| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $253 | $253 | $253 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $435 | $435 | $435 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $43 | $43 | $43 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $110 | $110 | $110 |
| Ultrasound transvaginal CPT 76830 • Imaging | $37 | $37 | $37 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $37 | $37 | $37 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $371 | $371 | $371 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $6 | $6 | $6 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $109 | $109 | $109 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $249 | $249 | $249 |
| Chorionic villus sampling CPT 59015 • Maternity | $149 | $149 | $149 |
| Fetal non-stress test CPT 59025 • Maternity | $38 | $38 | $38 |
| Insertion cervical dilator CPT 59200 • Maternity | $66 | $66 | $66 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $1,850 | $1,850 | $1,850 |
| Vaginal delivery only CPT 59409 • Maternity | $948 | $948 | $948 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $1,044 | $1,044 | $1,044 |
| External cephalic version CPT 59412 • Maternity | $129 | $129 | $129 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $601 | $601 | $601 |
| Postpartum care only CPT 59430 • Maternity | $120 | $120 | $120 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $1,850 | $1,850 | $1,850 |
| Cesarean delivery only CPT 59514 • Maternity | $1,114 | $1,114 | $1,114 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,223 | $1,223 | $1,223 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $2,000 | $2,000 | $2,000 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $91 | $91 | $91 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $128 | $128 | $128 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $234 | $234 | $234 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $34 | $34 | $34 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $55 | $55 | $55 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $81 | $81 | $81 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $165 | $165 | $165 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $48 | $48 | $48 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $30 | $30 | $30 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $30 | $30 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $162 | $162 | $162 |
| Office visit established patient minimal CPT 99211 • Office Visits | $30 | $30 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $30 | $30 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $30 | $30 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $30 | $30 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $30 | $30 | $30 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $30 | $30 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $30 | $30 | $30 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $193 | $193 | $193 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $110 | $110 | $110 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $30 | $30 |
| Consultation office high complexity CPT 99245 • Office Visits | $30 | $30 | $30 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $676 | $676 | $676 |