| Office visit new patient high complexity CPT 99205 • Office Visits | $296 | $296 | $296 |
| Office visit established patient minimal CPT 99211 • Office Visits | $31 | $31 | $31 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $63 | $63 | $63 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $104 | $104 | $104 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $115 | $134 | $154 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $208 | $208 | $208 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $145 | $145 | $145 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $196 | $196 | $196 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $291 | $291 | $291 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $56 | $56 | $56 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $104 | $104 | $104 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $150 | $150 | $150 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $105 | $105 | $105 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $155 | $155 | $155 |
| Consultation office low complexity CPT 99243 • Office Visits | $67 | $67 | $67 |
| Consultation office high complexity CPT 99245 • Office Visits | $319 | $319 | $319 |
| 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 | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $30 | $30 | $30 |
| 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 | $30 | $30 |
| Cataract surgery complex with intraocular lens CPT 66982 • 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 | $30 | $30 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $30 | $30 | $30 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $30 | $30 |
| 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 | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $145 | $145 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $34 | $34 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $24 | $24 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $29 | $29 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $73 | $73 | $73 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $87 | $87 | $87 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,492 | $2,492 | $2,492 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $2,315 | $2,315 | $2,315 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,703 | $2,703 | $2,703 |
| 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 | $412 | $412 | $412 |