| Office visit new patient moderate complexity CPT 99204 • Office Visits | $155 | $180 | $205 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $203 | $203 | $203 |
| Office visit established patient minimal CPT 99211 • Office Visits | $21 | $28 | $34 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $52 | $60 | $67 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $91 | $100 | $110 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $119 | $128 | $136 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $184 | $199 | $214 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $71 | $109 | $146 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $113 | $155 | $197 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $151 | $221 | $291 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $43 | $63 | $84 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $73 | $89 | $105 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $103 | $127 | $150 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $75 | $91 | $106 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $131 | $155 |
| Consultation office low complexity CPT 99243 • Office Visits | $32 | $32 | $32 |
| Consultation office high complexity CPT 99245 • Office Visits | $326 | $326 | $326 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $467 | $467 | $467 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $69 | $69 | $69 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,206 | $1,206 | $1,206 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $645 | $645 | $645 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $461 | $461 | $461 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $103 | $103 | $103 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $521 | $521 | $521 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $997 | $997 | $997 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $600 | $600 | $600 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $127 | $127 | $127 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $80 | $80 | $80 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $133 | $133 | $133 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $113 | $113 | $113 |
| Visual field examination CPT 92083 • Ophthalmology | $54 | $54 | $54 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $25 | $26 | $27 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $16 | $54 | $92 |
| Fundus photography CPT 92250 • Ophthalmology | $23 | $26 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $32 | $39 | $47 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $77 | $77 | $77 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $32 | $40 | $48 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,542 | $1,542 | $1,542 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,439 | $1,439 | $1,439 |
| Total hip replacement CPT 27130 • Orthopedics | $1,239 | $1,239 | $1,239 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,530 | $1,530 | $1,530 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,096 | $1,096 | $1,096 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,060 | $1,060 | $1,060 |
| Total knee replacement CPT 27447 • Orthopedics | $1,238 | $1,238 | $1,238 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $535 | $535 | $535 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $459 | $573 | $686 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $32 | $32 | $32 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $972 | $972 | $972 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $521 | $521 | $521 |