| TB skin test intradermal CPT 86580 • Laboratory | $5 | $6 | $8 |
| Blood typing ABO CPT 86900 • Laboratory | $5 | $5 | $5 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $5 | $5 | $5 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $5 | $10 | $15 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $20 | $23 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $28 | $36 | $44 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $7 | $11 | $13 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $151 | $151 | $151 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $234 | $234 | $234 |
| Chorionic villus sampling CPT 59015 • Maternity | $176 | $176 | $176 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $31 | $35 |
| Insertion cervical dilator CPT 59200 • Maternity | $89 | $89 | $89 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,861 | $1,912 | $1,964 |
| Vaginal delivery only CPT 59409 • Maternity | $649 | $767 | $885 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,017 | $1,017 | $1,017 |
| External cephalic version CPT 59412 • Maternity | $119 | $119 | $119 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $861 | $861 | $861 |
| Postpartum care only CPT 59430 • Maternity | $158 | $187 | $216 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,212 | $2,215 | $2,218 |
| Cesarean delivery only CPT 59514 • Maternity | $1,046 | $1,046 | $1,046 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,226 | $1,226 | $1,226 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,055 | $2,055 | $2,055 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $49 | $72 | $95 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $49 | $79 | $110 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $130 | $150 | $170 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $66 | $76 | $87 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $37 | $53 | $70 |
| Interactive complexity add-on CPT 90785 • Mental Health | $5 | $7 | $8 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $106 | $138 | $170 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $138 | $152 | $167 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $56 | $63 | $69 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $47 | $59 | $71 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $78 | $85 | $92 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $76 | $77 | $77 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $123 | $129 | $135 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $92 | $108 | $123 |
| 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 | $84 | $89 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $76 | $93 | $110 |
| Group psychotherapy CPT 90853 • Mental Health | $22 | $27 | $31 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $3 | $4 | $5 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $85 | $85 | $85 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $146 | $146 | $146 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $134 | $134 | $134 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $56 | $56 | $56 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $181 | $280 | $379 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $36 | $36 | $36 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $113 | $113 | $113 |