| Urine culture bacterial colony count CPT 87086 • Laboratory | $3 | $3 | $3 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $12 | $12 | $12 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $12 | $12 | $12 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $22 | $22 | $22 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $14 | $14 | $14 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $7 | $7 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $241 | $241 | $241 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $427 | $427 | $427 |
| Chorionic villus sampling CPT 59015 • Maternity | $277 | $277 | $277 |
| Fetal non-stress test CPT 59025 • Maternity | $35 | $35 | $35 |
| Insertion cervical dilator CPT 59200 • Maternity | $176 | $176 | $176 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $3,863 | $3,863 | $3,863 |
| Vaginal delivery only CPT 59409 • Maternity | $1,499 | $1,499 | $1,499 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,924 | $1,924 | $1,924 |
| External cephalic version CPT 59412 • Maternity | $218 | $218 | $218 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,689 | $1,689 | $1,689 |
| Postpartum care only CPT 59430 • Maternity | $292 | $292 | $292 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $4,317 | $4,317 | $4,317 |
| Cesarean delivery only CPT 59514 • Maternity | $1,705 | $1,705 | $1,705 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $2,360 | $2,360 | $2,360 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $4,102 | $4,102 | $4,102 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $127 | $127 | $127 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $145 | $145 | $145 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $99 | $99 | $99 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $87 | $87 | $87 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $60 | $60 | $60 |
| Interactive complexity add-on CPT 90785 • Mental Health | $25 | $25 | $25 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $233 | $233 | $233 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $257 | $257 | $257 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $114 | $114 | $114 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $107 | $107 | $107 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $152 | $152 | $152 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $149 | $149 | $149 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $205 | $205 | $205 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $177 | $177 | $177 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $236 | $236 | $236 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $103 | $103 | $103 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $166 | $166 | $166 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $172 | $172 | $172 |
| Group psychotherapy CPT 90853 • Mental Health | $45 | $45 | $45 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $8 | $8 | $8 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $264 | $264 | $264 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $229 | $229 | $229 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $271 | $271 | $271 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $589 | $589 | $589 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $603 | $603 | $603 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $109 | $109 | $109 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $143 | $143 | $143 |
| EMG needle each extremity complete CPT 95886 • Neurology | $157 | $157 | $157 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $67 | $67 | $67 |