| 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 | $11 | $14 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $7 | $8 | $8 |
| Blood typing ABO CPT 86900 • Laboratory | $2 | $2 | $2 |
| 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 | $28 | $28 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $13 | $13 | $13 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $13 | $13 | $13 |
| 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 | $39 | $39 | $39 |
| 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 | $847 | $847 | $847 |
| External cephalic version CPT 59412 • Maternity | $99 | $99 | $99 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $996 | $996 | $996 |
| Postpartum care only CPT 59430 • Maternity | $258 | $258 | $258 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $30 | $30 | $30 |
| 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 | $978 | $1,926 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $104 | $104 | $104 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $119 | $119 | $119 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $145 | $149 | $154 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $30 | $30 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $78 | $78 | $78 |
| Interactive complexity add-on CPT 90785 • Mental Health | $6 | $12 | $18 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $153 | $172 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $152 | $175 | $197 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $87 | $87 | $87 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $90 | $90 | $90 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $129 | $129 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $98 | $108 | $119 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $97 | $97 | $97 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $123 | $136 | $149 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $181 | $181 | $181 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $62 | $72 | $81 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $112 | $131 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $136 | $143 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $44 | $44 | $44 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $6 | $6 | $6 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |