| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Chemodenervation of muscle cervical dystonia CPT 64612 • Neurology | $44 | $81 | $117 |
| Electromyography (EMG) 1 extremity CPT 95860 • Neurology | $118 | $118 | $118 |
| Electromyography (EMG) 2 extremities CPT 95861 • Neurology | $170 | $170 | $170 |
| Nerve conduction study 3-4 nerves CPT 95908 • Neurology | $117 | $117 | $117 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $54 | $125 | $196 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $177 | $203 | $229 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $160 | $160 | $160 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $217 | $217 | $217 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $8 | $8 | $8 |
| Consultation office low complexity CPT 99243 • Office Visits | $44 | $62 | $79 |
| Consultation office high complexity CPT 99245 • Office Visits | $243 | $243 | $243 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $621 | $621 | $621 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $744 | $744 | $744 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $91 | $91 | $91 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $44 | $44 | $44 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $416 | $416 | $416 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $44 | $317 | $590 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $33 | $33 | $33 |
| Visual field examination CPT 92083 • Ophthalmology | $25 | $25 | $25 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $10 | $10 | $10 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $44 | $44 | $44 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $37 | $41 | $44 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,501 | $1,690 | $1,879 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,199 | $1,199 | $1,199 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $357 | $357 | $357 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $279 | $279 | $279 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,730 | $1,730 | $1,730 |
| Total knee replacement CPT 27447 • Orthopedics | $44 | $44 | $44 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $615 | $615 | $615 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $44 | $44 | $44 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $141 | $141 | $141 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $44 | $44 | $44 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $724 | $724 | $724 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $44 | $44 | $44 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $91 | $164 | $236 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $123 | $123 | $123 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $44 | $44 | $44 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $44 | $44 | $44 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $444 | $444 | $444 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $248 | $248 | $249 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $12 | $12 | $12 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $44 | $44 | $44 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $170 | $170 | $170 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $23 | $23 | $23 |
| Microdissection manual CPT 88381 • Pathology | $125 | $125 | $125 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $5 | $5 | $5 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $5 | $5 | $5 |