| Office visit established patient moderate complexity CPT 99214 • Office Visits | $130 | $130 | $130 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $253 | $253 | $253 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $217 | $217 | $217 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $149 | $149 | $149 |
| Consultation office low complexity CPT 99243 • Office Visits | $121 | $121 | $121 |
| Consultation office high complexity CPT 99245 • Office Visits | $242 | $242 | $242 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $507 | $507 | $507 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $744 | $744 | $744 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $91 | $91 | $91 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $341 | $341 | $341 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $815 | $815 | $815 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $100 | $100 | $100 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $59 | $59 | $59 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $50 | $50 | $50 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $10 | $10 | $10 |
| Fundus photography CPT 92250 • Ophthalmology | $13 | $13 | $13 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $55 | $60 | $64 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,502 | $2,036 | $2,570 |
| Total shoulder replacement CPT 23472 • Orthopedics | $2,054 | $2,054 | $2,054 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $292 | $292 | $292 |
| Total knee replacement CPT 27447 • Orthopedics | $1,062 | $1,062 | $1,062 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $488 | $488 | $488 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $247 | $247 | $247 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $766 | $766 | $766 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $141 | $141 | $141 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $455 | $455 | $455 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $814 | $814 | $814 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $141 | $141 | $141 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $236 | $236 | $236 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $69 | $69 | $69 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $36 | $36 | $36 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $44 | $44 | $44 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $399 | $399 | $399 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $221 | $221 | $222 |
| 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 | $178 | $178 | $178 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $128 | $128 | $128 |
| Microdissection manual CPT 88381 • Pathology | $331 | $331 | $331 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $2 | $2 | $3 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $5 | $5 | $5 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $6 | $6 | $6 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $6 | $6 | $6 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $14 | $14 | $14 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $16 | $16 | $16 |
| 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 | $12 | $12 | $12 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $8 | $8 | $8 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $47 | $47 | $47 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $47 | $47 | $47 |