| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $60 | $88 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $102 | $131 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $103 | $127 | $145 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $86 | $170 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $93 | $115 | $131 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $149 | $173 | $198 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $40 | $72 | $129 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $73 | $129 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $91 | $129 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $77 | $129 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $109 | $128 | $143 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $71 | $92 |
| Consultation office high complexity CPT 99245 • Office Visits | $172 | $227 | $255 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $30 | $394 | $758 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $30 | $30 | $30 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $197 | $282 | $368 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $483 | $483 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $226 | $261 | $296 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $663 | $663 | $663 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $189 | $508 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $77 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $200 | $541 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $139 | $357 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $10 | $20 | $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 | $122 | $123 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $60 | $61 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $30 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $41 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $26 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $4 | $4 | $4 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $52 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $265 | $959 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $30 | $30 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,800 | $1,800 | $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 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $332 | $332 | $332 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $30 | $30 |
| 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 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $120 | $120 | $120 |