| Fetal non-stress test CPT 59025 • Maternity | $29 | $29 | $29 |
| Postpartum care only CPT 59430 • Maternity | $168 | $168 | $168 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $85 | $85 | $85 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $98 | $98 | $98 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $24 | $24 | $24 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $27 | $27 | $27 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $122 | $122 | $122 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $160 | $160 | $160 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $52 | $52 | $52 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $71 | $71 | $71 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $102 | $102 | $102 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $113 | $113 | $113 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $3 | $3 | $3 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $66 | $66 | $66 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $85 | $85 | $85 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $152 | $152 | $152 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $225 | $225 | $225 |
| Office visit established patient minimal CPT 99211 • Office Visits | $20 | $20 | $20 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $56 | $56 | $56 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $85 | $85 | $85 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $107 | $107 | $107 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $168 | $168 | $168 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $76 | $76 | $76 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $113 | $113 | $113 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $151 | $151 | $151 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $43 | $43 | $43 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $73 | $73 | $73 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $93 | $93 | $93 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $75 | $75 | $75 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $106 | $106 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $323 | $323 | $323 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $103 | $103 | $103 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $127 | $127 | $127 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $133 | $133 | $133 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $113 | $113 | $113 |
| Visual field examination CPT 92083 • Ophthalmology | $54 | $54 | $54 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $25 | $25 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $26 | $26 | $26 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $47 | $47 | $47 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $77 | $77 | $77 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $48 | $48 | $48 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $459 | $459 | $459 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $110 | $110 | $110 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $242 | $242 | $242 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $85 | $85 | $85 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $921 | $921 | $921 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $44 | $44 | $44 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $96 | $96 | $96 |