| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $7 | $7 | $7 |
| Complete blood count with differential CPT 85025 • Laboratory | $6 | $6 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $5 | $5 | $5 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $13 | $14 | $14 |
| TB skin test intradermal CPT 86580 • Laboratory | $7 | $7 | $7 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $6 | $6 | $6 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $26 | $26 | $26 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $12 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $30 | $30 | $30 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $35 | $43 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $2,338 | $2,338 | $2,338 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $926 | $926 | $926 |
| External cephalic version CPT 59412 • Maternity | $99 | $99 | $99 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,578 | $2,578 | $2,578 |
| Cesarean delivery only CPT 59514 • Maternity | $30 | $30 | $30 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $651 | $1,272 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,013 | $2,013 | $2,013 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $119 | $119 | $119 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $145 | $145 | $145 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $51 | $71 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $82 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $5 | $9 | $14 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $128 | $163 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $129 | $154 | $167 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $50 | $60 | $78 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $58 | $68 | $76 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $81 | $113 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $84 | $97 | $115 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $106 | $118 | $128 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $111 | $126 | $144 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $101 | $114 | $132 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $50 | $80 | $96 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $71 | $111 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $81 | $117 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $21 | $46 | $77 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $122 | $122 | $122 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $341 | $341 | $341 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $109 | $109 | $109 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $158 | $158 | $158 |