| Office visit established patient high complexity CPT 99215 • Office Visits | $160 | $160 | $160 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $39 | $39 | $39 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $192 | $192 | $192 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $83 | $102 | $122 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $75 | $75 | $75 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $65 | $65 | $65 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $148 | $148 | $148 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $147 | $147 | $147 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $80 | $120 | $160 |
| Consultation office low complexity CPT 99243 • Office Visits | $83 | $93 | $111 |
| Consultation office high complexity CPT 99245 • Office Visits | $83 | $145 | $207 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,208 | $1,208 | $1,208 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $518 | $518 | $518 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $242 | $242 | $242 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $557 | $557 | $557 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $349 | $349 | $349 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $823 | $823 | $823 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $76 | $76 | $76 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $65 | $65 | $65 |
| Visual field examination CPT 92083 • Ophthalmology | $30 | $30 | $30 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $21 | $21 | $21 |
| Fundus photography CPT 92250 • Ophthalmology | $18 | $18 | $18 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $54 | $54 | $54 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,529 | $1,529 | $1,529 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $355 | $355 | $355 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $292 | $292 | $292 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $500 | $500 | $500 |
| 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 | $137 | $137 | $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 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $62 | $62 | $62 |
| 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 | $59 | $59 | $59 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $242 | $242 | $242 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $34 | $34 | $34 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $64 | $64 | $64 |
| 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 |