| Office visit new patient moderate complexity CPT 99204 • Office Visits | $139 | $139 | $139 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $161 | $161 | $161 |
| Office visit established patient minimal CPT 99211 • Office Visits | $22 | $22 | $22 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $54 | $54 | $54 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $65 | $65 | $65 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $124 | $124 | $124 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $149 | $149 | $149 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $170 | $170 | $170 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $170 | $170 | $170 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $198 | $198 | $198 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $110 | $110 | $110 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $110 | $110 | $110 |
| Consultation office low complexity CPT 99243 • Office Visits | $170 | $170 | $170 |
| Consultation office high complexity CPT 99245 • Office Visits | $254 | $254 | $254 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $601 | $601 | $601 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $37 | $37 | $37 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $237 | $237 | $237 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,047 | $1,047 | $1,047 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $482 | $482 | $482 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $288 | $288 | $288 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $715 | $715 | $715 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $521 | $521 | $521 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $109 | $109 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,141 | $1,141 | $1,141 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $495 | $495 | $495 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $326 | $326 | $326 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $123 | $123 | $123 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $566 | $566 | $566 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $112 | $112 | $112 |
| 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 | $60 | $60 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $48 | $48 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $35 | $35 | $35 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $51 | $51 | $51 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $63 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,545 | $1,545 | $1,545 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,800 | $1,800 | $1,800 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,414 | $1,414 | $1,414 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |