| Obstetric ultrasound complete CPT 76805 • Maternity | $48 | $48 | $48 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $74 | $74 | $74 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $30 | $30 | $30 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $35 | $62 | $89 |
| Interactive complexity add-on CPT 90785 • Mental Health | $3 | $3 | $3 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $146 | $146 | $146 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $146 | $146 | $146 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $75 | $75 | $75 |
| Psychotherapy 30 min add-on to E/M CPT 90833 • Mental Health | $81 | $81 | $81 |
| Psychotherapy 45 minutes CPT 90834 • Mental Health | $108 | $108 | $108 |
| Psychotherapy 45 min add-on to E/M CPT 90836 • Mental Health | $118 | $118 | $118 |
| Psychotherapy 60 minutes CPT 90837 • Mental Health | $105 | $105 | $105 |
| Psychotherapy 60 min add-on to E/M CPT 90838 • Mental Health | $136 | $136 | $136 |
| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $146 | $146 | $146 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $73 | $73 | $73 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $91 | $91 | $91 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $108 | $108 | $108 |
| Group psychotherapy CPT 90853 • Mental Health | $48 | $48 | $48 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $48 | $48 | $48 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $15 | $72 | $129 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $317 | $317 | $317 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $122 | $122 | $122 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $177 | $177 | $177 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $124 | $124 | $124 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $48 | $48 | $48 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $157 | $157 | $157 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $198 | $198 | $199 |
| Office visit established patient minimal CPT 99211 • Office Visits | $48 | $48 | $48 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $48 | $48 | $48 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $48 | $48 | $48 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $109 | $109 | $109 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $48 | $48 | $48 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $48 | $48 | $48 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $48 | $48 | $48 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $48 | $132 | $215 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $48 | $48 | $48 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $48 | $48 | $48 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $48 | $48 | $48 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $48 | $48 | $48 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $112 | $112 | $112 |
| Consultation office low complexity CPT 99243 • Office Visits | $115 | $125 | $134 |
| Consultation office high complexity CPT 99245 • Office Visits | $48 | $130 | $211 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $48 | $48 | $48 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $48 | $48 | $48 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,500 | $1,500 | $1,500 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $314 | $314 | $314 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $48 | $48 | $48 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $638 | $638 | $638 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $48 | $48 | $48 |