| Office visit established patient minimal CPT 99211 • Office Visits | $42 | $42 | $42 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $42 | $42 | $42 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $42 | $42 | $42 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $118 | $118 | $118 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $42 | $42 | $42 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $42 | $42 | $42 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $42 | $42 | $42 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $42 | $131 | $221 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $42 | $42 | $42 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $42 | $42 | $42 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $42 | $42 | $42 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $42 | $42 | $42 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $117 | $117 | $117 |
| Consultation office low complexity CPT 99243 • Office Visits | $64 | $64 | $64 |
| Consultation office high complexity CPT 99245 • Office Visits | $246 | $246 | $246 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,269 | $1,269 | $1,269 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $546 | $546 | $546 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $368 | $368 | $368 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $876 | $876 | $877 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $74 | $74 | $74 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $39 | $39 | $39 |
| Visual field examination CPT 92083 • Ophthalmology | $49 | $49 | $49 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $19 | $19 | $19 |
| Fundus photography CPT 92250 • Ophthalmology | $42 | $42 | $42 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $32 | $32 | $32 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $50 | $50 | $50 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $50 | $60 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,690 | $1,690 | $1,690 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,326 | $1,326 | $1,326 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $303 | $303 | $303 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,127 | $1,127 | $1,127 |
| Total knee replacement CPT 27447 • Orthopedics | $42 | $609 | $1,176 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $537 | $537 | $537 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $294 | $294 | $294 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $824 | $824 | $824 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $157 | $157 | $157 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $42 | $271 | $500 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $634 | $634 | $634 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $898 | $898 | $898 |
| Carpal tunnel release CPT 64721 • Orthopedics | $42 | $42 | $42 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $152 | $152 | $152 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $106 | $106 | $106 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $80 | $80 | $80 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $42 | $42 | $42 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $76 | $76 | $76 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $42 | $42 | $42 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $51 | $51 | $51 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $96 | $96 | $96 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $58 | $155 | $253 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $16 | $16 | $16 |