| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $17 | $17 | $17 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $17 | $17 | $17 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $10 | $10 | $10 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $10 | $10 | $10 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $143 | $355 | $461 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $150 | $555 | $757 |
| Chorionic villus sampling CPT 59015 • Maternity | $98 | $377 | $575 |
| Fetal non-stress test CPT 59025 • Maternity | $34 | $129 | $177 |
| Insertion cervical dilator CPT 59200 • Maternity | $78 | $201 | $263 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,807 | $5,768 | $7,748 |
| Vaginal delivery only CPT 59409 • Maternity | $944 | $2,342 | $3,041 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,278 | $2,922 | $3,877 |
| External cephalic version CPT 59412 • Maternity | $121 | $298 | $386 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,409 | $2,471 | $3,002 |
| Postpartum care only CPT 59430 • Maternity | $133 | $498 | $680 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $3,190 | $6,594 | $8,589 |
| Cesarean delivery only CPT 59514 • Maternity | $1,605 | $2,817 | $3,423 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,000 | $3,361 | $4,703 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $3,008 | $6,244 | $8,141 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $208 | $366 | $446 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $105 | $377 | $514 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $105 | $355 | $663 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $122 | $190 | $305 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $109 | $263 | $352 |
| Interactive complexity add-on CPT 90785 • Mental Health | $17 | $17 | $17 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $203 | $203 | $203 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $200 | $200 | $200 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $81 | $81 | $81 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $85 | $85 | $85 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $107 | $107 | $107 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $107 | $107 | $107 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $157 | $157 | $157 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $127 | $127 | $127 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $178 | $178 | $178 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $76 | $76 | $76 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $115 | $115 | $115 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $121 | $121 | $121 |
| Group psychotherapy CPT 90853 • Mental Health | $28 | $28 | $28 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $6 | $6 | $6 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $47 | $405 | $583 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $141 | $359 | $484 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $130 | $351 | $461 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $400 | $400 | $400 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $536 | $536 | $536 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $132 | $132 | $132 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $94 | $94 | $94 |
| EMG needle each extremity complete CPT 95886 • Neurology | $113 | $113 | $113 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $61 | $61 | $61 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $76 | $76 | $76 |