| External cephalic version CPT 59412 • Maternity | $157 | $7,754 | $15,352 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $1,226 | $4,104 | $6,982 |
| Postpartum care only CPT 59430 • Maternity | $278 | $3,630 | $6,982 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $3,497 | $5,240 | $6,982 |
| Cesarean delivery only CPT 59514 • Maternity | $1,393 | $4,187 | $6,982 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,915 | $4,448 | $6,982 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $3,316 | $5,149 | $6,982 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $126 | $126 | $126 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $145 | $145 | $145 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $188 | $188 | $188 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $86 | $86 | $86 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $99 | $99 | $99 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $236 | $3,154 | $6,072 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $195 | $349 | $502 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $189 | $345 | $502 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $104 | $104 | $104 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $150 | $150 | $150 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $228 | $228 | $228 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $288 | $288 | $288 |
| Office visit established patient minimal CPT 99211 • Office Visits | $28 | $28 | $28 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $60 | $60 | $60 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $102 | $102 | $102 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $150 | $150 | $150 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $202 | $202 | $202 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $142 | $142 | $142 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $193 | $193 | $193 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $285 | $285 | $285 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $55 | $55 | $55 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $102 | $102 | $102 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $147 | $147 | $147 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $102 | $102 | $102 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $151 | $151 | $151 |
| Consultation office low complexity CPT 99243 • Office Visits | $171 | $171 | $171 |
| Consultation office high complexity CPT 99245 • Office Visits | $313 | $313 | $313 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $910 | $3,946 | $6,982 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $103 | $303 | $502 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,788 | $15,625 | $29,462 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $367 | $3,219 | $6,072 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,646 | $8,499 | $15,352 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $966 | $8,159 | $15,352 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $442 | $3,257 | $6,072 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $1,200 | $8,276 | $15,352 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $964 | $8,158 | $15,352 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $154 | $328 | $502 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,814 | $15,638 | $29,462 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $779 | $3,425 | $6,072 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $512 | $3,292 | $6,072 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $900 | $8,126 | $15,352 |
| Excision chalazion single CPT 67800 • Ophthalmology | $189 | $346 | $502 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,129 | $8,240 | $15,352 |