| Chemodenervation of muscle neck CPT 64616 • Neurology | $189 | $295 | $502 |
| Electroencephalogram (EEG) awake and asleep CPT 95816 • Neurology | $436 | $436 | $436 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $511 | $511 | $511 |
| EMG needle each extremity complete CPT 95886 • Neurology | $116 | $116 | $116 |
| Nerve conduction study 7-8 nerves CPT 95910 • Neurology | $209 | $209 | $209 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $104 | $105 | $106 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $150 | $152 | $153 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $228 | $231 | $234 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $288 | $291 | $295 |
| Office visit established patient minimal CPT 99211 • Office Visits | $28 | $28 | $29 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $60 | $61 | $62 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $102 | $103 | $104 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $150 | $151 | $153 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $202 | $204 | $207 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $142 | $144 | $146 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $193 | $195 | $197 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $285 | $289 | $292 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $55 | $56 | $57 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $102 | $103 | $104 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $147 | $149 | $151 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $102 | $103 | $105 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $151 | $153 | $155 |
| Consultation office low complexity CPT 99243 • Office Visits | $171 | $173 | $175 |
| Consultation office high complexity CPT 99245 • Office Visits | $313 | $317 | $320 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $910 | $2,942 | $6,982 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $103 | $237 | $502 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,788 | $11,029 | $29,462 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $367 | $2,272 | $6,072 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,646 | $6,230 | $15,352 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $966 | $5,770 | $15,352 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $442 | $2,323 | $6,072 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $1,200 | $5,928 | $15,352 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $964 | $5,769 | $15,352 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $154 | $271 | $502 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,814 | $11,046 | $29,462 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $779 | $2,550 | $6,072 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $512 | $2,370 | $6,072 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $900 | $5,725 | $15,352 |
| Excision chalazion single CPT 67800 • Ophthalmology | $189 | $295 | $502 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,129 | $5,880 | $15,352 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $220 | $316 | $502 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $72 | $216 | $502 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $76 | $218 | $502 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $91 | $229 | $502 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,586 | $14,898 | $39,452 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $2,406 | $14,776 | $39,452 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,807 | $25,080 | $69,550 |
| Total shoulder replacement CPT 23472 • Orthopedics | $2,209 | $24,343 | $68,550 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $2,467 | $11,488 | $29,462 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $636 | $5,547 | $15,352 |