| Office visit established patient minimal CPT 99211 • Office Visits | $32 | $32 | $32 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $48 | $48 | $48 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $80 | $80 | $80 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $116 | $117 | $119 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $155 | $155 | $155 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $128 | $128 | $128 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $146 | $146 | $146 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $214 | $214 | $215 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $82 | $82 | $82 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $82 | $82 | $82 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $82 | $82 | $82 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $113 | $113 | $114 |
| Consultation office low complexity CPT 99243 • Office Visits | $153 | $153 | $153 |
| Consultation office high complexity CPT 99245 • Office Visits | $276 | $276 | $276 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $551 | $551 | $551 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $69 | $69 | $69 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,193 | $1,193 | $1,193 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $627 | $627 | $628 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $45 | $45 | $45 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $45 | $45 | $45 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $887 | $887 | $887 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $693 | $693 | $693 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $1,181 | $1,181 | $1,181 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $603 | $603 | $603 |
| Excision chalazion single CPT 67800 • Ophthalmology | $45 | $45 | $45 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $437 | $586 | $735 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $119 | $119 | $119 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $77 | $77 | $77 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $103 | $103 | $103 |
| Visual field examination CPT 92083 • Ophthalmology | $43 | $43 | $43 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $28 | $28 | $28 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $86 | $86 | $86 |
| Fundus photography CPT 92250 • Ophthalmology | $26 | $26 | $26 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $31 | $31 | $31 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $47 | $47 | $47 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $52 | $72 | $91 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,980 | $1,980 | $1,980 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,826 | $1,826 | $1,826 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,710 | $1,952 | $2,194 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,308 | $1,308 | $1,308 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,462 | $1,462 | $1,462 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $369 | $369 | $369 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $284 | $284 | $284 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $45 | $45 | $45 |
| Total hip replacement CPT 27130 • Orthopedics | $1,670 | $1,670 | $1,670 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,949 | $1,949 | $1,949 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,382 | $1,382 | $1,382 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,105 | $1,105 | $1,105 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,105 | $1,105 | $1,105 |