| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $105 | $105 | $105 |
| Fetal non-stress test CPT 59025 • Maternity | $42 | $42 | $42 |
| Insertion cervical dilator CPT 59200 • Maternity | $53 | $53 | $53 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $2,082 | $2,082 | $2,082 |
| Vaginal delivery only CPT 59409 • Maternity | $689 | $689 | $689 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $932 | $932 | $932 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $742 | $742 | $742 |
| Postpartum care only CPT 59430 • Maternity | $229 | $229 | $229 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,181 | $2,181 | $2,181 |
| Cesarean delivery only CPT 59514 • Maternity | $781 | $781 | $781 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,083 | $1,083 | $1,083 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,055 | $2,055 | $2,055 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $90 | $90 | $90 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $47 | $47 | $47 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $68 | $68 | $68 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $24 | $24 | $24 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $27 | $27 | $27 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $106 | $106 | $106 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $138 | $138 | $138 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $64 | $64 | $64 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $54 | $54 | $54 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $87 | $87 | $87 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $90 | $90 | $90 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $121 | $121 | $121 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $129 | $129 | $129 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $83 | $83 | $83 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $366 | $366 | $366 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $386 | $386 | $386 |
| EMG needle each extremity complete CPT 95886 • Neurology | $69 | $69 | $69 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $128 | $128 | $128 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $97 | $97 | $97 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $73 | $73 | $73 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $90 | $90 | $90 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $159 | $159 | $159 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $299 | $299 | $299 |
| Office visit established patient minimal CPT 99211 • Office Visits | $20 | $20 | $20 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $53 | $53 | $53 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $57 | $57 | $57 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $122 | $122 | $122 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $243 | $243 | $243 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $78 | $78 | $78 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $115 | $115 | $115 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $164 | $164 | $164 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $46 | $46 | $46 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $69 | $69 | $69 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $117 | $117 | $117 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $62 | $62 | $62 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $108 | $108 | $108 |