| Office visit new patient high complexity CPT 99205 • Office Visits | $210 | $210 | $210 |
| Office visit established patient minimal CPT 99211 • Office Visits | $22 | $25 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $46 | $52 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $64 | $88 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $82 | $122 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $145 | $161 | $176 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $83 | $152 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $93 | $122 | $152 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $140 | $170 | $212 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $47 | $81 | $115 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $70 | $115 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $86 | $115 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $70 | $115 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $109 | $123 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $46 | $69 | $92 |
| Consultation office high complexity CPT 99245 • Office Visits | $202 | $243 | $272 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $601 | $601 | $601 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $37 | $37 | $37 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $237 | $237 | $237 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $539 | $1,047 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $72 | $277 | $482 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $30 | $30 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $70 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $263 | $495 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $229 | $277 | $326 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $25 | $25 | $25 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $566 | $566 | $566 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $112 | $112 | $112 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $61 | $61 | $61 |
| Visual field examination CPT 92083 • Ophthalmology | $60 | $60 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $32 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $21 | $21 | $21 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $30 | $30 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,545 | $1,545 | $1,545 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,800 | $1,800 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $158 | $158 | $158 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $30 | $30 |
| Total hip replacement CPT 27130 • Orthopedics | $1,254 | $1,254 | $1,254 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,631 | $1,631 | $1,631 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $598 | $1,166 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $900 | $900 | $900 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $579 | $1,127 |