| Office visit new patient low complexity CPT 99203 • Office Visits | $151 | $151 | $151 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $50 | $188 | $327 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $50 | $241 | $432 |
| Office visit established patient minimal CPT 99211 • Office Visits | $31 | $31 | $31 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $76 | $76 | $76 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $126 | $126 | $126 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $50 | $50 | $50 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $244 | $244 | $244 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $134 | $134 | $134 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $180 | $180 | $180 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $50 | $157 | $264 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $52 | $52 | $52 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $95 | $95 | $95 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $136 | $136 | $136 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $96 | $96 | $96 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $95 | $117 | $140 |
| Consultation office low complexity CPT 99243 • Office Visits | $80 | $94 | $108 |
| Consultation office high complexity CPT 99245 • Office Visits | $201 | $248 | $294 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $580 | $580 | $580 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $36 | $36 | $36 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,013 | $1,013 | $1,013 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $468 | $470 | $472 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $478 | $478 | $478 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $315 | $315 | $316 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $422 | $422 | $422 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $733 | $733 | $733 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $80 | $80 | $80 |
| Visual field examination CPT 92083 • Ophthalmology | $32 | $32 | $32 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $14 | $14 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $44 | $44 | $44 |
| Fundus photography CPT 92250 • Ophthalmology | $14 | $14 | $14 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $72 | $72 | $72 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $50 | $50 | $50 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $50 | $50 | $50 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,300 | $2,300 | $2,300 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $2,147 | $2,147 | $2,147 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,585 | $1,840 | $2,095 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $349 | $349 | $349 |
| Total hip replacement CPT 27130 • Orthopedics | $1,741 | $1,741 | $1,741 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,506 | $1,506 | $1,506 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,620 | $1,620 | $1,620 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,038 | $1,038 | $1,038 |
| Total knee replacement CPT 27447 • Orthopedics | $50 | $604 | $1,158 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $530 | $537 | $544 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $295 | $295 | $295 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $810 | $921 | $1,031 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $154 | $154 | $154 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $971 | $971 | $971 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $514 | $514 | $514 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $50 | $273 | $496 |