| Office visit established patient minimal CPT 99211 • Office Visits | $23 | $23 | $23 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $41 | $41 | $41 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $58 | $58 | $58 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $90 | $90 | $90 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $131 | $131 | $131 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $74 | $74 | $74 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $122 | $122 | $122 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $170 | $170 | $170 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $37 | $37 | $37 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $60 | $60 | $60 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $86 | $86 | $86 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $77 | $77 | $77 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $105 | $105 | $105 |
| Consultation office low complexity CPT 99243 • Office Visits | $133 | $133 | $133 |
| Consultation office high complexity CPT 99245 • Office Visits | $242 | $242 | $242 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $625 | $625 | $625 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $67 | $67 | $67 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,129 | $1,129 | $1,129 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $380 | $380 | $380 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,034 | $1,034 | $1,034 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $549 | $549 | $549 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $403 | $403 | $403 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $989 | $989 | $989 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $753 | $753 | $753 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $376 | $376 | $376 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,594 | $1,594 | $1,594 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $636 | $636 | $636 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $992 | $992 | $992 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $550 | $550 | $550 |
| Excision chalazion single CPT 67800 • Ophthalmology | $162 | $162 | $162 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $565 | $565 | $565 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $199 | $199 | $199 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $76 | $76 | $76 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $139 | $139 | $139 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $70 | $70 | $70 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $103 | $103 | $103 |
| Visual field examination CPT 92083 • Ophthalmology | $76 | $76 | $76 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $35 | $35 | $35 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $33 | $33 | $33 |
| Fundus photography CPT 92250 • Ophthalmology | $90 | $90 | $90 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $56 | $56 | $56 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $62 | $62 | $62 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $75 | $75 | $75 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,100 | $2,100 | $2,100 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,603 | $1,603 | $1,603 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,250 | $2,250 | $2,250 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,569 | $1,569 | $1,569 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,983 | $1,983 | $1,983 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $439 | $439 | $439 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $308 | $308 | $308 |