| Inguinal hernia repair initial CPT 49505 • General Surgery | $450 | $450 | $450 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $450 | $450 | $450 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $450 | $450 | $450 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $625 | $625 | $625 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $450 | $450 | $450 |
| Parathyroidectomy CPT 60500 • General Surgery | $450 | $450 | $450 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $450 | $450 | $450 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $450 | $450 | $450 |
| Chorionic villus sampling CPT 59015 • Maternity | $450 | $450 | $450 |
| Insertion cervical dilator CPT 59200 • Maternity | $450 | $450 | $450 |
| Vaginal delivery only CPT 59409 • Maternity | $450 | $450 | $450 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $450 | $450 | $450 |
| Postpartum care only CPT 59430 • Maternity | $450 | $450 | $450 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $450 | $450 | $450 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $450 | $450 | $450 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $450 | $450 | $450 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $450 | $450 | $450 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $82 | $82 | $82 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $30 | $30 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $183 | $183 | $183 |
| 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 |
| 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 | $30 | $30 | $30 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $69 | $69 | $69 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $30 | $30 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $450 | $450 | $450 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $450 | $450 | $450 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $450 | $450 | $450 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $625 | $625 | $625 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $450 | $450 | $450 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $625 | $625 | $625 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $450 | $450 | $450 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $450 | $450 | $450 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $450 | $450 | $450 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $450 | $450 | $450 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $450 | $450 | $450 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $450 | $450 | $450 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $450 | $450 | $450 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $450 | $450 | $450 |
| Excision chalazion single CPT 67800 • Ophthalmology | $450 | $450 | $450 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $450 | $450 | $450 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $450 | $450 | $450 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $450 | $450 | $450 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $450 | $450 | $450 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $450 | $450 | $450 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $450 | $450 | $450 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $450 | $450 | $450 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $450 | $450 | $450 |