| 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 | $1 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $6 | $6 | $6 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $26 | $27 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $26 | $38 | $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 | $112 | $112 | $112 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $162 | $162 | $162 |
| Chorionic villus sampling CPT 59015 • Maternity | $126 | $126 | $126 |
| Fetal non-stress test CPT 59025 • Maternity | $39 | $39 | $39 |
| Insertion cervical dilator CPT 59200 • Maternity | $81 | $81 | $81 |
| Vaginal delivery only CPT 59409 • Maternity | $645 | $714 | $783 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $871 | $871 | $871 |
| 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 | $2,578 | $2,578 | $2,578 |
| Cesarean delivery only CPT 59514 • Maternity | $884 | $884 | $884 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,082 | $1,082 | $1,082 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,037 | $2,037 | $2,037 |
| 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 | $167 | $167 | $167 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $27 | $51 | $76 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $49 | $68 | $87 |
| Interactive complexity add-on CPT 90785 • Mental Health | $14 | $15 | $18 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $166 | $175 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $159 | $177 | $190 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $72 | $79 | $88 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $70 | $84 | $109 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $81 | $97 | $110 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $84 | $86 | $89 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $121 | $130 | $140 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $94 | $134 | $191 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $114 | $141 | $168 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $67 | $70 | $71 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $97 | $105 | $112 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $101 | $126 | $162 |
| Group psychotherapy CPT 90853 • Mental Health | $40 | $53 | $66 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $123 | $123 | $123 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $121 | $121 | $121 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $123 | $128 | $133 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $310 | $336 | $363 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $429 | $429 | $429 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $105 | $108 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $150 | $150 | $150 |