| Consultation office high complexity CPT 99245 • Office Visits | $206 | $206 | $206 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $876 | $876 | $876 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $374 | $374 | $374 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $40 | $40 | $40 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $40 | $40 | $40 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $69 | $69 | $69 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $254 | $254 | $254 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $596 | $596 | $596 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $65 | $65 | $65 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $11 | $11 | $11 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $41 | $41 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,685 | $1,685 | $1,685 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $351 | $351 | $351 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $40 | $40 | $40 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,023 | $1,023 | $1,023 |
| Total knee replacement CPT 27447 • Orthopedics | $1,276 | $1,276 | $1,276 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $459 | $459 | $459 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $545 | $545 | $545 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $520 | $520 | $520 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $58 | $98 | $138 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $97 | $97 | $97 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $133 | $133 | $133 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $80 | $80 | $80 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $105 | $105 | $105 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $375 | $375 | $375 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $156 | $156 | $156 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $39 | $39 | $39 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $129 | $129 | $129 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $73 | $73 | $73 |
| Microdissection manual CPT 88381 • Pathology | $119 | $119 | $119 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $3 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $8 | $8 | $8 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $9 | $9 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $7 | $7 | $7 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $16 | $16 | $16 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $17 | $17 | $17 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $14 | $14 | $14 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $15 | $15 | $15 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $10 | $10 | $10 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $48 | $48 | $48 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $48 | $48 | $48 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $33 | $33 | $33 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $17 | $17 | $17 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $17 | $17 | $17 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $16 | $16 | $16 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $24 | $24 | $24 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $19 | $19 | $19 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $17 | $17 | $17 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $22 | $23 |