| Free thyroxine (T4) CPT 84439 • Laboratory | $15 | $15 | $15 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $27 | $27 | $27 |
| Complete blood count with differential CPT 85025 • Laboratory | $13 | $13 | $13 |
| Complete blood count automated CPT 85027 • Laboratory | $11 | $11 | $11 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $7 | $7 | $7 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $5 | $5 | $5 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $30 | $30 | $30 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $9 | $9 | $9 |
| TB skin test intradermal CPT 86580 • Laboratory | $11 | $11 | $11 |
| Blood typing ABO CPT 86900 • Laboratory | $5 | $5 | $5 |
| Blood typing Rh CPT 86901 • Laboratory | $13 | $13 | $13 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $14 | $14 | $14 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $40 | $40 | $40 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $40 | $40 | $40 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $56 | $56 | $56 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $222 | $222 | $222 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $511 | $511 | $511 |
| Chorionic villus sampling CPT 59015 • Maternity | $283 | $283 | $283 |
| Fetal non-stress test CPT 59025 • Maternity | $111 | $111 | $111 |
| Insertion cervical dilator CPT 59200 • Maternity | $194 | $194 | $194 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,818 | $1,818 | $1,818 |
| Vaginal delivery only CPT 59409 • Maternity | $999 | $999 | $999 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,364 | $1,364 | $1,364 |
| External cephalic version CPT 59412 • Maternity | $337 | $337 | $337 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $807 | $807 | $807 |
| Postpartum care only CPT 59430 • Maternity | $130 | $130 | $130 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,250 | $2,250 | $2,250 |
| Cesarean delivery only CPT 59514 • Maternity | $1,425 | $1,425 | $1,425 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,613 | $1,613 | $1,613 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,855 | $2,855 | $2,855 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $108 | $108 | $108 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $179 | $179 | $179 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $83 | $93 | $102 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $112 | $112 | $112 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $143 | $143 | $143 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $111 | $111 | $111 |
| Group psychotherapy CPT 90853 • Mental Health | $49 | $49 | $49 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $206 | $206 | $206 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $398 | $398 | $398 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $95 | $95 | $95 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $166 | $166 | $166 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $143 | $143 | $143 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $249 | $249 | $249 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $60 | $60 | $60 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $89 | $89 | $89 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $127 | $141 | $156 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $162 | $162 | $162 |
| Office visit established patient minimal CPT 99211 • Office Visits | $27 | $27 | $27 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $57 | $57 | $57 |