| Initial hospital care moderate complexity CPT 99222 • Office Visits | $170 | $170 | $170 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $198 | $225 | $252 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $49 | $49 | $49 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $60 | $91 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $80 | $130 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $60 | $91 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $113 | $122 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $91 | $152 |
| Consultation office high complexity CPT 99245 • Office Visits | $191 | $234 | $278 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,474 | $1,474 | $1,474 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $483 | $483 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $369 | $369 | $369 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $988 | $988 | $988 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $412 | $794 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $110 | $190 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $762 | $1,494 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $228 | $425 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $741 | $741 | $741 |
| Excision chalazion single CPT 67800 • Ophthalmology | $124 | $124 | $124 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $772 | $772 | $772 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $187 | $187 | $187 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $66 | $76 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $139 | $156 |
| Visual field examination CPT 92083 • Ophthalmology | $35 | $35 | $35 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $32 | $36 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $58 | $86 |
| Fundus photography CPT 92250 • Ophthalmology | $36 | $49 | $62 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $60 | $60 | $60 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $5 | $23 | $40 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $57 | $60 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $287 | $287 | $287 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $2,047 | $2,294 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,811 | $1,811 | $1,811 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $111 | $192 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $180 | $180 | $180 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $130 | $229 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $165 | $299 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $75 | $75 | $75 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $125 | $219 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $104 | $179 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $348 | $348 | $348 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $530 | $600 | $671 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $231 | $433 |