| Psychotherapy crisis first 60 minutes CPT 90839 • Mental Health | $141 | $141 | $141 |
| Psychotherapy crisis each additional 30 minutes CPT 90840 • Mental Health | $153 | $153 | $153 |
| Family psychotherapy without patient CPT 90846 • Mental Health | $81 | $81 | $81 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $100 | $100 | $100 |
| Group psychotherapy CPT 90853 • Mental Health | $42 | $42 | $42 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $113 | $113 | $113 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $116 | $116 | $116 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $166 | $166 | $166 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $115 | $115 | $115 |
| Nerve conduction study 5-6 nerves CPT 95909 • Neurology | $238 | $238 | $238 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $117 | $136 | $155 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $58 | $106 | $154 |
| Office visit established patient minimal CPT 99211 • Office Visits | $4 | $4 | $4 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $89 | $89 | $89 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $163 | $163 | $163 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $107 | $107 | $107 |
| Consultation office low complexity CPT 99243 • Office Visits | $111 | $111 | $111 |
| Consultation office high complexity CPT 99245 • Office Visits | $245 | $245 | $245 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,208 | $1,208 | $1,208 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $518 | $518 | $518 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $814 | $814 | $814 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $137 | $137 | $137 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,216 | $1,216 | $1,216 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $821 | $821 | $821 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $823 | $1,369 | $1,915 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $88 | $88 | $88 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $76 | $76 | $76 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $65 | $65 | $65 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $37 | $37 | $37 |
| Fundus photography CPT 92250 • Ophthalmology | $58 | $58 | $58 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $46 | $46 | $46 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $54 | $54 | $54 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,529 | $1,529 | $1,529 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,219 | $1,219 | $1,219 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,357 | $1,357 | $1,357 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $626 | $626 | $626 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $2,671 | $2,671 | $2,671 |
| Total knee replacement CPT 27447 • Orthopedics | $1,083 | $1,083 | $1,083 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $1,287 | $1,287 | $1,287 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $740 | $740 | $740 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $144 | $144 | $144 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $460 | $460 | $460 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $584 | $584 | $584 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $137 | $243 | $349 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $217 | $469 | $722 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $66 | $66 | $66 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $1,210 | $1,210 | $1,210 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $642 | $642 | $642 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $18 | $18 | $18 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $59 | $59 | $59 |