| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $74 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $105 | $105 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $93 | $93 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $110 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $139 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $112 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $391 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $8 | $8 | $8 |
| Lipid panel CPT 80061 • Laboratory | $11 | $11 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $13 | $13 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $24 | $24 | $24 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $11 | $11 | $11 |
| Hemoglobin A1c CPT 83036 • Laboratory | $7 | $7 | $7 |
| Iron serum CPT 83540 • Laboratory | $1 | $1 | $1 |
| Iron binding capacity CPT 83550 • Laboratory | $6 | $6 | $7 |
| 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 | $1 | $1 | $1 |
| 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 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $6 | $6 | $6 |
| 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 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $30 | $30 | $30 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $112 | $194 |
| Chorionic villus sampling CPT 59015 • 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 |
| External cephalic version CPT 59412 • Maternity | $99 | $99 | $99 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $30 | $30 | $30 |
| Cesarean delivery only CPT 59514 • 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 | $834 | $2,441 |