Office Visits | $149 | $168 | $187 |
| Consultation office high complexity CPT 99245 • Office Visits | $296 | $296 | $296 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $559 | $921 | $1,171 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $35 | $742 | $977 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $977 | $1,549 | $2,500 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $351 | $768 | $977 |