| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $604 | $631 | $644 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $604 | $634 | $644 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $454 | $581 | $644 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $454 | $597 | $644 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $604 | $634 | $644 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $604 | $673 | $798 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $604 | $634 | $644 |
| Parathyroidectomy CPT 60500 • General Surgery | $518 | $602 | $644 |
| TB skin test intradermal CPT 86580 • Laboratory | $16 | $16 | $16 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $279 | $522 | $644 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $96 | $507 | $644 |
| Chorionic villus sampling CPT 59015 • Maternity | $279 | $522 | $644 |
| Fetal non-stress test CPT 59025 • Maternity | $96 | $96 | $96 |
| Insertion cervical dilator CPT 59200 • Maternity | $96 | $461 | $644 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $298 | $298 | $298 |
| Vaginal delivery only CPT 59409 • Maternity | $369 | $552 | $644 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $298 | $558 | $644 |
| External cephalic version CPT 59412 • Maternity | $369 | $369 | $369 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $298 | $298 | $298 |
| Postpartum care only CPT 59430 • Maternity | $298 | $529 | $644 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $298 | $298 | $298 |
| Cesarean delivery only CPT 59514 • Maternity | $298 | $298 | $298 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $298 | $529 | $644 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $298 | $298 | $298 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $279 | $522 | $644 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $96 | $507 | $644 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $96 | $461 | $644 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $112 | $112 | $112 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $172 | $172 | $172 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $209 | $241 | $257 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $162 | $281 | $341 |
| Office visit established patient minimal CPT 99211 • Office Visits | $14 | $14 | $14 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $87 | $87 | $87 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $65 | $65 | $65 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $197 | $197 | $197 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $278 | $278 | $278 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $152 | $152 | $152 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $152 | $152 | $152 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $212 | $243 | $304 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $59 | $59 | $59 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $116 | $116 | $116 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $116 | $116 | $116 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $449 | $579 | $644 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $96 | $461 | $644 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $518 | $602 | $644 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $279 | $574 | $798 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $369 | $552 | $644 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $369 | $575 | $644 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $279 | $522 | $644 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $369 | $552 | $644 |