| Group psychotherapy CPT 90853 • Mental Health | $42 | $42 | $42 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $40 | $40 | $40 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $120 | $120 | $120 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $105 | $105 | $105 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $152 | $152 | $152 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $106 | $106 | $106 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $127 | $127 | $127 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $40 | $40 | $40 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $130 | $130 | $131 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $173 | $175 | $177 |
| Office visit established patient minimal CPT 99211 • Office Visits | $40 | $40 | $40 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $40 | $40 | $40 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $40 | $40 | $40 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $100 | $100 | $100 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $40 | $40 | $40 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $40 | $40 | $40 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $40 | $40 | $40 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $40 | $98 | $155 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $40 | $40 | $40 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $40 | $40 | $40 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $40 | $40 | $40 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $40 | $40 | $40 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $82 | $82 | $82 |
| Consultation office low complexity CPT 99243 • Office Visits | $9 | $24 | $40 |
| Consultation office high complexity CPT 99245 • Office Visits | $40 | $146 | $251 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $40 | $40 | $40 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $40 | $40 | $40 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,268 | $1,268 | $1,268 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $40 | $40 | $40 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $538 | $538 | $538 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $801 | $801 | $801 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $584 | $584 | $584 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $40 | $40 | $40 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $40 | $40 | $40 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $40 | $203 | $366 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $40 | $40 | $40 |
| Excision chalazion single CPT 67800 • Ophthalmology | $40 | $40 | $40 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $858 | $858 | $858 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $125 | $125 | $125 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $106 | $106 | $106 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $12 | $12 | $12 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $40 | $40 | $40 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $40 | $40 | $40 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $40 | $40 | $40 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $5 | $36 | $67 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $40 | $40 | $40 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,935 | $1,935 | $1,935 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,520 | $1,520 | $1,520 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $352 | $352 | $352 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $40 | $40 | $40 |