| Cesarean delivery only CPT 59514 • Maternity | $30 | $30 | $30 |
| 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 | $109 | $109 | $109 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $30 | $30 | $30 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $74 | $74 | $74 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $30 | $30 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $52 | $69 | $87 |
| Interactive complexity add-on CPT 90785 • Mental Health | $14 | $14 | $14 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $130 | $152 | $174 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $194 | $194 | $195 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $75 | $75 | $75 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $68 | $68 | $68 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $87 | $87 | $87 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $66 | $66 | $66 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $109 | $109 | $109 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $115 | $115 | $115 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $140 | $140 | $140 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $62 | $62 | $62 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $80 | $80 | $80 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $99 | $99 | $99 |
| Group psychotherapy CPT 90853 • Mental Health | $19 | $19 | $19 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $150 | $150 | $150 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $147 | $147 | $147 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $383 | $383 | $383 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $451 | $451 | $451 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $128 | $128 | $128 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $183 | $183 | $183 |
| EMG needle each extremity complete CPT 95886 • Neurology | $100 | $100 | $100 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $101 | $101 | $101 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $131 | $131 | $132 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $157 | $157 | $157 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $206 | $206 | $206 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $321 | $321 | $321 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $75 | $75 | $75 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $106 | $106 | $106 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $16 | $69 | $121 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $203 | $203 | $204 |
| Office visit established patient minimal CPT 99211 • Office Visits | $22 | $22 | $22 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $44 | $44 | $44 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $73 | $73 | $73 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $107 | $107 | $107 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $143 | $143 | $143 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $100 | $100 | $100 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $135 | $135 | $135 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $199 | $199 | $200 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $38 | $38 | $38 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $71 | $71 | $71 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $102 | $102 | $102 |