| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $7 | $7 | $7 |
| Complete blood count with differential CPT 85025 • Laboratory | $6 | $6 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $1 | $1 | $1 |
| 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 | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| 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 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $10 | $13 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Fetal non-stress test CPT 59025 • Maternity | $46 | $46 | $46 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $30 | $30 | $30 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $30 | $30 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • 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 detailed fetal anatomy CPT 76811 • Maternity | $154 | $154 | $154 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $30 | $30 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $49 | $66 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $5 | $5 | $6 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $162 | $177 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $191 | $191 | $191 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $92 | $92 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $102 | $102 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $129 | $129 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $86 | $101 | $116 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $157 | $157 | $157 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $108 | $126 | $144 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $176 | $176 | $176 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $95 | $95 | $96 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $127 | $139 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $150 | $150 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $77 | $77 | $77 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $134 | $134 | $134 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $367 | $367 | $367 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $111 | $111 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $161 | $161 | $161 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $90 | $90 | $90 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $22 | $22 | $22 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $78 | $106 | $134 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $175 | $175 | $175 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $285 | $285 | $285 |