| TB skin test intradermal CPT 86580 • Laboratory | $7 | $7 | $7 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $21 | $21 | $21 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $21 | $21 | $21 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $10 | $10 | $10 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $197 | $197 | $197 |
| Chorionic villus sampling CPT 59015 • Maternity | $128 | $128 | $128 |
| Fetal non-stress test CPT 59025 • Maternity | $25 | $25 | $25 |
| Insertion cervical dilator CPT 59200 • Maternity | $43 | $43 | $43 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,760 | $1,760 | $1,760 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,054 | $1,054 | $1,054 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $1,760 | $1,760 | $1,760 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,290 | $1,290 | $1,290 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,760 | $1,760 | $1,760 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $33 | $33 | $33 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $23 | $42 | $61 |
| Interactive complexity add-on CPT 90785 • Mental Health | $20 | $20 | $20 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $135 | $158 | $180 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $153 | $167 | $180 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $77 | $77 | $77 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $106 | $106 | $106 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $88 | $88 | $88 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $127 | $127 | $127 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $136 | $136 | $136 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $177 | $177 | $177 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $88 | $88 | $88 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $99 | $99 | $99 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $121 | $121 | $121 |
| Group psychotherapy CPT 90853 • Mental Health | $44 | $44 | $44 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $3 | $3 | $3 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $100 | $109 | $118 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $88 | $88 | $88 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $128 | $128 | $128 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $88 | $88 | $88 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $176 | $176 | $176 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $222 | $222 | $222 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $117 | $117 | $117 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $217 | $217 | $217 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $116 | $116 | $116 |
| Consultation office low complexity CPT 99243 • Office Visits | $121 | $121 | $121 |
| Consultation office high complexity CPT 99245 • Office Visits | $242 | $242 | $242 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $507 | $507 | $507 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $744 | $744 | $744 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $341 | $341 | $341 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $815 | $815 | $815 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $63 | $63 | $63 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $33 | $33 | $33 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $50 | $50 | $50 |
| Visual field examination CPT 92083 • Ophthalmology | $17 | $17 | $17 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $16 | $16 | $16 |