| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $71 | $111 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $85 | $113 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $73 | $111 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $93 | $122 | $136 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $51 | $92 |
| Consultation office high complexity CPT 99245 • Office Visits | $172 | $247 | $285 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $30 | $30 | $30 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $30 | $30 | $30 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $262 | $262 | $262 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $625 | $625 | $626 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $30 | $30 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $72 | $114 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $764 | $1,497 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $219 | $409 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $736 | $850 | $964 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $188 | $188 | $188 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $49 | $70 | $91 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $128 | $128 | $128 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $34 | $34 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $32 | $41 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $22 | $26 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $51 | $51 | $51 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $46 | $62 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $60 | $66 | $72 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,931 | $1,931 | $1,931 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $30 | $30 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,053 | $2,053 | $2,053 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,839 | $1,839 | $1,839 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $483 | $483 | $483 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $357 | $357 | $357 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $179 | $327 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $646 | $1,261 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $339 | $648 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $110 | $190 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |