| Office visit established patient minimal CPT 99211 • Office Visits | $6 | $6 | $6 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $56 | $56 | $56 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $85 | $85 | $85 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $129 | $129 | $129 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $103 | $103 | $103 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $65 | $65 | $65 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $121 | $121 | $121 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $151 | $151 | $151 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $47 | $47 | $47 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $68 | $68 | $68 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $103 | $103 | $103 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $75 | $75 | $75 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $103 | $103 | $103 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $758 | $758 | $758 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $245 | $245 | $245 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $296 | $296 | $296 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $663 | $663 | $663 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $508 | $508 | $508 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $171 | $171 | $171 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $515 | $515 | $515 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $357 | $357 | $357 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $147 | $147 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $88 | $88 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $124 | $124 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $62 | $62 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $26 | $26 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $29 | $29 |
| Fundus photography CPT 92250 • Ophthalmology | $36 | $36 | $36 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $61 | $61 | $61 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,946 | $1,946 | $1,946 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $1,035 | $1,035 | $1,035 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $157 | $157 | $157 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $309 | $309 | $309 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $225 | $225 | $225 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $77 | $77 | $77 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $5 | $5 |
| 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 | $37 | $37 | $37 |
| Special stain group II CPT 88313 • Pathology | $5 | $5 | $5 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $13 | $13 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $16 | $16 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $11 | $11 |
| 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 | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $20 | $20 |