| Office visit established patient high complexity CPT 99215 • Office Visits | $149 | $149 | $149 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $109 | $109 | $109 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $148 | $148 | $148 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $218 | $218 | $218 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $80 | $80 | $80 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $115 | $115 | $115 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $80 | $80 | $80 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $116 | $116 | $116 |
| Consultation office low complexity CPT 99243 • Office Visits | $150 | $150 | $150 |
| Consultation office high complexity CPT 99245 • Office Visits | $272 | $272 | $272 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $700 | $700 | $700 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $70 | $70 | $70 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,186 | $1,186 | $1,186 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $26 | $26 | $26 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,165 | $1,165 | $1,165 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $621 | $621 | $621 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $439 | $439 | $439 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $26 | $26 | $26 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $26 | $26 | $26 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $173 | $173 | $173 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,613 | $1,613 | $1,613 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $694 | $694 | $694 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $1,181 | $1,181 | $1,181 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $593 | $593 | $593 |
| Excision chalazion single CPT 67800 • Ophthalmology | $26 | $26 | $26 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $586 | $586 | $586 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $26 | $26 | $26 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $79 | $79 | $79 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $148 | $148 | $148 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $55 | $55 | $55 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $84 | $84 | $84 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $26 | $26 | $26 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $49 | $49 | $49 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $26 | $26 | $26 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,887 | $1,887 | $1,887 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,781 | $1,781 | $1,781 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $498 | $498 | $498 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $26 | $26 | $26 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $580 | $580 | $580 |
| Total hip replacement CPT 27130 • Orthopedics | $1,708 | $1,708 | $1,708 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,995 | $1,995 | $1,995 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,392 | $1,392 | $1,392 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,431 | $1,431 | $1,431 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,513 | $1,513 | $1,513 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,323 | $1,323 | $1,323 |
| Total knee replacement CPT 27447 • Orthopedics | $1,831 | $1,831 | $1,831 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $648 | $648 | $648 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $26 | $26 | $26 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $802 | $802 | $802 |