| Office visit new patient moderate complexity CPT 99204 • Office Visits | $68 | $116 | $163 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $93 | $136 | $180 |
| Office visit established patient minimal CPT 99211 • Office Visits | $4 | $13 | $22 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $18 | $27 | $36 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $46 | $67 | $88 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $65 | $95 | $125 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $91 | $91 | $91 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $50 | $74 | $97 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $68 | $68 | $68 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $99 | $156 | $212 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $19 | $19 | $19 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $36 | $52 | $69 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $51 | $75 | $100 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $10 | $23 | $36 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $53 | $91 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $0 | $58 | $117 |
| Consultation office high complexity CPT 99245 • Office Visits | $0 | $136 | $273 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $204 | $204 | $204 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $27 | $27 | $27 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $381 | $381 | $381 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $158 | $158 | $158 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $90 | $569 | $1,048 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $392 | $437 | $483 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $77 | $77 | $77 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $382 | $382 | $382 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $279 | $400 | $522 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $47 | $78 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $85 | $613 | $1,142 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $384 | $440 | $495 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $98 | $212 | $327 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $234 | $234 | $234 |
| Excision chalazion single CPT 67800 • Ophthalmology | $79 | $101 | $124 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $454 | $613 | $772 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $38 | $38 | $38 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $23 | $23 | $23 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $77 | $77 | $77 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $46 | $66 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $65 | $94 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $14 | $14 | $14 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $8 | $24 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $24 | $36 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $9 | $22 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $28 | $28 | $28 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $18 | $36 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $21 | $42 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $891 | $891 | $891 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $521 | $521 | $521 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $151 | $976 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $105 | $105 | $105 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $835 | $1,206 | $1,576 |