| Office visit new patient low complexity CPT 99203 • Office Visits | $90 | $90 | $90 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $159 | $159 | $159 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $359 | $359 | $359 |
| Office visit established patient minimal CPT 99211 • Office Visits | $38 | $38 | $38 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $53 | $53 | $53 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $57 | $57 | $57 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $122 | $122 | $122 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $276 | $276 | $276 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $78 | $78 | $78 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $115 | $115 | $115 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $164 | $164 | $164 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $75 | $75 | $75 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $69 | $69 | $69 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $117 | $117 | $117 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $119 | $119 | $119 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $175 | $175 | $175 |
| Consultation office low complexity CPT 99243 • Office Visits | $110 | $110 | $110 |
| Consultation office high complexity CPT 99245 • Office Visits | $198 | $198 | $198 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $704 | $704 | $704 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $35 | $35 | $35 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $238 | $238 | $238 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,016 | $1,016 | $1,016 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $196 | $196 | $196 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $614 | $614 | $614 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $419 | $419 | $419 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $106 | $106 | $106 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,105 | $1,105 | $1,105 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $463 | $463 | $463 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $283 | $283 | $283 |
| Excision chalazion single CPT 67800 • Ophthalmology | $112 | $112 | $112 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $186 | $186 | $186 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $73 | $73 | $73 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $115 | $115 | $115 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $77 | $77 | $77 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $136 | $136 | $136 |
| Visual field examination CPT 92083 • Ophthalmology | $55 | $55 | $55 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $24 | $24 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $43 | $43 | $43 |
| Fundus photography CPT 92250 • Ophthalmology | $32 | $32 | $32 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $87 | $87 | $87 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $89 | $89 | $89 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $107 | $107 | $107 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,542 | $1,542 | $1,542 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $97 | $97 | $97 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $213 | $213 | $213 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $528 | $528 | $528 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $445 | $445 | $445 |
| Total hip replacement CPT 27130 • Orthopedics | $1,794 | $1,794 | $1,794 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,034 | $1,034 | $1,034 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,727 | $1,727 | $1,727 |