| Family psychotherapy without patient CPT 90846 • Mental Health | $100 | $125 | $150 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $150 | $150 | $150 |
| Group psychotherapy CPT 90853 • Mental Health | $69 | $69 | $69 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $30 | $30 | $30 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $133 | $133 | $134 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $73 | $192 | $310 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $429 | $429 | $429 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $101 | $106 | $111 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $80 | $111 | $141 |
| EMG needle each extremity complete CPT 95886 • Neurology | $97 | $97 | $97 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $38 | $63 | $89 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $56 | $83 | $111 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $134 | $134 | $134 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $175 | $175 | $175 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $285 | $285 | $285 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $71 | $72 | $74 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $112 | $112 | $112 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $122 | $143 | $163 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $180 | $180 | $180 |
| Office visit established patient minimal CPT 99211 • Office Visits | $4 | $17 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $54 | $54 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $59 | $88 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $98 | $112 | $125 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $176 | $176 | $176 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $91 | $152 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $152 | $152 | $152 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $193 | $202 | $212 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $115 | $115 | $115 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $73 | $115 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $100 | $107 | $115 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $73 | $115 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $130 | $130 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $58 | $58 | $58 |
| Consultation office high complexity CPT 99245 • Office Visits | $194 | $233 | $272 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $30 | $30 | $30 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $4 | $17 | $30 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $48 | $265 | $482 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $30 | $30 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $30 | $30 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,142 | $1,142 | $1,142 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $161 | $291 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $15 | $15 | $15 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $283 | $283 | $283 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $112 | $112 | $112 |