| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $25 | $25 | $25 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $70 | $512 | $955 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $176 | $440 | $955 |
| Chorionic villus sampling CPT 59015 • Maternity | $57 | $361 | $955 |
| Fetal non-stress test CPT 59025 • Maternity | $16 | $27 | $41 |
| Insertion cervical dilator CPT 59200 • Maternity | $91 | $523 | $955 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $2,138 | $2,138 | $2,138 |
| Vaginal delivery only CPT 59409 • Maternity | $955 | $955 | $955 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $955 | $955 | $955 |
| External cephalic version CPT 59412 • Maternity | $50 | $1,012 | $1,946 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $902 | $902 | $902 |
| Postpartum care only CPT 59430 • Maternity | $955 | $955 | $955 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,371 | $2,371 | $2,371 |
| Cesarean delivery only CPT 59514 • Maternity | $826 | $826 | $826 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $955 | $955 | $955 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,247 | $2,247 | $2,247 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $58 | $77 | $107 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $66 | $94 | $123 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $75 | $112 | $161 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $38 | $56 | $74 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $85 | $85 | $85 |
| Interactive complexity add-on CPT 90785 • Mental Health | $4 | $10 | $15 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $88 | $125 | $146 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $146 | $152 | $158 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $63 | $66 | $69 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $28 | $50 | $71 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $98 | $99 | $100 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $62 | $86 | $109 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $74 | $99 | $138 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $75 | $100 | $125 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $144 | $185 | $225 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $71 | $71 | $71 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $65 | $88 | $111 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $68 | $92 | $115 |
| Group psychotherapy CPT 90853 • Mental Health | $45 | $47 | $49 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $195 | $527 | $955 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $92 | $524 | $955 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $80 | $518 | $955 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $343 | $343 | $343 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $401 | $401 | $401 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $105 | $105 | $105 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $154 | $154 | $154 |
| EMG needle each extremity complete CPT 95886 • Neurology | $93 | $93 | $93 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $86 | $86 | $86 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $164 | $164 | $164 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $129 | $129 | $129 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $168 | $168 | $168 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $275 | $275 | $275 |