| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $105 | $124 | $143 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $69 | $108 |
| Consultation office high complexity CPT 99245 • Office Visits | $204 | $237 | $269 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $758 | $758 | $758 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $368 | $368 | $368 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $605 | $605 | $605 |
| 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 | $193 | $355 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $75 | $119 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $285 | $541 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $357 | $381 | $406 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $106 | $106 | $106 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $147 | $147 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $40 | $64 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $50 | $87 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $62 | $62 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $35 | $44 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $29 | $30 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $33 | $36 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $47 | $64 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,946 | $1,946 | $1,946 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,824 | $1,824 | $1,824 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,596 | $1,596 | $1,596 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $417 | $417 | $417 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $30 | $30 |
| 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 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $581 | $581 | $581 |
| 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 | $543 | $543 | $543 |
| 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 | $85 | $141 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $30 | $30 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $94 | $157 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $258 | $258 | $258 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $254 | $254 | $254 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $30 | $30 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $30 | $30 | $30 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $48 |