| Complete blood count automated CPT 85027 • Laboratory | $1 | $1 | $1 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $1 | $2 | $4 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $6 | $6 | $6 |
| 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 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $7 | $7 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $30 | $30 | $30 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $30 | $30 | $30 |
| Fetal non-stress test CPT 59025 • Maternity | $27 | $37 | $46 |
| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $30 | $30 | $30 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $30 | $30 |
| External cephalic version CPT 59412 • Maternity | $99 | $99 | $99 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $30 | $30 | $30 |
| Cesarean delivery only CPT 59514 • Maternity | $30 | $30 | $30 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $30 | $1,236 | $2,441 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $119 | $119 | $119 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $153 | $153 | $154 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $30 | $30 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $82 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $6 | $13 | $18 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $125 | $153 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $162 | $185 | $205 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $72 | $81 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $69 | $80 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $93 | $101 | $115 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $71 | $95 | $116 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $125 | $141 | $157 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $94 | $117 | $150 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $132 | $134 | $135 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $66 | $78 | $96 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $95 | $115 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $99 | $129 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $41 | $59 | $77 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $134 | $134 | $134 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $367 | $367 | $367 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $111 | $111 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $161 | $161 | $161 |
| EMG needle each extremity complete CPT 95886 • Neurology | $97 | $97 | $97 |