| Consultation office low complexity CPT 99243 • Office Visits | $9 | $9 | $9 |
| Consultation office high complexity CPT 99245 • Office Visits | $251 | $251 | $251 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $538 | $538 | $538 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $323 | $323 | $323 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $103 | $103 | $103 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $366 | $366 | $366 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $858 | $858 | $858 |
| 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 | $40 | $40 | $40 |
| 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 | $48 | $48 | $48 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $5 | $28 | $52 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,935 | $1,935 | $1,935 |
| Total knee replacement CPT 27447 • Orthopedics | $1,347 | $1,347 | $1,347 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $122 | $122 | $122 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $459 | $689 | $919 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $85 | $85 | $85 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $110 | $139 | $169 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $234 | $238 | $242 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $85 | $85 | $85 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $1,841 | $1,841 | $1,841 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $44 | $44 | $44 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $96 | $96 | $96 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $251 | $251 | $251 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $127 | $127 | $127 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $395 | $395 | $395 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $217 | $217 | $217 |
| 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 | $17 | $17 | $17 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $194 | $194 | $194 |
| 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 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| 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 | $11 | $11 | $11 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $25 | $25 | $25 |