| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $356 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $7 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $3 | $3 |
| Lipid panel CPT 80061 • Laboratory | $4 | $7 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $7 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $1 | $2 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $13 | $13 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $8 | $17 | $25 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $11 | $11 | $11 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $5 | $5 | $5 |
| Iron serum CPT 83540 • Laboratory | $1 | $1 | $1 |
| Iron binding capacity CPT 83550 • Laboratory | $7 | $7 | $7 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $5 | $5 | $5 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $2 | $4 | $7 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $5 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $1 | $2 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $7 | $7 | $7 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $6 | $8 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $15 | $21 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $18 | $18 | $18 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $28 | $40 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $7 | $7 | $7 |
| 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 | $1,861 | $1,861 | $1,861 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $339 | $649 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $30 | $30 |
| Postpartum care only CPT 59430 • Maternity | $216 | $216 | $216 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,212 | $2,212 | $2,212 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $30 | $30 | $30 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $95 | $95 | $95 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $110 | $110 | $110 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $154 | $162 | $170 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $48 | $66 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $85 | $87 |
| Interactive complexity add-on CPT 90785 • Mental Health | $6 | $7 | $8 |