| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $171 | $171 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,192 | $1,192 | $1,192 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $515 | $515 | $515 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $357 | $357 | $357 |
| Excision chalazion single CPT 67800 • Ophthalmology | $121 | $121 | $121 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $201 | $201 | $201 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $147 | $147 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $88 | $88 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $125 | $125 | $125 |
| Visual field examination CPT 92083 • Ophthalmology | $26 | $26 | $26 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $26 | $26 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $29 | $29 |
| Fundus photography CPT 92250 • Ophthalmology | $29 | $29 | $29 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $129 | $129 | $129 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $265 | $265 | $265 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $141 | $141 | $141 |
| Carpal tunnel release CPT 64721 • Orthopedics | $438 | $438 | $438 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $157 | $157 | $157 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $232 | $232 | $232 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $225 | $225 | $225 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $126 | $126 | $126 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $26 | $26 | $26 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $45 | $45 | $45 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $11 | $11 | $11 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $35 | $35 | $35 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $103 | $103 | $103 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $108 | $108 | $108 |
| Special stain group II CPT 88313 • Pathology | $5 | $5 | $5 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $27 | $27 | $27 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $44 | $44 | $44 |
| Microdissection manual CPT 88381 • Pathology | $22 | $22 | $22 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $11 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $11 | $11 |
| 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 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $31 | $31 | $31 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $25 | $25 | $25 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $22 | $22 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $23 | $23 | $23 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $9 | $9 | $9 |
| Immunization admin injection single CPT 90471 • Preventive Care | $20 | $20 | $20 |