| 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 | $4 | $4 | $4 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $18 | $18 | $18 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $18 | $18 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $26 | $26 | $26 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Fetal non-stress test CPT 59025 • Maternity | $29 | $29 | $29 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $2,700 | $2,700 | $2,700 |
| Vaginal delivery only CPT 59409 • Maternity | $951 | $951 | $951 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $610 | $610 | $610 |
| Postpartum care only CPT 59430 • Maternity | $339 | $339 | $339 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $3,749 | $3,749 | $3,749 |
| Cesarean delivery only CPT 59514 • Maternity | $1,342 | $1,342 | $1,342 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $85 | $85 | $85 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $73 | $73 | $73 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $31 | $31 | $31 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $22 | $22 | $22 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $89 | $89 | $89 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $130 | $130 | $130 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $44 | $44 | $44 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $56 | $56 | $56 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $58 | $58 | $58 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $87 | $87 | $87 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $72 | $72 | $72 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $96 | $96 | $96 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $90 | $90 | $90 |
| EMG needle each extremity complete CPT 95886 • Neurology | $141 | $141 | $141 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $94 | $94 | $94 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $201 | $201 | $201 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $148 | $148 | $148 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $432 | $432 | $432 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $53 | $53 | $53 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $103 | $103 | $103 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $169 | $169 | $169 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $359 | $359 | $359 |
| Office visit established patient minimal CPT 99211 • Office Visits | $20 | $20 | $20 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $56 | $56 | $56 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $55 | $55 | $55 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $92 | $92 | $92 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $102 | $102 | $102 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $76 | $76 | $76 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $126 | $126 | $126 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $186 | $186 | $186 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $36 | $36 | $36 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $66 | $66 | $66 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $93 | $93 | $93 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $67 | $67 | $67 |