| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,060 | $1,060 | $1,060 |
| External cephalic version CPT 59412 • Maternity | $122 | $122 | $122 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $915 | $915 | $915 |
| Postpartum care only CPT 59430 • Maternity | $164 | $164 | $164 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,330 | $2,330 | $2,330 |
| Cesarean delivery only CPT 59514 • Maternity | $1,082 | $1,082 | $1,082 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,276 | $1,276 | $1,276 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,167 | $2,167 | $2,167 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $158 | $158 | $158 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $176 | $176 | $176 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $131 | $190 | $249 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $41 | $75 | $110 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $121 | $121 | $121 |
| Interactive complexity add-on CPT 90785 • Mental Health | $6 | $6 | $6 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $190 | $190 | $190 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $158 | $158 | $158 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $63 | $63 | $63 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $53 | $53 | $53 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $103 | $103 | $103 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $86 | $86 | $86 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $150 | $150 | $150 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $138 | $138 | $138 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $111 | $111 | $111 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $138 | $138 | $138 |
| Group psychotherapy CPT 90853 • Mental Health | $39 | $39 | $39 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $6 | $6 | $6 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $176 | $176 | $176 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $175 | $175 | $175 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $261 | $261 | $261 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $280 | $280 | $280 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $99 | $99 | $99 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $46 | $95 | $144 |
| EMG needle each extremity complete CPT 95886 • Neurology | $108 | $108 | $108 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $117 | $117 | $117 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $144 | $144 | $144 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $98 | $135 | $172 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $227 | $227 | $227 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $374 | $374 | $374 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $49 | $49 | $49 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $88 | $88 | $88 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $126 | $126 | $126 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $728 | $728 | $728 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $73 | $73 | $73 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,240 | $1,240 | $1,240 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $312 | $332 | $352 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,224 | $1,224 | $1,224 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $653 | $653 | $653 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $462 | $462 | $462 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $1,116 | $1,116 | $1,116 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $799 | $799 | $799 |