| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $142 | $253 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $30 | $192 | $318 |
| Office visit established patient minimal CPT 99211 • Office Visits | $11 | $25 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $29 | $45 | $66 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $56 | $84 | $111 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $96 | $165 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $30 | $126 | $223 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $74 | $148 | $261 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $124 | $190 | $261 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $172 | $254 | $315 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $37 | $66 | $116 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $61 | $94 | $123 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $85 | $112 | $162 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $78 | $110 | $146 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $157 | $214 |
| Consultation office low complexity CPT 99243 • Office Visits | $90 | $166 | $247 |
| Consultation office high complexity CPT 99245 • Office Visits | $178 | $325 | $453 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $30 | $528 | $941 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $30 | $55 | $78 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,105 | $1,312 | $1,701 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $30 | $295 | $511 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $861 | $1,534 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $482 | $597 | $822 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $30 | $335 | $602 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $30 | $774 | $1,481 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $595 | $1,115 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $177 | $328 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $1,216 | $2,239 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $562 | $976 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $831 | $1,528 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $30 | $430 | $801 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $93 | $153 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $447 | $820 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $108 | $158 | $225 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $38 | $90 | $137 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $72 | $150 | $251 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $30 | $88 | $144 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $48 | $160 | $246 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $55 | $108 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $23 | $40 | $76 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $82 | $151 |
| Fundus photography CPT 92250 • Ophthalmology | $58 | $87 | $132 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $55 | $91 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $57 | $95 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $66 | $115 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,891 | $2,978 | $3,662 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $2,040 | $2,723 | $3,385 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,050 | $3,221 | $3,969 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,313 | $2,387 | $3,044 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $2,365 | $3,160 |