| Urine culture bacterial colony count CPT 87086 • Laboratory | $5 | $5 | $5 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $21 | $21 | $21 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $21 | $21 | $21 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $10 | $10 | $10 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $10 | $10 | $10 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $119 | $119 | $119 |
| Fetal non-stress test CPT 59025 • Maternity | $49 | $49 | $49 |
| Insertion cervical dilator CPT 59200 • Maternity | $44 | $44 | $44 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,760 | $1,760 | $1,760 |
| Vaginal delivery only CPT 59409 • Maternity | $795 | $795 | $795 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,054 | $1,054 | $1,054 |
| External cephalic version CPT 59412 • Maternity | $101 | $101 | $101 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,037 | $1,037 | $1,037 |
| Postpartum care only CPT 59430 • Maternity | $272 | $272 | $272 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $1,760 | $1,760 | $1,760 |
| Cesarean delivery only CPT 59514 • Maternity | $894 | $894 | $894 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,291 | $1,291 | $1,291 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,760 | $1,760 | $1,760 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $77 | $77 | $77 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $89 | $89 | $89 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $55 | $55 | $55 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $53 | $53 | $53 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $61 | $61 | $61 |
| Interactive complexity add-on CPT 90785 • Mental Health | $20 | $20 | $20 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $153 | $167 | $180 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $180 | $180 | $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 | $80 | $80 | $80 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $101 | $101 | $101 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $113 | $113 | $113 |
| 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 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $87 | $87 | $87 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $121 | $121 | $121 |
| Group psychotherapy CPT 90853 • Mental Health | $52 | $52 | $52 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $111 | $111 | $111 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $118 | $118 | $118 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $117 | $117 | $117 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $297 | $297 | $297 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $348 | $348 | $348 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $128 | $128 | $128 |
| EMG needle each extremity complete CPT 95886 • Neurology | $78 | $78 | $78 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $71 | $71 | $71 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $88 | $88 | $88 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $106 | $106 | $106 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $138 | $138 | $138 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $224 | $224 | $224 |