| Office visit established patient minimal CPT 99211 • Office Visits | $22 | $29 | $38 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $57 | $61 | $68 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $68 | $88 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $93 | $142 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $176 | $200 | $220 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $78 | $127 | $171 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $30 | $140 | $219 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $30 | $173 | $289 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $33 | $81 | $130 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $78 | $130 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $92 | $130 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $82 | $130 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $100 | $115 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $108 | $145 | $171 |
| Consultation office high complexity CPT 99245 • Office Visits | $255 | $263 | $272 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $30 | $428 | $827 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $30 | $33 | $36 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $30 | $99 | $169 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $482 | $482 | $482 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $30 | $124 | $217 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $30 | $353 | $676 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $266 | $503 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $109 | $111 | $113 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $951 | $1,046 | $1,141 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $30 | $30 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $75 | $119 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $142 | $142 | $142 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $77 | $80 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $86 | $116 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $87 | $89 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $119 | $121 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $60 | $61 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $27 | $33 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $42 | $45 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $35 | $36 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $44 | $58 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $32 | $35 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $36 | $43 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $223 | $938 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $787 | $1,543 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,774 | $1,787 | $1,800 |
| Total shoulder replacement CPT 23472 • Orthopedics | $30 | $30 | $30 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $390 | $401 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $30 | $30 | $30 |