| Iron binding capacity CPT 83550 • Laboratory | $2 | $2 | $2 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $2 | $2 | $2 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $1 | $1 | $1 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $2 | $2 | $2 |
| Complete blood count with differential CPT 85025 • Laboratory | $1 | $1 | $1 |
| Complete blood count automated CPT 85027 • Laboratory | $2 | $2 | $2 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $1 | $1 | $1 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $0 | $0 | $0 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $1 | $1 | $1 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $7 | $7 | $7 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $10 | $10 | $10 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $1 | $1 | $1 |
| TB skin test intradermal CPT 86580 • Laboratory | $1 | $1 | $1 |
| Blood typing ABO CPT 86900 • Laboratory | $1 | $1 | $1 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $1 | $1 | $1 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $20 | $20 | $20 |
| Gonorrhea nucleic acid amplification CPT 87591 • 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 | $5 | $5 | $5 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $2 | $2 | $2 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $63 | $63 | $63 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $24 | $24 | $24 |
| Chorionic villus sampling CPT 59015 • Maternity | $77 | $77 | $77 |
| Fetal non-stress test CPT 59025 • Maternity | $23 | $23 | $23 |
| Insertion cervical dilator CPT 59200 • Maternity | $46 | $46 | $46 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $44 | $44 | $44 |
| Vaginal delivery only CPT 59409 • Maternity | $634 | $634 | $634 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $44 | $44 | $44 |
| External cephalic version CPT 59412 • Maternity | $44 | $44 | $44 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $835 | $835 | $835 |
| Postpartum care only CPT 59430 • Maternity | $22 | $22 | $22 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $380 | $380 | $380 |
| Cesarean delivery only CPT 59514 • Maternity | $44 | $44 | $44 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $44 | $44 | $44 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $950 | $950 | $950 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $104 | $104 | $104 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $21 | $21 | $21 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $26 | $26 | $26 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $12 | $12 | $12 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $35 | $35 | $35 |
| Interactive complexity add-on CPT 90785 • Mental Health | $17 | $17 | $17 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $153 | $153 | $153 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $152 | $152 | $152 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $76 | $76 | $76 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $161 | $161 | $161 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $89 | $89 | $89 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $106 | $106 | $106 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $155 | $155 | $155 |