| 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 detailed fetal anatomy CPT 76811 • Maternity | $83 | $83 | $83 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $51 | $51 | $51 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $47 | $47 | $47 |
| Interactive complexity add-on CPT 90785 • Mental Health | $16 | $16 | $16 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $110 | $155 | $200 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $152 | $158 | $165 |
| 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 | $108 | $108 | $108 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $129 | $129 | $129 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $196 | $196 | $196 |
| 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 | $55 | $55 | $55 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $125 | $125 | $125 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $126 | $126 | $126 |
| Group psychotherapy CPT 90853 • Mental Health | $55 | $55 | $55 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $145 | $145 | $145 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $15 | $15 | $15 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $155 | $155 | $155 |
| 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 | $104 | $150 | $196 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $177 | $177 | $177 |
| 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 | $160 | $160 | $160 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $154 | $154 | $154 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $141 | $141 | $141 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $146 | $146 | $146 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $162 | $189 | $216 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $111 | $111 | $111 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $113 | $113 | $113 |
| Consultation office low complexity CPT 99243 • Office Visits | $10 | $73 | $136 |