| Complete blood count automated CPT 85027 • Laboratory | $80 | $80 | $80 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $80 | $80 | $80 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $80 | $80 | $80 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $80 | $80 | $80 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $80 | $80 | $80 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $80 | $80 | $80 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $80 | $80 | $80 |
| TB skin test intradermal CPT 86580 • Laboratory | $80 | $80 | $80 |
| Blood typing ABO CPT 86900 • Laboratory | $80 | $80 | $80 |
| Blood typing Rh CPT 86901 • Laboratory | $80 | $80 | $80 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $80 | $80 | $80 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $80 | $80 | $80 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $80 | $80 | $80 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $80 | $80 | $80 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $80 | $80 | $80 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $80 | $80 | $80 |
| Chorionic villus sampling CPT 59015 • Maternity | $80 | $80 | $80 |
| Fetal non-stress test CPT 59025 • Maternity | $80 | $80 | $80 |
| Insertion cervical dilator CPT 59200 • Maternity | $80 | $80 | $80 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $80 | $80 | $80 |
| Vaginal delivery only CPT 59409 • Maternity | $80 | $80 | $80 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $80 | $80 | $80 |
| External cephalic version CPT 59412 • Maternity | $80 | $80 | $80 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $80 | $80 | $80 |
| Postpartum care only CPT 59430 • Maternity | $80 | $80 | $80 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $80 | $80 | $80 |
| Cesarean delivery only CPT 59514 • Maternity | $80 | $80 | $80 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $80 | $80 | $80 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $80 | $80 | $80 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $80 | $80 | $80 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $80 | $80 | $80 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $80 | $80 | $80 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $80 | $80 | $80 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $80 | $80 | $80 |
| Interactive complexity add-on CPT 90785 • Mental Health | $80 | $80 | $80 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $80 | $80 | $80 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $80 | $80 | $80 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $80 | $80 | $80 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $80 | $80 | $80 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $80 | $80 | $80 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $80 | $80 | $80 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $80 | $80 | $80 |
| Group psychotherapy CPT 90853 • Mental Health | $80 | $80 | $80 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $80 | $80 | $80 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $80 | $80 | $80 |