| Iron binding capacity CPT 83550 • Laboratory | $6 | $6 | $6 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $15 | $15 | $15 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $3 | $3 | $3 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $13 | $13 | $13 |
| Complete blood count with differential CPT 85025 • Laboratory | $3 | $3 | $3 |
| Complete blood count automated CPT 85027 • Laboratory | $1 | $1 | $1 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $1 | $1 | $1 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $1 | $1 | $1 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $2 | $2 | $2 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $3 | $3 | $3 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $1 | $1 | $1 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing ABO CPT 86900 • Laboratory | $0 | $0 | $0 |
| Blood typing Rh CPT 86901 • Laboratory | $1 | $1 | $1 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $3 | $3 | $3 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $6 | $16 | $26 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $20 | $23 | $26 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $10 | $10 | $10 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $2 | $2 | $2 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $7 | $7 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $112 | $112 | $112 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $195 | $195 | $195 |
| Chorionic villus sampling CPT 59015 • Maternity | $24 | $24 | $24 |
| Fetal non-stress test CPT 59025 • Maternity | $23 | $23 | $23 |
| Insertion cervical dilator CPT 59200 • Maternity | $36 | $36 | $36 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,169 | $1,169 | $1,169 |
| Vaginal delivery only CPT 59409 • Maternity | $428 | $428 | $428 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,157 | $1,157 | $1,157 |
| External cephalic version CPT 59412 • Maternity | $50 | $50 | $50 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $166 | $166 | $166 |
| Postpartum care only CPT 59430 • Maternity | $26 | $26 | $26 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $1,142 | $1,142 | $1,142 |
| Cesarean delivery only CPT 59514 • Maternity | $30 | $30 | $30 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $200 | $200 | $200 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $961 | $961 | $961 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $41 | $72 | $104 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $24 | $24 | $24 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $231 | $231 | $231 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $37 | $37 | $37 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $50 | $50 | $50 |
| Interactive complexity add-on CPT 90785 • Mental Health | $3 | $8 | $13 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $117 | $124 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $151 | $157 | $162 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $64 | $73 | $82 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $55 | $80 | $106 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $92 | $100 | $108 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $81 | $100 | $119 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $106 | $113 | $121 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $155 | $170 | $185 |