| Iron serum CPT 83540 • Laboratory | $5 | $5 | $5 |
| Iron binding capacity CPT 83550 • Laboratory | $7 | $7 | $7 |
| Complete blood count with differential CPT 85025 • Laboratory | $6 | $6 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $5 | $5 | $5 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $15 | $15 | $15 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $28 | $28 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $3 | $8 | $13 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Fetal non-stress test CPT 59025 • Maternity | $23 | $31 | $39 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $33 | $36 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,967 | $1,967 | $1,967 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $451 | $872 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $30 | $30 | $30 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,056 | $2,056 | $2,056 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $154 | $154 | $154 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $27 | $29 | $30 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $82 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $16 | $16 | $16 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $154 | $154 | $154 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $170 | $170 | $171 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $75 | $75 | $75 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $77 | $77 | $77 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $83 | $91 | $100 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $104 | $114 | $125 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $149 | $149 | $149 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $128 | $128 | $129 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $156 | $156 | $156 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $63 | $69 | $75 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $79 | $92 | $106 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $109 | $109 | $109 |
| Group psychotherapy CPT 90853 • Mental Health | $36 | $36 | $36 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $7 | $7 | $7 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $65 | $100 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $118 | $118 | $118 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $360 | $360 | $360 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $109 | $109 | $109 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $157 | $157 | $157 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $88 | $88 | $88 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $109 | $109 | $109 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $76 | $104 | $131 |