| Blood typing Rh CPT 86901 • Laboratory | $4 | $4 | $4 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $11 | $11 | $11 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $33 | $33 | $33 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $33 | $33 | $33 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $16 | $16 | $16 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $16 | $16 | $16 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $154 | $426 | $650 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $50 | $478 | $650 |
| Chorionic villus sampling CPT 59015 • Maternity | $50 | $401 | $650 |
| Fetal non-stress test CPT 59025 • Maternity | $56 | $56 | $56 |
| Insertion cervical dilator CPT 59200 • Maternity | $136 | $452 | $650 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $475 | $2,232 | $3,989 |
| Vaginal delivery only CPT 59409 • Maternity | $475 | $799 | $1,570 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $475 | $815 | $1,999 |
| External cephalic version CPT 59412 • Maternity | $198 | $274 | $350 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,546 | $1,546 | $1,546 |
| Postpartum care only CPT 59430 • Maternity | $349 | $550 | $650 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $475 | $2,441 | $4,408 |
| Cesarean delivery only CPT 59514 • Maternity | $475 | $1,120 | $1,765 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $475 | $969 | $2,418 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $475 | $2,327 | $4,178 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $94 | $94 | $94 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $177 | $177 | $177 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $347 | $347 | $347 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $106 | $106 | $106 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $189 | $189 | $189 |
| Interactive complexity add-on CPT 90785 • Mental Health | $23 | $23 | $23 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $216 | $216 | $216 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $227 | $227 | $227 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $105 | $105 | $105 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $107 | $107 | $107 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $139 | $139 | $139 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $135 | $135 | $135 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $207 | $207 | $207 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $178 | $178 | $178 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $217 | $217 | $217 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $104 | $104 | $104 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $168 | $168 | $168 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $174 | $174 | $174 |
| Group psychotherapy CPT 90853 • Mental Health | $43 | $43 | $43 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $8 | $8 | $8 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $167 | $454 | $650 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $281 | $481 | $650 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $252 | $535 | $650 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $93 | $93 | $93 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $530 | $530 | $530 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $84 | $84 | $84 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $134 | $134 | $134 |
| EMG needle each extremity complete CPT 95886 • Neurology | $75 | $75 | $75 |