| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $57 | $171 | $285 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $111 | $111 | $111 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $56 | $91 | $111 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $166 | $166 | $166 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $36 | $54 | $73 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $112 | $112 | $112 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $70 | $70 | $70 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $153 | $153 | $153 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $350 | $4,292 | $19,682 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $57 | $209 | $350 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $57 | $204 | $350 |
| EMG needle each extremity complete CPT 95886 • Neurology | $90 | $90 | $90 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $69 | $69 | $69 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $108 | $108 | $108 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $138 | $138 | $138 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $227 | $227 | $227 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $59 | $59 | $59 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $88 | $88 | $88 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $135 | $135 | $135 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $174 | $174 | $174 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $120 | $120 | $120 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $136 | $136 | $136 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $61 | $61 | $61 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $115 | $115 | $115 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $721 | $8,292 | $42,765 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $50 | $174 | $328 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $328 | $2,022 | $4,750 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $57 | $454 | $904 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $850 | $6,041 | $33,816 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $850 | $5,742 | $28,516 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $57 | $284 | $353 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $328 | $6,762 | $33,816 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $850 | $6,132 | $33,816 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $57 | $218 | $350 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,200 | $7,169 | $33,816 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $57 | $763 | $1,340 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $57 | $316 | $421 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $850 | $10,140 | $45,983 |
| Excision chalazion single CPT 67800 • Ophthalmology | $106 | $2,460 | $13,476 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $850 | $8,274 | $42,765 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $57 | $191 | $350 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $56 | $184 | $350 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $44 | $2,322 | $15,000 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $60 | $2,323 | $15,000 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,390 | $11,192 | $39,500 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,390 | $15,370 | $45,000 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $57 | $2,818 | $11,876 |
| Total shoulder replacement CPT 23472 • Orthopedics | $57 | $6,356 | $28,404 |