| Complete blood count with differential CPT 85025 • Laboratory | $3 | $3 | $3 |
| Complete blood count automated CPT 85027 • Laboratory | $3 | $3 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $2 | $2 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $1 | $1 | $1 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $5 | $5 | $5 |
| 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 | $15 | $15 | $15 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $18 | $18 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $28 | $28 | $28 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $105 | $105 | $105 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $27 | $27 |
| Insertion cervical dilator CPT 59200 • Maternity | $53 | $53 | $53 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,861 | $1,861 | $1,861 |
| Vaginal delivery only CPT 59409 • Maternity | $689 | $689 | $689 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $932 | $932 | $932 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $742 | $742 | $742 |
| Postpartum care only CPT 59430 • Maternity | $229 | $229 | $229 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,212 | $2,212 | $2,212 |
| Cesarean delivery only CPT 59514 • Maternity | $781 | $781 | $781 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,083 | $1,083 | $1,083 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,055 | $2,055 | $2,055 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $95 | $95 | $95 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $47 | $47 | $47 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $170 | $170 | $170 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $24 | $24 | $24 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $27 | $27 | $27 |
| Interactive complexity add-on CPT 90785 • Mental Health | $8 | $8 | $8 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $106 | $106 | $106 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $167 | $167 | $167 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $69 | $69 | $69 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $71 | $71 | $71 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $78 | $78 | $78 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $76 | $76 | $76 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $123 | $123 | $123 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $92 | $92 | $92 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $145 | $145 | $145 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $46 | $46 | $46 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $78 | $78 | $78 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $76 | $76 | $76 |
| Group psychotherapy CPT 90853 • Mental Health | $22 | $22 | $22 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $3 | $3 | $3 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $366 | $366 | $366 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $379 | $379 | $379 |
| EMG needle each extremity complete CPT 95886 • Neurology | $69 | $69 | $69 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $128 | $128 | $128 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $97 | $97 | $97 |