| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $97 | $228 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $81 | $194 | $307 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $138 | $262 | $451 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $49 | $69 | $88 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $84 | $162 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $118 | $233 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $101 | $163 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $109 | $159 | $238 |
| Consultation office straightforward CPT 99241 • Office Visits | $49 | $49 | $49 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $52 | $74 |
| Consultation office high complexity CPT 99245 • Office Visits | $66 | $273 | $499 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $483 | $483 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $276 | $521 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $30 | $30 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $30 | $30 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $772 | $772 | $772 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $74 | $98 | $122 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $30 | $30 |
| Fundus photography CPT 92250 • Ophthalmology | $15 | $23 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $35 | $35 | $35 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $110 | $157 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $5,459 | $5,459 | $5,459 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $5,100 | $5,100 | $5,100 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $3,872 | $5,943 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,414 | $1,414 | $1,414 |
| 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 | $792 | $792 | $792 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $157 | $284 |
| Total hip replacement CPT 27130 • Orthopedics | $3,124 | $3,124 | $3,124 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $4,062 | $4,062 | $4,062 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $1,467 | $2,904 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $2,985 | $2,985 | $2,985 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $1,419 | $2,808 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $1,576 | $3,121 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $722 | $1,415 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $1,092 | $2,153 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $225 | $421 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $1,317 | $2,604 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $1,370 | $1,370 | $1,370 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $530 | $925 | $1,319 |