| 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 detailed fetal anatomy CPT 76811 • Maternity | $154 | $154 | $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 | $4 | $6 | $9 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $155 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $83 | $147 | $191 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $39 | $63 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $30 | $67 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $95 | $112 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $60 | $88 | $116 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $83 | $98 | $113 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $67 | $88 | $108 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $95 | $102 | $109 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $4 | $50 | $96 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $71 | $105 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $60 | $97 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $21 | $30 | $40 |
| 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 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $90 | $90 | $90 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $112 | $112 | $112 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $134 | $134 | $134 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $175 | $175 | $175 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $285 | $285 | $285 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $25 | $48 | $71 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $32 | $32 | $32 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $57 | $110 | $164 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $66 | $157 | $216 |
| Office visit established patient minimal CPT 99211 • Office Visits | $30 | $68 | $105 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $25 | $40 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $49 | $77 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $47 | $70 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $55 | $97 | $138 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $59 | $88 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $88 | $88 | $88 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $66 | $132 | $198 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $90 | $90 | $90 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $68 | $105 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $37 | $43 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $79 | $129 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $130 | $132 | $135 |
| Consultation office straightforward CPT 99241 • Office Visits | $95 | $95 | $95 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $48 | $66 |
| Consultation office high complexity CPT 99245 • Office Visits | $66 | $161 | $255 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |