| Office visit new patient high complexity CPT 99205 • Office Visits | $207 | $207 | $207 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $54 | $54 | $54 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $92 | $92 | $92 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $142 | $142 | $142 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $123 | $123 | $123 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $164 | $164 | $164 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $46 | $46 | $46 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $75 | $75 | $75 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $76 | $76 | $76 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $2,064 | $2,064 | $2,064 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $1,174 | $1,174 | $1,174 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $54 | $54 | $54 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $1,254 | $1,254 | $1,254 |
| Excision chalazion single CPT 67800 • Ophthalmology | $64 | $64 | $64 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $998 | $998 | $998 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $27 | $27 | $27 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $35 | $35 | $35 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $9,070 | $9,070 | $9,070 |
| Total shoulder replacement CPT 23472 • Orthopedics | $8,925 | $8,925 | $8,925 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $11,581 | $11,581 | $11,581 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $1,637 | $1,637 | $1,637 |
| Total hip replacement CPT 27130 • Orthopedics | $8,148 | $8,148 | $8,148 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $1,317 | $1,317 | $1,317 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $76 | $76 | $76 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $1,783 | $1,783 | $1,783 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $1,502 | $1,502 | $1,502 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $1,502 | $1,502 | $1,502 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $4,795 | $4,795 | $4,795 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $4,450 | $4,450 | $4,450 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $342 | $342 | $342 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $342 | $342 | $342 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $2,021 | $2,021 | $2,021 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $53 | $53 | $53 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $376 | $376 | $376 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $376 | $376 | $376 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $131 | $131 | $131 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $56 | $56 | $56 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $376 | $376 | $376 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $17 | $17 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $18 | $18 | $18 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $7 | $7 | $7 |
| Immunization admin injection single CPT 90471 • Preventive Care | $22 | $22 | $22 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $82 | $82 | $82 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $69 | $69 | $69 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $75 | $75 | $75 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $96 | $96 | $96 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $528 | $528 | $528 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $528 | $528 | $528 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $1,392 | $1,392 | $1,392 |
| Radiation therapy simulation simple CPT 77280 • Radiation Therapy | $65 | $65 | $65 |