| Vaginal delivery including postpartum care CPT 59410 • Maternity | $30 | $530 | $1,029 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,010 | $1,010 | $1,010 |
| Postpartum care only CPT 59430 • Maternity | $239 | $239 | $239 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,869 | $2,869 | $2,869 |
| Cesarean delivery only CPT 59514 • Maternity | $1,130 | $1,130 | $1,130 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $30 | $795 | $1,560 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,441 | $2,441 | $2,441 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $63 | $63 | $63 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $63 | $63 | $63 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $154 | $188 | $222 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $36 | $41 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $91 | $100 |
| Interactive complexity add-on CPT 90785 • Mental Health | $6 | $12 | $19 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $159 | $175 | $191 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $146 | $169 | $191 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $79 | $86 | $93 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $88 | $95 | $102 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $113 | $122 | $130 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $89 | $102 | $116 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $170 | $170 | $170 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $138 | $141 | $145 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $72 | $72 | $72 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $137 | $144 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $107 | $128 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $26 | $26 | $26 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $97 | $97 | $97 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $97 | $164 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $134 | $168 | $202 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $73 | $220 | $367 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $517 | $517 | $517 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $111 | $111 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $32 | $32 | $32 |
| EMG needle each extremity complete CPT 95886 • Neurology | $116 | $116 | $116 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $45 | $56 | $68 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $112 | $132 | $153 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $134 | $158 | $183 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $175 | $208 | $240 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $285 | $330 | $375 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $63 | $67 | $71 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $106 | $106 | $106 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $164 | $183 | $203 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $216 | $235 | $255 |
| Office visit established patient minimal CPT 99211 • Office Visits | $24 | $27 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $55 | $55 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $61 | $91 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $64 | $98 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $180 | $180 | $180 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $65 | $101 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $170 | $170 | $170 |