| Office visit established patient minimal CPT 99211 • Office Visits | $19 | $56 | $105 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $25 | $44 | $57 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $40 | $71 | $91 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $33 | $90 | $118 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $53 | $118 | $182 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $85 | $94 | $108 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $88 | $111 | $134 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $50 | $148 | $217 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $51 | $71 | $90 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $81 | $93 | $105 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $43 | $92 | $122 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $58 | $89 | $129 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $116 | $123 | $135 |
| Consultation office straightforward CPT 99241 • Office Visits | $25 | $25 | $25 |
| Consultation office low complexity CPT 99243 • Office Visits | $66 | $106 | $143 |
| Consultation office high complexity CPT 99245 • Office Visits | $66 | $178 | $243 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $50 | $50 | $50 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,208 | $1,208 | $1,208 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,336 | $1,336 | $1,336 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $621 | $621 | $621 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $662 | $662 | $662 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $139 | $139 | $139 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,441 | $1,441 | $1,441 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $633 | $633 | $633 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $416 | $416 | $416 |
| Excision chalazion single CPT 67800 • Ophthalmology | $160 | $160 | $160 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,002 | $1,002 | $1,002 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $97 | $97 | $97 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $76 | $81 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $42 | $46 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $18 | $33 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $44 | $44 | $44 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $33 | $33 | $33 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $50 | $54 | $59 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $69 | $69 | $69 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,879 | $1,879 | $1,879 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,462 | $1,567 | $1,673 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $451 | $451 | $451 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $31 | $31 | $31 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,243 | $1,243 | $1,243 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,278 | $1,278 | $1,278 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $40 | $40 | $40 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,199 | $1,199 | $1,199 |
| Total knee replacement CPT 27447 • Orthopedics | $1,331 | $1,331 | $1,331 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $615 | $615 | $615 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $344 | $344 | $344 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $974 | $974 | $974 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $177 | $177 | $177 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,118 | $1,118 | $1,118 |