| Hepatic function panel CPT 80076 • Laboratory | $7 | $7 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $13 | $13 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $24 | $24 | $24 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $10 | $10 | $11 |
| Iron serum CPT 83540 • Laboratory | $1 | $1 | $1 |
| Iron binding capacity CPT 83550 • Laboratory | $7 | $7 | $7 |
| 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 | $1 | $1 | $1 |
| 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 | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $7 | $7 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Chorionic villus sampling CPT 59015 • Maternity | $151 | $151 | $151 |
| Fetal non-stress test CPT 59025 • Maternity | $46 | $46 | $46 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $30 | $30 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • 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 | $30 | $1,236 | $2,441 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $154 | $154 | $154 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $37 | $43 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $32 | $57 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $4 | $5 | $6 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $75 | $143 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $83 | $155 | $191 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $60 | $82 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $40 | $81 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $95 | $118 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $50 | $88 | $116 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $110 | $147 | $184 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $60 | $104 | $144 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $95 | $136 | $176 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $4 | $57 | $96 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $95 | $132 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $60 | $120 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $40 | $53 | $66 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |