| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $2 | $2 | $2 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $20 | $23 | $27 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $1 | $1 | $1 |
| Creatinine urine CPT 82570 • Laboratory | $4 | $4 | $4 |
| Ferritin CPT 82728 • Laboratory | $2 | $2 | $2 |
| IgA IgD IgG IgM each CPT 82784 • Laboratory | $8 | $8 | $8 |
| Glucose quantitative blood CPT 82947 • Laboratory | $3 | $3 | $3 |
| Hemoglobin A1c CPT 83036 • Laboratory | $9 | $9 | $9 |
| Iron serum CPT 83540 • Laboratory | $6 | $6 | $6 |
| Iron binding capacity CPT 83550 • Laboratory | $3 | $5 | $8 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $14 | $14 | $14 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $8 | $8 | $8 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $7 | $11 | $15 |
| Complete blood count with differential CPT 85025 • Laboratory | $7 | $7 | $7 |
| Complete blood count automated CPT 85027 • Laboratory | $6 | $6 | $6 |
| 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 | $4 | $4 | $4 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $12 | $12 | $12 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $6 | $7 | $7 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $7 | $7 | $7 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $23 | $23 | $23 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $14 | $14 | $14 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $6 | $6 | $6 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $30 | $30 | $30 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $129 | $228 |
| Fetal non-stress test CPT 59025 • Maternity | $38 | $42 | $46 |
| 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 | $30 | $30 | $30 |
| External cephalic version CPT 59412 • Maternity | $30 | $30 | $30 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $917 | $917 | $917 |
| Postpartum care only CPT 59430 • Maternity | $217 | $217 | $217 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $1,950 | $1,950 | $1,950 |
| Cesarean delivery only CPT 59514 • Maternity | $30 | $30 | $30 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $30 | $30 | $30 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $104 | $104 | $104 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $30 | $30 | $30 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $43 | $43 | $43 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $95 | $95 | $95 |
| Interactive complexity add-on CPT 90785 • Mental Health | $3 | $6 | $12 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $158 | $200 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $151 | $154 | $159 |