| Office visit new patient straightforward CPT 99202 • Office Visits | $50 | $79 | $108 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $110 | $133 | $157 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $130 | $184 | $239 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $221 | $261 | $301 |
| Office visit established patient minimal CPT 99211 • Office Visits | $23 | $26 | $29 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $55 | $59 | $63 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $83 | $95 | $106 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $99 | $128 | $156 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $164 | $188 | $211 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $70 | $110 | $149 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $201 | $237 | $273 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $298 | $321 | $343 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $58 | $80 | $103 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $106 | $131 | $155 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $91 | $123 | $154 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $78 | $93 | $107 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $131 | $144 | $158 |
| Consultation office low complexity CPT 99243 • Office Visits | $179 | $179 | $179 |
| Consultation office high complexity CPT 99245 • Office Visits | $327 | $327 | $327 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $676 | $1,114 | $1,725 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $106 | $233 | $360 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,849 | $3,939 | $6,029 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $218 | $500 | $903 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,701 | $2,811 | $3,920 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $999 | $2,459 | $3,920 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $457 | $680 | $903 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $666 | $1,942 | $3,920 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $486 | $1,801 | $3,920 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $159 | $259 | $360 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,875 | $3,952 | $6,029 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $805 | $854 | $903 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $530 | $716 | $903 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $930 | $2,425 | $3,920 |
| Excision chalazion single CPT 67800 • Ophthalmology | $122 | $226 | $360 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,167 | $2,543 | $3,920 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $64 | $217 | $360 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $75 | $75 | $75 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $141 | $141 | $141 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $85 | $85 | $85 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $120 | $120 | $120 |
| Visual field examination CPT 92083 • Ophthalmology | $56 | $56 | $56 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $26 | $26 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $16 | $16 | $16 |
| Fundus photography CPT 92250 • Ophthalmology | $47 | $47 | $47 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $52 | $162 | $360 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $164 | $360 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $46 | $167 | $360 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,608 | $4,102 | $7,025 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $2,024 | $3,845 | $7,025 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,783 | $6,911 | $15,048 |