| Iron binding capacity CPT 83550 • Laboratory | $1 | $1 | $1 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $2 | $2 | $2 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $3 | $3 | $3 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $5 | $5 | $5 |
| Complete blood count with differential CPT 85025 • Laboratory | $2 | $2 | $2 |
| Complete blood count automated CPT 85027 • Laboratory | $2 | $2 | $2 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $1 | $1 | $1 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $1 | $1 | $1 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $2 | $2 | $2 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $7 | $7 | $7 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $5 | $5 | $5 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $1 | $1 | $1 |
| TB skin test intradermal CPT 86580 • Laboratory | $6 | $6 | $6 |
| Blood typing ABO CPT 86900 • Laboratory | $0 | $0 | $0 |
| Blood typing Rh CPT 86901 • Laboratory | $0 | $0 | $0 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $5 | $5 | $5 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $10 | $14 | $19 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $4 | $11 | $19 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $2 | $2 | $2 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $9 | $9 | $9 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $44 | $44 | $44 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $79 | $118 | $157 |
| Chorionic villus sampling CPT 59015 • Maternity | $77 | $102 | $126 |
| Fetal non-stress test CPT 59025 • Maternity | $17 | $17 | $17 |
| Insertion cervical dilator CPT 59200 • Maternity | $9 | $9 | $9 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,900 | $1,900 | $1,900 |
| Vaginal delivery only CPT 59409 • Maternity | $317 | $317 | $317 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $842 | $842 | $842 |
| External cephalic version CPT 59412 • Maternity | $40 | $40 | $40 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $63 | $63 | $63 |
| Postpartum care only CPT 59430 • Maternity | $71 | $71 | $71 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $44 | $972 | $1,900 |
| Cesarean delivery only CPT 59514 • Maternity | $356 | $356 | $356 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $44 | $44 | $44 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $44 | $212 | $380 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $90 | $90 | $90 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $34 | $34 | $34 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $131 | $131 | $131 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $22 | $33 | $44 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $14 | $42 | $70 |
| Interactive complexity add-on CPT 90785 • Mental Health | $16 | $18 | $19 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $153 | $167 | $180 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $135 | $158 | $180 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $56 | $66 | $75 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $66 | $71 | $77 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $107 | $107 | $107 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $101 | $110 | $119 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $112 | $120 | $127 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $117 | $127 | $137 |