| Office visit established patient minimal CPT 99211 • Office Visits | $30 | $30 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $57 | $57 | $57 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $88 | $88 | $88 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $124 | $125 | $125 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $176 | $176 | $176 |
| 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 | $129 | $129 | $129 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $129 | $129 | $129 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $129 | $129 | $129 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $129 | $129 | $129 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $129 | $129 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $145 | $158 | $171 |
| Consultation office high complexity CPT 99245 • Office Visits | $255 | $255 | $255 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $483 | $483 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $30 | $30 | $30 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $521 | $521 | $521 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $327 | $327 | $327 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $772 | $772 | $772 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $93 | $93 | $93 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $74 | $74 | $74 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $20 | $20 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $35 | $43 | $51 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $44 | $57 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $284 | $433 | $581 |
| Total hip replacement CPT 27130 • Orthopedics | $1,254 | $1,254 | $1,254 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,199 | $1,199 | $1,199 |
| Total knee replacement CPT 27447 • Orthopedics | $1,253 | $1,253 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $568 | $568 | $568 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $865 | $865 | $865 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $169 | $169 | $169 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,045 | $1,045 | $1,045 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $550 | $550 | $550 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $529 | $529 | $530 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $956 | $956 | $956 |
| Carpal tunnel release CPT 64721 • Orthopedics | $433 | $433 | $433 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $158 | $158 | $159 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $26 | $26 | $26 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $254 | $254 | $254 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $2,287 | $2,287 | $2,287 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $74 | $74 | $74 |