| 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 | $533 | $1,035 |
| 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 | $651 | $1,272 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $30 | $1,236 | $2,441 |
| 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 | $32 | $67 | $87 |
| Interactive complexity add-on CPT 90785 • Mental Health | $5 | $6 | $8 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $106 | $153 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $191 | $193 | $196 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $69 | $85 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $54 | $86 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $78 | $112 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $69 | $94 | $116 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $134 | $159 | $184 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $92 | $115 | $144 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $145 | $160 | $176 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $57 | $74 | $96 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $78 | $114 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $76 | $125 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $30 | $53 | $77 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $3 | $3 | $3 |
| 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 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $379 | $379 | $379 |
| 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 | $22 | $22 | $22 |
| 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 | $70 | $71 | $73 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $103 | $106 | $109 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $124 | $144 | $164 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $175 | $202 | $216 |
| Office visit established patient minimal CPT 99211 • Office Visits | $8 | $23 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $55 | $56 | $57 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $70 | $91 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $91 | $125 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $176 | $180 | $184 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $88 | $170 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $169 | $169 | $170 |