| Heterophile antibodies screen CPT 86308 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $6 | $8 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $7 | $7 | $7 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $11 | $11 | $11 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $9 | $11 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $105 | $105 | $105 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $195 | $195 | $195 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $37 | $46 |
| Insertion cervical dilator CPT 59200 • Maternity | $104 | $104 | $104 |
| Vaginal delivery only CPT 59409 • Maternity | $675 | $729 | $784 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,036 | $1,036 | $1,036 |
| External cephalic version CPT 59412 • Maternity | $90 | $90 | $90 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $694 | $694 | $694 |
| Postpartum care only CPT 59430 • Maternity | $120 | $120 | $120 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,578 | $2,578 | $2,578 |
| Cesarean delivery only CPT 59514 • Maternity | $805 | $805 | $805 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $40 | $656 | $1,273 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,441 | $2,441 | $2,441 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $77 | $77 | $77 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $89 | $89 | $89 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $113 | $113 | $113 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $43 | $49 | $54 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $62 | $72 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $4 | $4 | $4 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $124 | $153 | $182 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $124 | $124 | $124 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $68 | $73 | $78 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $78 | $97 | $115 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $157 | $157 | $157 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $105 | $105 | $106 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $124 | $124 | $124 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $62 | $67 | $72 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $78 | $96 | $113 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $78 | $85 | $91 |
| Group psychotherapy CPT 90853 • Mental Health | $59 | $59 | $59 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $122 | $122 | $122 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $132 | $132 | $132 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $109 | $121 | $134 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $194 | $280 | $367 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $213 | $213 | $213 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $68 | $90 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $161 | $161 | $161 |
| EMG needle each extremity complete CPT 95886 • Neurology | $73 | $73 | $73 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $79 | $84 | $90 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $98 | $105 | $112 |