| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $103 | $103 | $103 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $63 | $63 | $63 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $133 | $133 | $133 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $113 | $113 | $113 |
| Visual field examination CPT 92083 • Ophthalmology | $54 | $54 | $54 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $25 | $25 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $26 | $26 | $26 |
| Fundus photography CPT 92250 • Ophthalmology | $33 | $33 | $33 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $47 | $47 | $47 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $43 | $45 | $48 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $39 | $55 | $84 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $459 | $459 | $459 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $110 | $110 | $110 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $242 | $242 | $242 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $215 | $215 | $215 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $1,841 | $1,841 | $1,841 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $67 | $67 | $67 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $348 | $348 | $348 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $167 | $167 | $167 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $127 | $127 | $127 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $31 | $31 | $31 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $11 | $11 | $11 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $12 | $12 | $12 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $19 | $19 | $19 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $33 | $43 | $53 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $39 | $39 | $39 |
| Special stain group II CPT 88313 • Pathology | $32 | $32 | $32 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $31 | $31 | $31 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $52 | $52 | $52 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $10 | $10 | $10 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $20 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $14 | $14 | $14 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $26 | $26 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $22 | $22 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $35 | $35 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $19 | $23 | $24 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $7 | $10 | $13 |
| Immunization admin injection single CPT 90471 • Preventive Care | $15 | $21 | $24 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $11 | $13 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $284 | $360 | $436 |