| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $87 | $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 | $129 | $134 | $143 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $63 | $95 |
| Consultation office high complexity CPT 99245 • Office Visits | $45 | $150 | $255 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $45 | $402 | $758 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $45 | $45 | $45 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $368 | $368 | $368 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $38 | $45 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $483 | $483 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $296 | $296 | $296 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $663 | $663 | $663 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $269 | $508 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $82 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $197 | $515 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $25 | $142 | $357 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $45 | $45 | $45 |
| Excision chalazion single CPT 67800 • Ophthalmology | $15 | $15 | $15 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $45 | $321 | $596 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $142 | $142 | $142 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $147 | $147 | $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 | $34 | $48 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $26 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $40 | $45 |
| Fundus photography CPT 92250 • Ophthalmology | $7 | $22 | $36 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $40 | $43 | $45 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $51 | $66 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $265 | $959 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $45 | $45 | $45 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,710 | $1,755 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,462 | $1,519 | $1,576 |
| 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 | $45 | $45 | $45 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $45 | $45 | $45 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $38 | $45 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $568 | $1,105 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $38 | $45 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $38 | $45 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $45 | $45 | $45 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $38 | $45 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $38 | $45 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $38 | $45 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $45 | $45 | $45 |