| Office visit established patient moderate complexity CPT 99214 • Office Visits | $125 | $125 | $125 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $176 | $176 | $176 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $170 | $170 | $170 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $170 | $170 | $170 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $30 | $114 | $198 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $129 | $129 | $129 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $129 | $129 | $129 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $129 | $129 | $129 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $129 | $129 | $129 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $102 | $102 | $102 |
| Consultation office low complexity CPT 99243 • Office Visits | $117 | $117 | $117 |
| Consultation office high complexity CPT 99245 • Office Visits | $213 | $213 | $213 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $483 | $483 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $772 | $772 | $772 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $24 | $24 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $63 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Total knee replacement CPT 27447 • Orthopedics | $1,253 | $1,253 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $865 | $865 | $865 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $529 | $529 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Carpal tunnel release CPT 64721 • Orthopedics | $433 | $433 | $433 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $159 | $159 | $159 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $258 | $258 | $258 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $2,287 | $2,287 | $2,287 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $48 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $242 | $242 | $242 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $50 | $50 | $50 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $170 | $170 | $170 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $88 | $88 | $88 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $437 | $437 | $437 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $24 | $24 | $24 |
| Cytopathology concentration technique CPT 88108 • Pathology | $109 | $109 | $109 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $194 | $194 | $194 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $37 | $37 | $37 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $25 | $25 | $25 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $62 | $62 | $62 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $34 | $34 | $34 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $44 | $44 | $44 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $71 | $71 | $71 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $94 | $94 | $94 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $54 | $54 | $54 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $169 | $232 | $295 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $413 | $413 | $413 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $126 | $126 | $126 |