| Postpartum care only CPT 59430 • Maternity | $147 | $147 | $147 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,467 | $2,467 | $2,467 |
| Cesarean delivery only CPT 59514 • Maternity | $1,524 | $1,524 | $1,524 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,748 | $1,748 | $1,748 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,193 | $2,193 | $2,193 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $116 | $116 | $116 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $83 | $83 | $83 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $117 | $117 | $117 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $117 | $117 | $117 |
| Group psychotherapy CPT 90853 • Mental Health | $34 | $34 | $34 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $159 | $159 | $159 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $201 | $201 | $201 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $81 | $81 | $81 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $130 | $130 | $130 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $113 | $113 | $113 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $47 | $47 | $47 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $63 | $63 | $63 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $89 | $89 | $89 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $129 | $129 | $129 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $161 | $161 | $161 |
| Office visit established patient minimal CPT 99211 • Office Visits | $20 | $20 | $20 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $34 | $34 | $34 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $52 | $52 | $52 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $78 | $78 | $78 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $117 | $117 | $117 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $78 | $78 | $78 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $117 | $117 | $117 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $157 | $157 | $157 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $41 | $41 | $41 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $64 | $64 | $64 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $107 | $107 | $107 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $68 | $68 | $68 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $89 | $89 | $89 |
| Consultation office low complexity CPT 99243 • Office Visits | $117 | $117 | $117 |
| Consultation office high complexity CPT 99245 • Office Visits | $212 | $212 | $212 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $857 | $857 | $857 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $147 | $147 | $147 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $830 | $830 | $830 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,754 | $1,754 | $1,754 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $417 | $417 | $417 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $2,324 | $2,324 | $2,324 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $400 | $400 | $400 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $3,402 | $3,402 | $3,402 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $996 | $996 | $996 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $1,048 | $1,048 | $1,048 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $1,245 | $1,245 | $1,245 |
| Excision chalazion single CPT 67800 • Ophthalmology | $181 | $181 | $181 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $688 | $688 | $688 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $363 | $363 | $363 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $63 | $63 | $63 |