| Office visit established patient minimal CPT 99211 • Office Visits | $9 | $9 | $9 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $18 | $18 | $18 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $30 | $30 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $45 | $45 | $45 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $61 | $61 | $61 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $44 | $44 | $44 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $59 | $59 | $59 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $87 | $87 | $87 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $17 | $17 | $17 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $32 | $32 | $32 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $45 | $45 | $45 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $31 | $31 | $31 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $45 | $45 | $45 |
| Consultation office low complexity CPT 99243 • Office Visits | $45 | $45 | $45 |
| Consultation office high complexity CPT 99245 • Office Visits | $104 | $104 | $104 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $295 | $295 | $295 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $29 | $29 | $29 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $481 | $481 | $481 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $125 | $125 | $125 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $491 | $491 | $491 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $257 | $257 | $257 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $186 | $186 | $186 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $447 | $447 | $447 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $321 | $321 | $321 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $88 | $88 | $88 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $673 | $673 | $673 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $280 | $280 | $280 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $498 | $498 | $498 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $250 | $250 | $250 |
| Excision chalazion single CPT 67800 • Ophthalmology | $53 | $53 | $53 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $295 | $295 | $295 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $49 | $49 | $49 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $33 | $33 | $33 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $43 | $43 | $43 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $34 | $34 | $34 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $34 | $34 | $34 |
| Visual field examination CPT 92083 • Ophthalmology | $23 | $23 | $23 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $7 | $7 | $7 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $35 | $35 | $35 |
| Fundus photography CPT 92250 • Ophthalmology | $10 | $10 | $10 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $17 | $17 | $17 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $25 | $25 | $25 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $33 | $33 | $33 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $849 | $849 | $849 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $699 | $699 | $699 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $909 | $909 | $909 |
| Total shoulder replacement CPT 23472 • Orthopedics | $659 | $659 | $659 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $801 | $801 | $801 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $189 | $189 | $189 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $118 | $118 | $118 |