| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $7 | $10 | $13 |
| Complete blood count with differential CPT 85025 • Laboratory | $6 | $6 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $1 | $3 | $5 |
| 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 | $1 | $2 | $4 |
| 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 | $7 | $8 |
| 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 | $7 | $7 | $7 |
| 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 | $27 | $37 | $46 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| 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 | $533 | $1,035 |
| 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 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 | $1,236 | $2,441 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $103 | $103 | $103 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $119 | $119 | $119 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $154 | $154 | $154 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $51 | $71 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $82 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $5 | $7 | $11 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $143 | $167 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $159 | $180 | $191 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $54 | $80 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $72 | $92 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $81 | $107 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $71 | $91 | $116 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $138 | $139 | $140 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $94 | $116 | $144 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $134 | $155 | $176 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $50 | $76 | $96 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $95 | $124 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $116 | $139 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $40 | $49 | $58 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |