| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $96 | $96 | $96 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $103 | $103 | $103 |
| Consultation office low complexity CPT 99243 • Office Visits | $112 | $112 | $112 |
| Consultation office high complexity CPT 99245 • Office Visits | $197 | $197 | $197 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $758 | $758 | $758 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $245 | $245 | $245 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $257 | $257 | $257 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $663 | $663 | $663 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $436 | $436 | $436 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $171 | $171 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,192 | $1,192 | $1,192 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $515 | $515 | $515 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $357 | $357 | $357 |
| Excision chalazion single CPT 67800 • Ophthalmology | $121 | $121 | $121 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $63 | $63 | $63 |
| 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 | $59 | $59 | $59 |
| 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 small joint CPT 20600 • Orthopedics | $47 | $47 | $47 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $77 | $77 | $77 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $61 | $61 | $61 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $265 | $265 | $265 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $459 | $459 | $459 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $141 | $141 | $141 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,354 | $1,354 | $1,354 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $110 | $110 | $110 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $242 | $242 | $242 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $215 | $215 | $215 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $357 | $357 | $357 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $44 | $44 | $44 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $232 | $232 | $232 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $167 | $167 | $167 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $126 | $126 | $126 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $134 | $134 | $134 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $551 | $551 | $551 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $295 | $295 | $295 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $31 | $31 | $31 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $11 | $11 | $11 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $3 | $3 | $3 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $19 | $19 | $19 |
| 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 I for microorganisms CPT 88312 • Pathology | $39 | $39 | $39 |
| Special stain group II CPT 88313 • Pathology | $32 | $32 | $32 |