| Insertion cervical dilator CPT 59200 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $30 | $30 | $30 |
| Vaginal delivery only CPT 59409 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $30 | $30 |
| External cephalic version CPT 59412 • Maternity | $99 | $99 | $99 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $996 | $996 | $996 |
| Postpartum care only CPT 59430 • Maternity | $258 | $258 | $258 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $30 | $30 | $30 |
| Cesarean delivery only CPT 59514 • Maternity | $884 | $884 | $884 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $30 | $30 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,441 | $2,441 | $2,441 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $103 | $103 | $103 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $30 | $30 | $30 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $81 | $81 | $81 |
| 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 | $5 | $5 | $5 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $191 | $191 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $191 | $191 | $191 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $92 | $92 | $92 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $102 | $102 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $110 | $110 | $110 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $98 | $98 | $98 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $184 | $184 | $184 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $144 | $144 | $144 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $176 | $176 | $176 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $95 | $95 | $95 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $150 | $150 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $150 | $150 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $77 | $77 | $77 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $133 | $133 | $133 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $366 | $366 | $366 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $429 | $429 | $429 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $60 | $60 | $60 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $80 | $80 | $80 |
| EMG needle each extremity complete CPT 95886 • Neurology | $52 | $52 | $52 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $89 | $89 | $89 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $65 | $65 | $65 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $78 | $78 | $78 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $104 | $104 | $104 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $183 | $183 | $183 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $70 | $70 | $70 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $109 | $109 | $109 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $139 | $139 | $139 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $215 | $215 | $215 |
| Office visit established patient minimal CPT 99211 • Office Visits | $8 | $8 | $8 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $54 | $54 | $54 |