| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $164 | $164 | $164 |
| Chorionic villus sampling CPT 59015 • Maternity | $127 | $127 | $127 |
| Fetal non-stress test CPT 59025 • Maternity | $39 | $39 | $39 |
| Insertion cervical dilator CPT 59200 • Maternity | $36 | $36 | $36 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $30 | $30 | $30 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $871 | $871 | $872 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,056 | $2,056 | $2,056 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $72 | $72 | $72 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $82 | $82 | $82 |
| Interactive complexity add-on CPT 90785 • Mental Health | $4 | $4 | $4 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $115 | $157 | $200 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $151 | $151 | $152 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $82 | $82 | $82 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $106 | $106 | $106 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $81 | $81 | $81 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $103 | $103 | $103 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $106 | $106 | $106 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $185 | $185 | $185 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $163 | $163 | $163 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $74 | $74 | $74 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $89 | $89 | $89 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $157 | $157 | $157 |
| Group psychotherapy CPT 90853 • Mental Health | $47 | $47 | $47 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $73 | $116 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $109 | $109 | $109 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $157 | $157 | $157 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $109 | $109 | $109 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $179 | $179 | $179 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $68 | $107 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $180 | $195 | $211 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $110 | $110 | $110 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $16 | $16 | $16 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $110 | $110 | $110 |
| Consultation office low complexity CPT 99243 • Office Visits | $9 | $70 | $131 |
| Consultation office high complexity CPT 99245 • Office Visits | $21 | $21 | $21 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,140 | $1,140 | $1,140 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $482 | $482 | $482 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $520 | $520 | $520 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $88 | $88 | $88 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $326 | $326 | $326 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $771 | $771 | $771 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $91 | $91 | $91 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $78 | $78 | $78 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $38 | $38 | $38 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $58 | $58 | $58 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,663 | $1,663 | $1,663 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,301 | $1,301 | $1,301 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $391 | $391 | $391 |