| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $88 | $145 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $30 | $30 | $30 |
| Office visit established patient minimal CPT 99211 • Office Visits | $19 | $19 | $19 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $47 | $47 | $47 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $78 | $78 | $78 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $30 | $30 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $156 | $156 | $156 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $135 | $135 | $135 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $153 | $153 | $153 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $30 | $128 | $225 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $81 | $81 | $81 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $81 | $81 | $81 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $115 | $115 | $115 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $81 | $81 | $81 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $117 | $117 | $118 |
| Consultation office low complexity CPT 99243 • Office Visits | $100 | $107 | $114 |
| Consultation office high complexity CPT 99245 • Office Visits | $30 | $124 | $217 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $590 | $590 | $590 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $49 | $49 | $49 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,467 | $1,467 | $1,467 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,356 | $1,356 | $1,356 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $623 | $623 | $624 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $928 | $928 | $928 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $641 | $641 | $641 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $227 | $424 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $742 | $742 | $742 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $184 | $184 | $184 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $96 | $96 | $96 |
| Visual field examination CPT 92083 • Ophthalmology | $33 | $33 | $33 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $53 | $53 | $53 |
| Fundus photography CPT 92250 • Ophthalmology | $38 | $38 | $38 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $30 | $30 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,883 | $1,883 | $1,883 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,755 | $1,755 | $1,755 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,050 | $2,050 | $2,050 |
| Total hip replacement CPT 27130 • Orthopedics | $1,422 | $1,422 | $1,422 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,849 | $1,849 | $1,849 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,317 | $1,317 | $1,317 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,276 | $1,276 | $1,276 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $726 | $1,421 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $332 | $633 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $504 | $978 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,180 | $1,180 | $1,180 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $618 | $618 | $618 |