| 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 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $13 | $13 | $13 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $475 | $475 | $475 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $60 | $355 | $650 |
| Chorionic villus sampling CPT 59015 • Maternity | $60 | $355 | $650 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $27 | $27 |
| Insertion cervical dilator CPT 59200 • Maternity | $457 | $466 | $475 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $670 | $1,504 | $2,338 |
| Vaginal delivery only CPT 59409 • Maternity | $475 | $573 | $670 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $475 | $573 | $670 |
| External cephalic version CPT 59412 • Maternity | $99 | $278 | $457 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $996 | $996 | $996 |
| Postpartum care only CPT 59430 • Maternity | $475 | $475 | $475 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $670 | $1,624 | $2,578 |
| Cesarean delivery only CPT 59514 • Maternity | $670 | $777 | $884 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $650 | $660 | $670 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $670 | $1,556 | $2,441 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $103 | $103 | $103 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $76 | $76 | $76 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $153 | $153 | $153 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $43 | $43 | $43 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $49 | $49 | $49 |
| Interactive complexity add-on CPT 90785 • Mental Health | $25 | $25 | $25 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $162 | $162 | $162 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $162 | $162 | $162 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $78 | $78 | $78 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $76 | $76 | $76 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $129 | $129 | $129 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $144 | $144 | $144 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $220 | $220 | $220 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $190 | $190 | $190 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $132 | $132 | $132 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $110 | $110 | $110 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $178 | $178 | $178 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $185 | $185 | $185 |
| Group psychotherapy CPT 90853 • Mental Health | $77 | $77 | $77 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $9 | $9 | $9 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $457 | $466 | $475 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $457 | $466 | $475 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $475 | $573 | $670 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $595 | $595 | $595 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $678 | $678 | $678 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $207 | $207 | $207 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $291 | $291 | $291 |
| EMG needle each extremity complete CPT 95886 • Neurology | $154 | $154 | $154 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $164 | $164 | $164 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $211 | $211 | $211 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $250 | $250 | $250 |