| Office visit new patient moderate complexity CPT 99204 • Office Visits | $132 | $148 | $164 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $183 | $185 | $188 |
| Office visit established patient minimal CPT 99211 • Office Visits | $30 | $30 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $54 | $54 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $53 | $75 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $69 | $109 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $176 | $176 | $176 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $100 | $170 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $131 | $131 | $131 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $147 | $172 | $198 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $70 | $110 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $65 | $99 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $70 | $110 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $97 | $103 | $110 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $30 | $30 |
| Consultation office high complexity CPT 99245 • Office Visits | $243 | $248 | $254 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $30 | $30 | $30 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $30 | $30 | $30 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,304 | $1,304 | $1,304 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $482 | $482 | $483 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $30 | $30 | $30 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $30 | $30 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $30 | $30 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $203 | $377 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $873 | $873 | $873 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $72 | $72 | $72 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $65 | $65 | $65 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $30 | $30 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $157 | $284 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $615 | $1,199 |