| Cesarean delivery only CPT 59514 • Maternity | $1,145 | $1,145 | $1,145 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,231 | $1,231 | $1,231 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $124 | $124 | $124 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $83 | $83 | $83 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $102 | $102 | $102 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $116 | $116 | $116 |
| Group psychotherapy CPT 90853 • Mental Health | $28 | $28 | $28 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $82 | $82 | $82 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $160 | $160 | $160 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $82 | $82 | $82 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $89 | $89 | $89 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $65 | $65 | $65 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $111 | $111 | $111 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $51 | $51 | $51 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $71 | $71 | $71 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $106 | $106 | $106 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $140 | $140 | $140 |
| Office visit established patient minimal CPT 99211 • Office Visits | $15 | $15 | $15 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $38 | $38 | $38 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $49 | $49 | $49 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $61 | $61 | $61 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $120 | $120 | $120 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $72 | $72 | $72 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $119 | $119 | $119 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $153 | $153 | $153 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $60 | $60 | $60 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $78 | $78 | $78 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $77 | $77 | $77 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $65 | $65 | $65 |
| Consultation office low complexity CPT 99243 • Office Visits | $101 | $101 | $101 |
| Consultation office high complexity CPT 99245 • Office Visits | $192 | $192 | $192 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $581 | $581 | $581 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $55 | $55 | $55 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $559 | $559 | $559 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $984 | $984 | $984 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $639 | $639 | $639 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $1,080 | $1,080 | $1,080 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $241 | $241 | $241 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $2,093 | $2,093 | $2,093 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $777 | $777 | $777 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $917 | $917 | $917 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $613 | $613 | $613 |
| Excision chalazion single CPT 67800 • Ophthalmology | $97 | $97 | $97 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $672 | $672 | $672 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $94 | $94 | $94 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $49 | $49 | $49 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $71 | $71 | $71 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $40 | $40 | $40 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $51 | $51 | $51 |
| Visual field examination CPT 92083 • Ophthalmology | $49 | $49 | $49 |