| Influenza virus assay with direct optical CPT 87804 • Laboratory | $15 | $15 | $15 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $9 | $9 | $9 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $137 | $137 | $137 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $158 | $198 | $239 |
| Fetal non-stress test CPT 59025 • Maternity | $40 | $48 | $56 |
| Insertion cervical dilator CPT 59200 • Maternity | $92 | $92 | $92 |
| Vaginal delivery only CPT 59409 • Maternity | $634 | $800 | $965 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $842 | $842 | $842 |
| External cephalic version CPT 59412 • Maternity | $123 | $123 | $123 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,220 | $1,220 | $1,220 |
| Postpartum care only CPT 59430 • Maternity | $313 | $313 | $313 |
| Cesarean delivery only CPT 59514 • Maternity | $1,094 | $1,094 | $1,094 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,031 | $1,031 | $1,031 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,900 | $1,900 | $1,900 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $55 | $55 | $55 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $99 | $99 | $99 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $131 | $131 | $131 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $62 | $62 | $62 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $71 | $74 | $78 |
| Interactive complexity add-on CPT 90785 • Mental Health | $5 | $14 | $19 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $136 | $180 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $75 | $156 | $225 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $39 | $67 | $86 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $33 | $63 | $79 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $60 | $95 | $117 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $50 | $96 | $119 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $75 | $106 | $137 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $80 | $117 | $137 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $95 | $129 | $162 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $5 | $54 | $89 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $69 | $98 | $116 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $69 | $102 | $121 |
| Group psychotherapy CPT 90853 • Mental Health | $23 | $32 | $40 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $166 | $166 | $166 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $130 | $130 | $130 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $128 | $128 | $128 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $362 | $381 | $399 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $430 | $430 | $430 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $69 | $93 | $118 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $170 | $170 | $170 |
| EMG needle each extremity complete CPT 95886 • Neurology | $111 | $111 | $111 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $41 | $67 | $94 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $117 | $122 | $127 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $55 | $98 | $140 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $121 | $152 | $183 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $215 | $256 | $297 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $40 | $65 | $82 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $32 | $73 | $114 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $50 | $127 | $169 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $66 | $161 | $224 |