| Office visit established patient high complexity CPT 99215 • Office Visits | $143 | $143 | $143 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $100 | $100 | $100 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $135 | $135 | $135 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $199 | $199 | $200 |
| 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 | $102 | $102 | $102 |
| 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 | $105 | $105 | $106 |
| Consultation office low complexity CPT 99243 • Office Visits | $114 | $114 | $115 |
| Consultation office high complexity CPT 99245 • Office Visits | $209 | $209 | $209 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $30 | $30 | $30 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $30 | $30 | $30 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,020 | $1,020 | $1,020 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $554 | $554 | $554 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $30 | $30 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $664 | $664 | $664 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $71 | $71 | $71 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $12 | $12 | $12 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $30 | $30 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $48 | $67 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,930 | $1,930 | $1,930 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $30 | $30 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,095 | $2,095 | $2,095 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $778 | $1,526 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $531 | $1,031 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $319 | $608 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $30 | $30 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $30 | $30 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $30 | $30 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $104 | $179 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $281 | $281 | $282 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $278 | $278 | $278 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $30 | $30 | $30 |