| Nuclear antigen antibody CPT 86235 • Laboratory | $7 | $7 | $7 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $5 | $5 | $5 |
| TB skin test intradermal CPT 86580 • Laboratory | $12 | $12 | $12 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $3 | $3 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $9 | $9 | $9 |
| 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 | $19 | $19 | $19 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $19 | $19 | $19 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $99 | $99 | $99 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Fetal non-stress test CPT 59025 • Maternity | $18 | $28 | $38 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $363 | $695 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $836 | $836 | $836 |
| External cephalic version CPT 59412 • Maternity | $88 | $88 | $88 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $877 | $877 | $877 |
| Postpartum care only CPT 59430 • Maternity | $227 | $227 | $227 |
| Cesarean delivery only CPT 59514 • Maternity | $788 | $788 | $788 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,170 | $2,170 | $2,170 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $104 | $104 | $104 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $150 | $150 | $150 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $153 | $153 | $154 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $37 | $43 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $36 | $70 | $104 |
| Interactive complexity add-on CPT 90785 • Mental Health | $3 | $5 | $6 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $162 | $177 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $151 | $151 | $152 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $82 | $87 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $102 | $104 | $106 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $97 | $113 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $98 | $108 | $119 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $146 | $146 | $146 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $108 | $147 | $185 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $163 | $163 | $163 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $43 | $58 | $73 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $100 | $125 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $150 | $154 | $157 |
| Group psychotherapy CPT 90853 • Mental Health | $77 | $77 | $77 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $123 | $123 | $123 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $134 | $135 | $137 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $351 | $359 | $367 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $498 | $498 | $498 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $127 | $127 | $128 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $161 | $173 | $185 |
| EMG needle each extremity complete CPT 95886 • Neurology | $112 | $112 | $112 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $38 | $70 | $102 |