| Office visit new patient straightforward CPT 99202 • Office Visits | $75 | $75 | $75 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $106 | $106 | $106 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $45 | $84 | $122 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $45 | $45 | $45 |
| Office visit established patient minimal CPT 99211 • Office Visits | $23 | $23 | $23 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $45 | $45 | $45 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $74 | $74 | $74 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $45 | $45 | $45 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $145 | $145 | $145 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $100 | $100 | $100 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $136 | $136 | $136 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $200 | $200 | $201 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $38 | $38 | $38 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $71 | $71 | $71 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $103 | $103 | $103 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $72 | $72 | $72 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $106 | $107 |
| Consultation office low complexity CPT 99243 • Office Visits | $45 | $45 | $45 |
| Consultation office high complexity CPT 99245 • Office Visits | $224 | $224 | $224 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $550 | $550 | $550 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $46 | $46 | $46 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,097 | $1,097 | $1,097 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $505 | $505 | $506 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $45 | $45 | $45 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $519 | $519 | $519 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $343 | $343 | $343 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $598 | $598 | $598 |
| Excision chalazion single CPT 67800 • Ophthalmology | $45 | $45 | $45 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $45 | $45 | $45 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $45 | $45 | $45 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $85 | $85 | $85 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $127 | $127 | $127 |
| Visual field examination CPT 92083 • Ophthalmology | $27 | $27 | $27 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $25 | $25 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $63 | $63 | $63 |
| Fundus photography CPT 92250 • Ophthalmology | $45 | $45 | $45 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $45 | $45 | $45 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $45 | $45 | $45 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,639 | $1,639 | $1,639 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,543 | $1,543 | $1,543 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,790 | $1,790 | $1,790 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $45 | $45 | $45 |
| Total hip replacement CPT 27130 • Orthopedics | $1,338 | $1,338 | $1,338 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,182 | $1,182 | $1,182 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $45 | $45 | $45 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,144 | $1,144 | $1,144 |
| Total knee replacement CPT 27447 • Orthopedics | $45 | $691 | $1,337 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $571 | $571 | $572 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $45 | $45 | $45 |