| Office visit established patient high complexity CPT 99215 • Office Visits | $41 | $41 | $41 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $159 | $159 | $159 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $159 | $159 | $159 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $41 | $128 | $214 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $75 | $75 | $75 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $76 | $76 | $76 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $77 | $77 | $77 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $114 | $114 | $114 |
| Consultation office low complexity CPT 99243 • Office Visits | $41 | $41 | $41 |
| Consultation office high complexity CPT 99245 • Office Visits | $41 | $141 | $241 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $492 | $492 | $492 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $53 | $53 | $53 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $896 | $896 | $896 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $921 | $921 | $921 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $486 | $486 | $486 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $41 | $41 | $41 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $41 | $41 | $41 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $86 | $86 | $86 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $534 | $534 | $534 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $41 | $476 | $911 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $464 | $464 | $464 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $41 | $41 | $41 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $92 | $92 | $92 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $68 | $68 | $68 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $45 | $45 | $45 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $73 | $73 | $73 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $14 | $14 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $77 | $77 | $77 |
| Fundus photography CPT 92250 • Ophthalmology | $41 | $41 | $41 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $41 | $41 | $41 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $41 | $41 | $41 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $41 | $41 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,380 | $1,380 | $1,380 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,275 | $1,275 | $1,275 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,502 | $1,502 | $1,502 |
| Total shoulder replacement CPT 23472 • Orthopedics | $41 | $41 | $41 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $41 | $41 | $41 |
| Total hip replacement CPT 27130 • Orthopedics | $1,171 | $1,171 | $1,171 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,367 | $1,367 | $1,367 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $970 | $970 | $970 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $901 | $901 | $901 |
| Total knee replacement CPT 27447 • Orthopedics | $41 | $647 | $1,252 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $41 | $253 | $465 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $41 | $315 | $589 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $41 | $41 | $41 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $877 | $877 | $877 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $561 | $561 | $561 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $41 | $283 | $524 |