| Influenza virus assay with direct optical CPT 87804 • Laboratory | $12 | $12 | $12 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $13 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $145 | $145 | $145 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $29 | $29 | $29 |
| Fetal non-stress test CPT 59025 • Maternity | $45 | $45 | $46 |
| Vaginal delivery only CPT 59409 • Maternity | $764 | $764 | $764 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,012 | $1,012 | $1,012 |
| External cephalic version CPT 59412 • Maternity | $97 | $97 | $97 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $980 | $980 | $980 |
| Postpartum care only CPT 59430 • Maternity | $255 | $255 | $255 |
| Cesarean delivery only CPT 59514 • Maternity | $862 | $862 | $862 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,242 | $1,242 | $1,242 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,025 | $2,025 | $2,025 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $119 | $119 | $119 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $137 | $137 | $137 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $31 | $31 | $31 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $36 | $42 | $47 |
| Interactive complexity add-on CPT 90785 • Mental Health | $16 | $16 | $16 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $129 | $141 | $152 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $165 | $165 | $166 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $84 | $84 | $84 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $89 | $89 | $89 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $90 | $90 | $90 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $98 | $98 | $98 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $123 | $123 | $123 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $150 | $150 | $150 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $152 | $152 | $152 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $57 | $57 | $57 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $94 | $94 | $94 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $126 | $126 | $126 |
| Group psychotherapy CPT 90853 • Mental Health | $53 | $53 | $53 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $145 | $145 | $145 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $15 | $15 | $15 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $447 | $447 | $447 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $524 | $524 | $524 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $134 | $134 | $135 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $195 | $195 | $195 |
| EMG needle each extremity complete CPT 95886 • Neurology | $118 | $118 | $118 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $108 | $108 | $108 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $135 | $135 | $135 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $212 | $212 | $212 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $344 | $344 | $344 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $79 | $79 | $79 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $114 | $114 | $114 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $138 | $157 | $175 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $183 | $200 | $218 |
| Office visit established patient minimal CPT 99211 • Office Visits | $23 | $23 | $23 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $48 | $48 | $48 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $77 | $77 | $77 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $12 | $12 | $12 |