| Obstetric ultrasound limited CPT 76815 • Maternity | $115 | $115 | $115 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $129 | $129 | $129 |
| Interactive complexity add-on CPT 90785 • Mental Health | $19 | $19 | $19 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $174 | $174 | $174 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $188 | $188 | $188 |
| Lumbar puncture diagnostic CPT 62270 • Neurology | $203 | $203 | $203 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $173 | $173 | $173 |
| Chemodenervation of muscle neck CPT 64616 • Neurology | $155 | $155 | $155 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $440 | $440 | $440 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $502 | $502 | $502 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $153 | $153 | $153 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $213 | $213 | $213 |
| EMG needle each extremity complete CPT 95886 • Neurology | $116 | $116 | $116 |
| Nerve conduction study 1-2 nerves CPT 95907 • Neurology | $120 | $120 | $120 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $148 | $148 | $148 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $179 | $179 | $179 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $235 | $235 | $235 |
| Nerve conduction study 13 or more nerves CPT 95913 • Neurology | $389 | $389 | $389 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $94 | $94 | $94 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $137 | $137 | $137 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $211 | $211 | $211 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $264 | $264 | $264 |
| Office visit established patient minimal CPT 99211 • Office Visits | $25 | $25 | $25 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $55 | $55 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $93 | $93 | $93 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $102 | $102 | $102 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $184 | $184 | $184 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $131 | $131 | $131 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $178 | $178 | $178 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $262 | $262 | $262 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $51 | $51 | $51 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $93 | $93 | $93 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $134 | $134 | $134 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $93 | $93 | $93 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $138 | $138 | $138 |
| Consultation office low complexity CPT 99243 • Office Visits | $160 | $160 | $160 |
| Consultation office high complexity CPT 99245 • Office Visits | $291 | $291 | $291 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $798 | $798 | $798 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $90 | $90 | $90 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,527 | $1,527 | $1,527 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $443 | $443 | $443 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,568 | $1,568 | $1,568 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $823 | $823 | $823 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $385 | $385 | $385 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $1,055 | $1,055 | $1,055 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $847 | $847 | $847 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $134 | $134 | $134 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $2,119 | $2,119 | $2,119 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $680 | $680 | $680 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $1,324 | $1,324 | $1,324 |