| Office visit established patient low complexity CPT 99213 • Office Visits | $45 | $45 | $45 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $95 | $95 | $95 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $45 | $45 | $45 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $45 | $45 | $45 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $45 | $45 | $45 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $45 | $129 | $214 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $45 | $45 | $45 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $45 | $45 | $45 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $96 | $96 | $96 |
| Consultation office low complexity CPT 99243 • Office Visits | $108 | $108 | $108 |
| Consultation office high complexity CPT 99245 • Office Visits | $45 | $45 | $45 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $45 | $45 | $45 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $45 | $45 | $45 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $153 | $153 | $153 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $45 | $45 | $45 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $374 | $374 | $374 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $45 | $45 | $45 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $45 | $45 | $45 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $25 | $35 | $45 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $45 | $45 | $45 |
| Excision chalazion single CPT 67800 • Ophthalmology | $95 | $95 | $95 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $45 | $45 | $45 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $28 | $28 | $28 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $45 | $45 | $45 |
| Fundus photography CPT 92250 • Ophthalmology | $14 | $14 | $14 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $41 | $41 | $41 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $45 | $49 | $52 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $45 | $45 | $45 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,710 | $1,710 | $1,710 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $369 | $369 | $369 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $268 | $268 | $268 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $271 | $271 | $271 |
| Total hip replacement CPT 27130 • Orthopedics | $45 | $45 | $45 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $45 | $45 | $45 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $45 | $45 | $45 |
| 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 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $45 | $45 | $45 |
| Total knee replacement CPT 27447 • Orthopedics | $45 | $45 | $45 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $45 | $45 | $45 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $273 | $273 | $273 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $159 | $159 | $159 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $45 | $45 | $45 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $45 | $45 | $45 |