| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $349 | $349 | $349 |
| Excision chalazion single CPT 67800 • Ophthalmology | $133 | $133 | $133 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $823 | $823 | $823 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $80 | $80 | $80 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $43 | $43 | $43 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $65 | $65 | $65 |
| Visual field examination CPT 92083 • Ophthalmology | $22 | $22 | $22 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $13 | $13 | $13 |
| Fundus photography CPT 92250 • Ophthalmology | $31 | $31 | $31 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $54 | $54 | $54 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,529 | $1,529 | $1,529 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,219 | $1,219 | $1,219 |
| Total knee replacement CPT 27447 • Orthopedics | $1,083 | $1,083 | $1,083 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $492 | $492 | $492 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $740 | $740 | $740 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $144 | $144 | $144 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $460 | $460 | $460 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $584 | $584 | $584 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $136 | $136 | $137 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $217 | $217 | $217 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $115 | $115 | $115 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $343 | $343 | $343 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $62 | $62 | $62 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $92 | $92 | $92 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $366 | $366 | $366 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $200 | $200 | $200 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $30 | $30 | $30 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $242 | $242 | $242 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $85 | $85 | $85 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $34 | $34 | $34 |
| Microdissection manual CPT 88381 • Pathology | $167 | $167 | $167 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $8 | $8 | $8 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $9 | $9 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $9 | $9 | $9 |
| 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 | $18 | $18 | $18 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $66 | $66 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $47 | $47 | $48 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $25 | $25 | $25 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $22 | $22 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $21 | $21 | $22 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $23 | $23 | $23 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $33 | $33 | $33 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $28 | $28 | $28 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $5 | $5 | $5 |