| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $99 | $99 | $99 |
| Interactive complexity add-on CPT 90785 • Mental Health | $18 | $18 | $18 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $147 | $160 | $173 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $194 | $194 | $195 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $84 | $84 | $84 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $87 | $87 | $87 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $112 | $112 | $112 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $94 | $94 | $94 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $143 | $143 | $143 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $146 | $146 | $146 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $176 | $176 | $176 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $63 | $63 | $63 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $136 | $136 | $136 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $141 | $141 | $141 |
| Group psychotherapy CPT 90853 • Mental Health | $40 | $40 | $40 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $207 | $207 | $207 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $114 | $114 | $114 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $165 | $165 | $165 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $146 | $146 | $146 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $174 | $174 | $174 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $96 | $96 | $96 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $136 | $136 | $136 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $207 | $207 | $207 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $50 | $155 | $261 |
| Office visit established patient minimal CPT 99211 • Office Visits | $50 | $50 | $50 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $57 | $57 | $57 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $93 | $93 | $93 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $8 | $8 | $8 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $183 | $183 | $183 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $127 | $127 | $127 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $172 | $172 | $172 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $254 | $254 | $254 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $80 | $80 | $80 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $91 | $91 | $91 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $130 | $130 | $130 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $92 | $92 | $92 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $135 | $135 | $135 |
| Consultation office low complexity CPT 99243 • Office Visits | $131 | $143 | $155 |
| Consultation office high complexity CPT 99245 • Office Visits | $281 | $281 | $281 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $698 | $698 | $698 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $315 | $315 | $315 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $1,331 | $1,331 | $1,331 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $832 | $832 | $832 |
| Visual field examination CPT 92083 • Ophthalmology | $107 | $107 | $107 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $19 | $19 | $19 |
| Fundus photography CPT 92250 • Ophthalmology | $50 | $50 | $50 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $50 | $50 | $50 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $76 | $76 | $76 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,473 | $2,473 | $2,473 |
| Total knee replacement CPT 27447 • Orthopedics | $2,025 | $2,025 | $2,025 |