| Vaginal delivery only CPT 59409 • Maternity | $8,700 | $8,700 | $8,700 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $8,700 | $8,700 | $8,700 |
| Postpartum care only CPT 59430 • Maternity | $8,700 | $8,700 | $8,700 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $11,500 | $11,500 | $11,500 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $107 | $162 | $190 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $129 | $201 | $237 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $174 | $211 | $230 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $74 | $115 | $135 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $153 | $153 | $153 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $205 | $205 | $205 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $87 | $87 | $87 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $66 | $66 | $66 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $134 | $134 | $134 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $8,700 | $8,700 | $8,700 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $8,700 | $8,700 | $8,700 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $8,700 | $8,700 | $8,700 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $325 | $325 | $325 |
| EMG needle each extremity complete CPT 95886 • Neurology | $90 | $90 | $90 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $152 | $152 | $152 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $274 | $274 | $274 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $86 | $86 | $86 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $129 | $129 | $129 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $164 | $164 | $164 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $219 | $219 | $219 |
| Office visit established patient minimal CPT 99211 • Office Visits | $25 | $25 | $25 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $54 | $54 | $54 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $94 | $94 | $94 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $106 | $106 | $106 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $162 | $162 | $162 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $87 | $87 | $87 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $119 | $119 | $119 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $158 | $158 | $158 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $38 | $38 | $38 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $61 | $61 | $61 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $87 | $87 | $87 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $96 | $96 | $96 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $141 | $141 | $141 |
| Consultation office low complexity CPT 99243 • Office Visits | $112 | $112 | $112 |
| Consultation office high complexity CPT 99245 • Office Visits | $197 | $197 | $197 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $11,500 | $11,500 | $11,500 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $8,700 | $8,700 | $8,700 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $14,500 | $14,500 | $14,500 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $8,700 | $8,700 | $8,700 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $10,500 | $10,500 | $10,500 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $8,700 | $8,700 | $8,700 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $257 | $4,478 | $8,700 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $11,500 | $11,500 | $11,500 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $436 | $5,968 | $11,500 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $8,700 | $8,700 | $8,700 |