| 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 | $6 | $6 | $6 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $26 | $27 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $26 | $27 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $59 | $59 | $59 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $12 | $12 | $12 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $18 | $29 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $90 | $90 | $90 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $117 | $164 |
| Chorionic villus sampling CPT 59015 • Maternity | $30 | $76 | $122 |
| Fetal non-stress test CPT 59025 • Maternity | $25 | $37 | $46 |
| Insertion cervical dilator CPT 59200 • Maternity | $83 | $83 | $83 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $45 | $965 | $1,885 |
| Vaginal delivery only CPT 59409 • Maternity | $639 | $639 | $639 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $919 | $1,883 |
| External cephalic version CPT 59412 • Maternity | $81 | $81 | $81 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $807 | $807 | $807 |
| Postpartum care only CPT 59430 • Maternity | $209 | $209 | $209 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $40 | $963 | $1,885 |
| Cesarean delivery only CPT 59514 • Maternity | $721 | $721 | $721 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,036 | $1,036 | $1,036 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,885 | $3,292 | $3,995 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $91 | $91 | $91 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $119 | $119 | $119 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $62 | $99 | $136 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $71 | $71 | $71 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $29 | $48 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $16 | $16 | $16 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $143 | $163 | $184 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $168 | $199 | $262 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $92 | $92 | $92 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $102 | $102 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $59 | $94 | $129 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $88 | $102 | $115 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $146 | $165 | $184 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $144 | $144 | $144 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $150 | $150 | $150 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $81 | $82 | $82 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $90 | $110 | $130 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $157 | $157 | $157 |
| Group psychotherapy CPT 90853 • Mental Health | $67 | $72 | $77 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $110 | $110 | $110 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $114 | $159 | $243 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $121 | $121 | $121 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $336 | $336 | $336 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $394 | $394 | $394 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $109 | $110 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $157 | $158 | $160 |