| Obstetric ultrasound complete CPT 76805 • Maternity | $45 | $45 | $45 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $40 | $40 | $40 |
| Interactive complexity add-on CPT 90785 • Mental Health | $3 | $3 | $3 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $111 | $129 | $147 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $185 | $201 | $217 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $58 | $66 | $75 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $99 | $99 | $99 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $77 | $107 | $137 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $108 | $125 | $143 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $191 | $191 | $191 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $164 | $164 | $164 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $146 | $146 | $146 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $51 | $57 | $62 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $74 | $91 | $108 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $74 | $91 | $108 |
| Group psychotherapy CPT 90853 • Mental Health | $44 | $44 | $44 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $45 | $45 | $45 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $147 | $147 | $147 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $148 | $148 | $148 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $300 | $300 | $300 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $370 | $370 | $370 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $64 | $89 | $115 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $33 | $33 | $33 |
| EMG needle each extremity complete CPT 95886 • Neurology | $46 | $46 | $46 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $39 | $39 | $39 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $23 | $70 | $117 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $184 | $184 | $184 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $190 | $190 | $190 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $107 | $107 | $107 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $59 | $59 | $59 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $59 | $111 | $164 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $213 | $231 | $248 |
| Office visit established patient minimal CPT 99211 • Office Visits | $45 | $45 | $45 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $44 | $59 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $44 | $59 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $67 | $104 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $59 | $59 | $59 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $45 | $45 | $45 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $45 | $45 | $45 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $45 | $120 | $196 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $104 | $104 | $104 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $146 | $146 | $146 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $45 | $45 | $45 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $103 | $103 | $103 |
| Consultation office low complexity CPT 99243 • Office Visits | $106 | $106 | $106 |
| Consultation office high complexity CPT 99245 • Office Visits | $45 | $123 | $201 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $45 | $45 | $45 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $45 | $45 | $45 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $45 | $45 | $45 |