| Vaginal delivery only CPT 59409 • Maternity | $884 | $2,661 | $4,439 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $810 | $2,624 | $4,439 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $831 | $831 | $831 |
| Postpartum care only CPT 59430 • Maternity | $212 | $2,326 | $4,439 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,063 | $2,063 | $2,063 |
| Cesarean delivery only CPT 59514 • Maternity | $119 | $119 | $119 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $5,737 | $5,737 | $5,737 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $50 | $50 | $50 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $50 | $50 | $50 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $97 | $97 | $97 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $64 | $64 | $64 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $38 | $38 | $38 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $234 | $234 | $234 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $153 | $153 | $153 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $71 | $71 | $71 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $93 | $93 | $93 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $95 | $95 | $95 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $75 | $75 | $75 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $126 | $126 | $126 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $100 | $100 | $100 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $69 | $2,254 | $4,439 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $246 | $2,342 | $4,439 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $179 | $2,309 | $4,439 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $335 | $335 | $335 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $390 | $390 | $390 |
| EMG needle each extremity complete CPT 95886 • Neurology | $83 | $83 | $83 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $126 | $126 | $126 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $98 | $98 | $98 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $130 | $130 | $130 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $231 | $231 | $231 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $89 | $89 | $89 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $108 | $108 | $108 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $139 | $139 | $139 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $280 | $280 | $280 |
| Office visit established patient minimal CPT 99211 • Office Visits | $20 | $20 | $20 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $38 | $38 | $38 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $69 | $69 | $69 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $115 | $115 | $115 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $227 | $227 | $227 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $99 | $99 | $99 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $178 | $178 | $178 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $222 | $222 | $222 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $63 | $63 | $63 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $101 | $101 | $101 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $151 | $151 | $151 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $103 | $103 | $103 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $141 | $141 | $141 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $605 | $3,171 | $5,737 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $4,439 | $4,439 | $4,439 |