| Urine culture bacterial colony count CPT 87086 • Laboratory | $4 | $4 | $4 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $26 | $26 | $26 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $106 | $389 | $673 |
| Fetal non-stress test CPT 59025 • Maternity | $33 | $33 | $33 |
| Insertion cervical dilator CPT 59200 • Maternity | $58 | $366 | $673 |
| Vaginal delivery only CPT 59409 • Maternity | $673 | $673 | $673 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $673 | $673 | $673 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $885 | $885 | $885 |
| Postpartum care only CPT 59430 • Maternity | $223 | $448 | $673 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $83 | $83 | $83 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $66 | $83 | $100 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $58 | $58 | $58 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $43 | $54 | $65 |
| Interactive complexity add-on CPT 90785 • Mental Health | $10 | $10 | $10 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $120 | $120 | $120 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $197 | $197 | $197 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $50 | $50 | $50 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $83 | $83 | $83 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $86 | $86 | $86 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $163 | $163 | $163 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $113 | $113 | $113 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $122 | $122 | $122 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $75 | $75 | $75 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $78 | $78 | $78 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $83 | $83 | $83 |
| Group psychotherapy CPT 90853 • Mental Health | $22 | $22 | $22 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $383 | $528 | $673 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $122 | $398 | $673 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $80 | $377 | $673 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $66 | $66 | $66 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $88 | $88 | $88 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $166 | $166 | $166 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $227 | $227 | $227 |
| Office visit established patient minimal CPT 99211 • Office Visits | $21 | $21 | $21 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $52 | $52 | $52 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $105 | $105 | $105 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $71 | $71 | $71 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $98 | $98 | $98 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $70 | $70 | $70 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $116 | $116 | $116 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $147 | $147 | $147 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $42 | $42 | $42 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $63 | $63 | $63 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $102 | $102 | $102 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $76 | $76 | $76 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $104 | $104 | $104 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $1,739 | $1,739 | $1,739 |