| Office visit established patient high complexity CPT 99215 • Office Visits | $211 | $211 | $211 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $117 | $161 | $205 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $205 | $205 | $205 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $36 | $134 | $231 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $36 | $96 | $156 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $36 | $96 | $156 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $36 | $96 | $156 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $132 | $144 | $156 |
| Consultation office low complexity CPT 99243 • Office Visits | $36 | $120 | $205 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,257 | $1,257 | $1,257 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $36 | $331 | $626 |
| Excision chalazion single CPT 67800 • Ophthalmology | $118 | $133 | $149 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $36 | $36 | $36 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $53 | $64 | $76 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $341 | $520 | $698 |
| Total hip replacement CPT 27130 • Orthopedics | $1,506 | $1,506 | $1,506 |
| Total knee replacement CPT 27447 • Orthopedics | $1,504 | $1,504 | $1,504 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,255 | $1,255 | $1,255 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $636 | $636 | $636 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $809 | $809 | $809 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $1,147 | $1,147 | $1,147 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $50 | $69 | $89 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $61 | $61 | $61 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $15 | $15 | $15 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $26 | $26 | $26 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $20 | $20 | $20 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $22 | $22 | $22 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $38 | $38 | $38 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $66 | $66 | $66 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $262 | $262 | $262 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $25 | $25 | $25 |
| Special stain group II CPT 88313 • Pathology | $74 | $74 | $74 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $81 | $81 | $81 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $93 | $93 | $93 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $39 | $75 | $111 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $55 | $55 | $55 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $55 | $55 | $55 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $55 | $55 | $55 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $55 | $55 | $55 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $55 | $55 | $55 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $55 | $55 | $55 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $34 | $34 | $34 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $55 | $55 | $55 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $55 | $55 | $55 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $55 | $55 | $55 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $101 | $101 | $101 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $101 | $101 | $101 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $55 | $55 | $55 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $55 | $62 | $69 |