Price lookup
Search a service and see its price with and without membership.
Member fee schedule, version 1
416 services
| Service | Code | Price without membership | Essential | Plus | Premier |
|---|---|---|---|---|---|
| Contact Lens Exam Office Visit | SRV-YXDGZ4 | $99.00 | $89.10 | $84.15 | $79.20 |
| Family Psychotherapy w/o Patient Present, 26-50 Minutes Office Visit | 90846 | $110.00 | $77.00 | $66.00 | $55.00 |
| Family Psychotherapy w/ Patient Present, 26-50 Minutes Office Visit | 90847 | $120.00 | $84.00 | $72.00 | $60.00 |
| Group Psychotherapy, 45-60 Minutes Office Visit | 90853 | $45.00 | $31.50 | $27.00 | $22.50 |
| Individual Psychotherapy, 16-37 Minutes Office Visit | 90832 | $80.00 | $56.00 | $48.00 | $40.00 |
| Individual Psychotherapy, 38-52 Minutes Office Visit | 90834 | $113.00 | $79.10 | $67.80 | $56.50 |
| Individual Psychotherapy, 53+ Minutes Office Visit | 90837 | $160.00 | $112.00 | $96.00 | $80.00 |
| Intermediate 15 Minutes Office Visit | 99213 | $150.00 | $105.00 | $90.00 | $75.00 |
| Intermediate 30 Minutes Office Visit | 99203 | $180.00 | $126.00 | $108.00 | $90.00 |
| Limited 10 Minutes Office Visit | 99212 | $150.00 | $105.00 | $90.00 | $75.00 |
| Limited 20 Minutes Office Visit | 99202 | $180.00 | $126.00 | $108.00 | $90.00 |
| N-648 Medical Certification for Disability Exceptions Office Visit | SRV-59CU27 | $700.00 | $630.00 | $595.00 | $560.00 |
| Physical Exam for Work / School / Sport Office Visit | SRV-FGWK5W | $80.00 | $56.00 | $48.00 | $40.00 |
| Pre-Op Office Visit | SRV-C9F3ND | $80.00 | $56.00 | $48.00 | $40.00 |
| Psychiatric Diagnostic Evaluation Non-Medical Office Visit | 90791 | $180.00 | $126.00 | $108.00 | $90.00 |
| Psychiatric Diagnostic Evaluation w/ Medical Services Office Visit | 90792 | $180.00 | $126.00 | $108.00 | $90.00 |
| Psychotherapy Add-on w/ E/M Service, Same Day, 16-37 Minutes Office Visit | 90833 | $60.00 | $42.00 | $36.00 | $30.00 |
| Psychotherapy Add-on w/ E/M Service, Same Day, 38-52 Minutes Office Visit | 90836 | $120.00 | $84.00 | $72.00 | $60.00 |
| Psychotherapy Add-on w/ E/M Service, Same Day, 53+ Minutes Office Visit | 90838 | $140.00 | $98.00 | $84.00 | $70.00 |
| Psychotherapy for Crisis, 30-74 Minutes Office Visit | 90839 | $160.00 | $112.00 | $96.00 | $80.00 |
“—”: the plan has no special price for that service; its benefits or the price without membership apply.
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