| Initial hospital care high complexity CPT 99223 • Office Visits | $137 | $178 | $198 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $47 | $88 | $129 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $76 | $129 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $101 | $144 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $78 | $129 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $130 | $136 | $143 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $30 | $30 |
| Consultation office high complexity CPT 99245 • Office Visits | $255 | $255 | $255 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $758 | $758 | $758 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $245 | $245 | $245 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $483 | $483 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $296 | $296 | $296 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $747 | $747 | $747 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $269 | $508 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $100 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $586 | $1,141 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $285 | $541 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $193 | $357 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $772 | $772 | $772 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $93 | $120 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $87 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $74 | $107 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $48 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $35 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $29 | $30 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $34 | $36 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $64 | $66 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,800 | $1,946 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $157 | $284 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $642 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $529 | $529 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $532 | $1,035 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $232 | $433 |