| Office visit established patient high complexity CPT 99215 • Office Visits | $154 | $154 | $154 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $141 | $141 | $141 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $146 | $146 | $146 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $162 | $189 | $216 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $111 | $111 | $111 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $86 | $100 | $113 |
| Consultation office low complexity CPT 99243 • Office Visits | $10 | $10 | $10 |
| Consultation office high complexity CPT 99245 • Office Visits | $29 | $133 | $236 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $53 | $53 | $53 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $681 | $681 | $681 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $153 | $153 | $153 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $460 | $460 | $460 |
| Excision chalazion single CPT 67800 • Ophthalmology | $174 | $174 | $174 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $796 | $943 | $1,090 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $201 | $201 | $201 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $106 | $106 | $106 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $156 | $156 | $156 |
| Visual field examination CPT 92083 • Ophthalmology | $33 | $33 | $33 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $31 | $31 | $31 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $61 | $61 | $61 |
| Fundus photography CPT 92250 • Ophthalmology | $26 | $26 | $26 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $77 | $77 | $77 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,159 | $2,159 | $2,159 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,444 | $1,444 | $1,444 |
| Total knee replacement CPT 27447 • Orthopedics | $1,509 | $1,509 | $1,509 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $687 | $687 | $687 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $345 | $345 | $345 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $1,055 | $1,055 | $1,055 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $641 | $641 | $641 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $194 | $194 | $194 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $305 | $305 | $305 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $301 | $301 | $301 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $2,719 | $2,719 | $2,719 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $48 | $48 | $48 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $57 | $57 | $57 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $287 | $287 | $287 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $130 | $130 | $130 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $201 | $201 | $201 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $104 | $104 | $104 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $44 | $44 | $44 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $285 | $285 | $285 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $49 | $49 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $50 | $50 | $50 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $17 | $17 | $17 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $12 | $12 | $12 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $20 | $20 | $20 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $24 | $24 | $24 |