| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $93 | $93 | $93 |
| Ultrasound transvaginal CPT 76830 • Imaging | $93 | $104 | $114 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $93 | $93 | $93 |
| Screening mammography bilateral CPT 77067 • Imaging | $123 | $123 | $123 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $1,164 | $1,164 | $1,164 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $9 | $9 | $9 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $6 | $6 | $6 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $11 | $11 | $11 |
| Complete blood count with differential CPT 85025 • Laboratory | $5 | $5 | $5 |
| TB skin test intradermal CPT 86580 • Laboratory | $5 | $5 | $5 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $8 | $8 | $8 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $98 | $4,671 | $13,476 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $57 | $152 | $266 |
| Chorionic villus sampling CPT 59015 • Maternity | $57 | $198 | $438 |
| Fetal non-stress test CPT 59025 • Maternity | $32 | $73 | $132 |
| Insertion cervical dilator CPT 59200 • Maternity | $57 | $106 | $132 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $57 | $359 | $661 |
| Vaginal delivery only CPT 59409 • Maternity | $57 | $659 | $1,262 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $57 | $359 | $661 |
| External cephalic version CPT 59412 • Maternity | $57 | $1,351 | $2,735 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $57 | $359 | $661 |
| Postpartum care only CPT 59430 • Maternity | $57 | $359 | $661 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $57 | $359 | $661 |
| Cesarean delivery only CPT 59514 • Maternity | $57 | $359 | $661 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $57 | $359 | $661 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $57 | $359 | $661 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $93 | $93 | $93 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $93 | $93 | $93 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $138 | $138 | $138 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $41 | $41 | $41 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $158 | $158 | $158 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $67 | $67 | $67 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $438 | $6,909 | $19,682 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $57 | $106 | $132 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $57 | $101 | $132 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $401 | $401 | $401 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $449 | $449 | $449 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $58 | $58 | $58 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $56 | $56 | $56 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $165 | $165 | $165 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $191 | $191 | $191 |
| Office visit established patient minimal CPT 99211 • Office Visits | $17 | $17 | $17 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $38 | $38 | $38 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $70 | $70 | $70 |