| Blood typing Rh CPT 86901 • Laboratory | $4 | $4 | $4 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $5 | $5 | $5 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $23 | $23 | $23 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $23 | $23 | $23 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $5 | $5 | $5 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $5 | $5 | $5 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $87 | $92 | $96 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $245 | $245 | $245 |
| Chorionic villus sampling CPT 59015 • Maternity | $180 | $180 | $180 |
| Fetal non-stress test CPT 59025 • Maternity | $47 | $47 | $47 |
| Insertion cervical dilator CPT 59200 • Maternity | $48 | $70 | $92 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,850 | $1,850 | $1,850 |
| Vaginal delivery only CPT 59409 • Maternity | $929 | $929 | $929 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,038 | $1,038 | $1,038 |
| External cephalic version CPT 59412 • Maternity | $123 | $123 | $123 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $568 | $568 | $568 |
| Postpartum care only CPT 59430 • Maternity | $151 | $151 | $151 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,097 | $2,097 | $2,097 |
| Cesarean delivery only CPT 59514 • Maternity | $1,096 | $1,096 | $1,096 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,237 | $1,237 | $1,237 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,954 | $1,954 | $1,954 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $55 | $55 | $55 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $56 | $70 | $84 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $109 | $109 | $109 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $94 | $94 | $94 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $36 | $48 | $60 |
| Interactive complexity add-on CPT 90785 • Mental Health | $6 | $6 | $6 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $97 | $119 | $140 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $127 | $136 | $145 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $56 | $58 | $59 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $49 | $52 | $55 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $84 | $90 | $96 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $81 | $81 | $81 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $85 | $109 | $133 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $109 | $119 | $130 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $91 | $97 | $103 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $95 | $109 | $123 |
| Group psychotherapy CPT 90853 • Mental Health | $34 | $34 | $34 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $6 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $180 | $180 | $180 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $101 | $149 | $197 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $66 | $106 | $146 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $192 | $192 | $192 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $100 | $100 | $100 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $39 | $39 | $39 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $30 | $30 | $30 |
| EMG needle each extremity complete CPT 95886 • Neurology | $102 | $102 | $102 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $110 | $110 | $110 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $58 | $58 | $58 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $162 | $162 | $162 |