| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $29 | $29 | $29 |
| Fetal non-stress test CPT 59025 • Maternity | $18 | $32 | $46 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $2,018 | $2,018 | $2,018 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,012 | $1,012 | $1,012 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $980 | $980 | $980 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,018 | $2,018 | $2,018 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,018 | $2,018 | $2,018 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $82 | $82 | $82 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $94 | $94 | $95 |
| Interactive complexity add-on CPT 90785 • Mental Health | $16 | $16 | $16 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $152 | $152 | $152 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $165 | $165 | $166 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $84 | $84 | $84 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $89 | $89 | $89 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $90 | $90 | $90 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $98 | $98 | $98 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $123 | $123 | $123 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $150 | $150 | $150 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $152 | $152 | $152 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $76 | $76 | $76 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $107 | $107 | $107 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $126 | $126 | $126 |
| Group psychotherapy CPT 90853 • Mental Health | $63 | $63 | $63 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $155 | $155 | $155 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $338 | $338 | $338 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $66 | $93 | $119 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $174 | $174 | $174 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $96 | $96 | $96 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $120 | $120 | $120 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $60 | $60 | $60 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $131 | $153 | $175 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $219 | $219 | $219 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $114 | $114 | $114 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $145 | $164 | $183 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $77 | $77 | $77 |
| Consultation office low complexity CPT 99243 • Office Visits | $137 | $137 | $137 |
| Consultation office high complexity CPT 99245 • Office Visits | $29 | $29 | $29 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $60 | $60 | $60 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $135 | $135 | $135 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $407 | $407 | $407 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $106 | $106 | $106 |
| Visual field examination CPT 92083 • Ophthalmology | $28 | $28 | $28 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $43 | $43 | $43 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $7 | $7 | $7 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,907 | $1,907 | $1,907 |
| Total knee replacement CPT 27447 • Orthopedics | $1,333 | $1,333 | $1,333 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $607 | $607 | $607 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $932 | $932 | $932 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $566 | $566 | $566 |