| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $11 | $11 | $11 |
| Complete blood count with differential CPT 85025 • Laboratory | $5 | $5 | $5 |
| 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 | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $4 |
| 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 | $3 | $3 | $3 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $15 | $15 | $15 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $15 | $15 | $15 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $32 | $32 | $32 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $7 | $7 |
| Fetal non-stress test CPT 59025 • Maternity | $29 | $29 | $29 |
| Insertion cervical dilator CPT 59200 • Maternity | $55 | $55 | $55 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,861 | $1,861 | $1,861 |
| Vaginal delivery only CPT 59409 • Maternity | $649 | $649 | $649 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,031 | $1,031 | $1,031 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $250 | $250 | $250 |
| Postpartum care only CPT 59430 • Maternity | $168 | $168 | $168 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,212 | $2,212 | $2,212 |
| Cesarean delivery only CPT 59514 • Maternity | $148 | $148 | $148 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,366 | $1,366 | $1,366 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,429 | $2,429 | $2,429 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $38 | $38 | $38 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $110 | $110 | $110 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $170 | $170 | $170 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $25 | $25 | $25 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $83 | $83 | $83 |
| Interactive complexity add-on CPT 90785 • Mental Health | $13 | $13 | $13 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $125 | $125 | $125 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $106 | $106 | $106 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $78 | $78 | $78 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $66 | $66 | $66 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $82 | $82 | $82 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $84 | $84 | $84 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $121 | $121 | $121 |
| 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 | $29 | $29 | $29 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $62 | $62 | $62 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $379 | $379 | $379 |
| EMG needle each extremity complete CPT 95886 • Neurology | $104 | $104 | $104 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $131 | $131 | $131 |