| Free thyroxine (T4) CPT 84439 • Laboratory | $5 | $6 | $7 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $8 | $11 | $13 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $5 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $3 | $3 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $1 | $1 | $1 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $3 | $3 | $3 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $4 | $4 |
| Blood typing ABO CPT 86900 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $6 | $6 | $6 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $18 | $22 | $26 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $22 | $26 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $22 | $22 | $22 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Fetal non-stress test CPT 59025 • Maternity | $39 | $39 | $39 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,620 | $1,620 | $1,620 |
| Vaginal delivery only CPT 59409 • Maternity | $781 | $781 | $781 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,008 | $1,008 | $1,008 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $944 | $944 | $944 |
| Postpartum care only CPT 59430 • Maternity | $211 | $211 | $211 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,372 | $2,372 | $2,372 |
| Cesarean delivery only CPT 59514 • Maternity | $887 | $887 | $887 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $82 | $82 | $82 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $91 | $91 | $91 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $66 | $66 | $66 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $57 | $57 | $57 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $74 | $74 | $74 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $123 | $123 | $123 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $157 | $157 | $157 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $52 | $52 | $52 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $54 | $54 | $54 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $77 | $77 | $77 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $101 | $101 | $101 |
| Group psychotherapy CPT 90853 • Mental Health | $18 | $18 | $18 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $81 | $81 | $81 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $132 | $132 | $132 |
| EMG needle each extremity complete CPT 95886 • Neurology | $76 | $76 | $76 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $91 | $91 | $91 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $66 | $66 | $66 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $143 | $143 | $143 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $67 | $67 | $67 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $99 | $99 | $99 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $176 | $176 | $176 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $188 | $188 | $188 |
| Office visit established patient minimal CPT 99211 • Office Visits | $23 | $23 | $23 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $46 | $46 | $46 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $86 | $86 | $86 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $114 | $114 | $114 |