| Glucose quantitative blood CPT 82947 • Laboratory | $17 | $17 | $17 |
| Hemoglobin A1c CPT 83036 • Laboratory | $24 | $24 | $24 |
| Iron serum CPT 83540 • Laboratory | $27 | $27 | $27 |
| Iron binding capacity CPT 83550 • Laboratory | $32 | $32 | $32 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $25 | $25 | $25 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $49 | $49 | $49 |
| Complete blood count with differential CPT 85025 • Laboratory | $26 | $26 | $26 |
| Complete blood count automated CPT 85027 • Laboratory | $24 | $24 | $24 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $8 | $8 | $8 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $13 | $13 | $13 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $21 | $21 | $21 |
| TB skin test intradermal CPT 86580 • Laboratory | $9 | $9 | $9 |
| Blood typing ABO CPT 86900 • Laboratory | $7 | $7 | $7 |
| Blood typing Rh CPT 86901 • Laboratory | $8 | $8 | $8 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $21 | $21 | $21 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $68 | $68 | $68 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $271 | $271 | $271 |
| Chorionic villus sampling CPT 59015 • Maternity | $203 | $203 | $203 |
| Fetal non-stress test CPT 59025 • Maternity | $68 | $68 | $68 |
| Insertion cervical dilator CPT 59200 • Maternity | $162 | $162 | $162 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,354 | $1,354 | $1,354 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $846 | $846 | $846 |
| External cephalic version CPT 59412 • Maternity | $237 | $237 | $237 |
| Postpartum care only CPT 59430 • Maternity | $135 | $135 | $135 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $1,693 | $1,693 | $1,693 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,185 | $1,185 | $1,185 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $179 | $179 | $179 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $122 | $122 | $122 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $2 | $2 | $2 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $2 | $2 | $2 |
| Group psychotherapy CPT 90853 • Mental Health | $33 | $33 | $33 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $110 | $110 | $110 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $188 | $188 | $188 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $112 | $112 | $112 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $123 | $123 | $123 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $94 | $94 | $94 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $133 | $133 | $133 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $60 | $60 | $60 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $85 | $85 | $85 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $112 | $112 | $112 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $150 | $150 | $150 |
| Office visit established patient minimal CPT 99211 • Office Visits | $30 | $30 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $35 | $35 | $35 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $50 | $50 | $50 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $90 | $90 | $90 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $125 | $125 | $125 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $135 | $135 | $135 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $106 | $106 | $106 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $134 | $134 | $134 |