| Office visit established patient minimal CPT 99211 • Office Visits | $13 | $13 | $13 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $35 | $35 | $35 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $75 | $75 | $75 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $86 | $86 | $86 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $138 | $138 | $138 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $99 | $99 | $99 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $164 | $164 | $164 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $229 | $229 | $229 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $50 | $50 | $50 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $81 | $81 | $81 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $115 | $115 | $115 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $103 | $103 | $103 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $140 | $140 | $140 |
| Consultation office low complexity CPT 99243 • Office Visits | $135 | $135 | $135 |
| Consultation office high complexity CPT 99245 • Office Visits | $267 | $267 | $267 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $856 | $856 | $856 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $78 | $78 | $78 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,701 | $1,701 | $1,701 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $511 | $511 | $511 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,534 | $1,534 | $1,534 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $822 | $822 | $822 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $526 | $526 | $526 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $1,481 | $1,481 | $1,481 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $1,115 | $1,115 | $1,115 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $254 | $254 | $254 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $2,239 | $2,239 | $2,239 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $976 | $976 | $976 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $1,353 | $1,353 | $1,353 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $801 | $801 | $801 |
| Excision chalazion single CPT 67800 • Ophthalmology | $153 | $153 | $153 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $820 | $820 | $820 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $225 | $225 | $225 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $69 | $69 | $69 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $132 | $132 | $132 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $93 | $93 | $93 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $137 | $137 | $137 |
| Visual field examination CPT 92083 • Ophthalmology | $104 | $104 | $104 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $47 | $47 | $47 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $76 | $76 | $76 |
| Fundus photography CPT 92250 • Ophthalmology | $35 | $35 | $35 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $67 | $67 | $67 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $68 | $68 | $68 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $80 | $80 | $80 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $3,023 | $3,023 | $3,023 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $2,379 | $2,379 | $2,379 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $3,258 | $3,258 | $3,258 |
| Total shoulder replacement CPT 23472 • Orthopedics | $2,365 | $2,365 | $2,365 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $2,902 | $2,902 | $2,902 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $643 | $643 | $643 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $430 | $430 | $430 |