| Inguinal hernia repair initial CPT 49505 • General Surgery | $549 | $671 | $793 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $549 | $1,117 | $1,685 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $549 | $671 | $793 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $400 | $481 | $561 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $642 | $792 | $943 |
| Parathyroidectomy CPT 60500 • General Surgery | $642 | $792 | $943 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $365 | $365 | $365 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $50 | $208 | $365 |
| Chorionic villus sampling CPT 59015 • Maternity | $50 | $208 | $365 |
| Insertion cervical dilator CPT 59200 • Maternity | $365 | $392 | $419 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $642 | $642 | $642 |
| Vaginal delivery only CPT 59409 • Maternity | $365 | $503 | $642 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $365 | $503 | $642 |
| External cephalic version CPT 59412 • Maternity | $419 | $419 | $419 |
| Postpartum care only CPT 59430 • Maternity | $365 | $365 | $365 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $642 | $642 | $642 |
| Cesarean delivery only CPT 59514 • Maternity | $642 | $642 | $642 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $642 | $646 | $650 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $642 | $642 | $642 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $365 | $392 | $419 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $365 | $392 | $419 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $50 | $208 | $365 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $74 | $74 | $74 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $32 | $32 | $32 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $32 | $32 | $32 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $192 | $192 | $192 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $32 | $32 | $32 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $32 | $32 | $32 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $32 | $32 | $32 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $650 | $776 | $902 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $50 | $208 | $365 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $943 | $1,314 | $1,685 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $400 | $410 | $419 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $549 | $671 | $793 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $400 | $481 | $561 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $365 | $392 | $419 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $650 | $937 | $1,224 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $365 | $795 | $1,224 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $365 | $392 | $419 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $943 | $1,098 | $1,252 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $419 | $535 | $650 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $365 | $392 | $419 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $470 | $556 | $642 |
| Excision chalazion single CPT 67800 • Ophthalmology | $365 | $392 | $419 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $650 | $776 | $902 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $50 | $208 | $365 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $365 | $392 | $419 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $365 | $392 | $419 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $365 | $392 | $419 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $630 | $636 | $642 |