| Initial hospital care low complexity CPT 99221 • Office Visits | $76 | $76 | $76 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $96 | $96 | $96 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $128 | $128 | $128 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $43 | $43 | $43 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $58 | $58 | $58 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $93 | $93 | $93 |
| 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 | $106 | $106 | $106 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $680 | $680 | $680 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $844 | $844 | $844 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $103 | $103 | $103 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $309 | $309 | $309 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $63 | $63 | $63 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $133 | $133 | $133 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $75 | $75 | $75 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $113 | $113 | $113 |
| Visual field examination CPT 92083 • Ophthalmology | $54 | $54 | $54 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $25 | $25 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $40 | $40 | $40 |
| Fundus photography CPT 92250 • Ophthalmology | $24 | $24 | $24 |
| 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 | $52 | $52 | $52 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $592 | $592 | $592 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $459 | $459 | $459 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $2,093 | $2,093 | $2,093 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $1,036 | $1,036 | $1,036 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $1,036 | $1,036 | $1,036 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $1,036 | $1,036 | $1,036 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $3,045 | $3,045 | $3,045 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,981 | $1,981 | $1,981 |
| Carpal tunnel release CPT 64721 • Orthopedics | $667 | $667 | $667 |
| 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 | $127 | $127 | $127 |
| 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 III CPT 88304 • Pathology | $19 | $19 | $19 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $17 | $17 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $39 | $39 | $39 |