| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $11 | $11 | $11 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $15 | $15 | $15 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $7 | $7 | $8 |
| 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 | $30 | $30 | $30 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $56 | $62 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $14 | $14 | $14 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $14 | $14 | $14 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $115 | $115 | $115 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Chorionic villus sampling CPT 59015 • Maternity | $130 | $130 | $130 |
| Fetal non-stress test CPT 59025 • Maternity | $47 | $47 | $47 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $30 | $30 | $30 |
| Vaginal delivery only CPT 59409 • Maternity | $804 | $804 | $804 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $30 | $30 |
| External cephalic version CPT 59412 • Maternity | $101 | $101 | $101 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,002 | $1,002 | $1,002 |
| Postpartum care only CPT 59430 • Maternity | $252 | $252 | $252 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $30 | $30 | $30 |
| Cesarean delivery only CPT 59514 • Maternity | $909 | $909 | $909 |
| 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 | $90 | $90 | $90 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $103 | $103 | $103 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $72 | $72 | $72 |
| Interactive complexity add-on CPT 90785 • Mental Health | $3 | $3 | $3 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $146 | $146 | $146 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $146 | $146 | $146 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $75 | $75 | $75 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $81 | $81 | $81 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $81 | $81 | $81 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $101 | $101 | $101 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $105 | $105 | $105 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $136 | $136 | $136 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $146 | $146 | $146 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $62 | $62 | $62 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $91 | $91 | $91 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $108 | $108 | $108 |
| Group psychotherapy CPT 90853 • Mental Health | $44 | $44 | $44 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $152 | $152 | $152 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $159 | $159 | $159 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $300 | $300 | $300 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $428 | $428 | $428 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $115 | $115 | $115 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $33 | $33 | $33 |