| Office visit established patient minimal CPT 99211 • Office Visits | $25 | $25 | $25 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $37 | $37 | $37 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $74 | $74 | $74 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $12 | $12 | $12 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $118 | $118 | $118 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $144 | $144 | $144 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $108 | $108 | $108 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $159 | $159 | $159 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $92 | $92 | $92 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $80 | $80 | $80 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $82 | $82 | $82 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $92 | $92 | $92 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $112 | $114 | $116 |
| Consultation office low complexity CPT 99243 • Office Visits | $62 | $102 | $142 |
| Consultation office high complexity CPT 99245 • Office Visits | $242 | $242 | $242 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $479 | $479 | $479 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $39 | $39 | $39 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,174 | $1,174 | $1,174 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $205 | $205 | $205 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $531 | $531 | $531 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $237 | $237 | $237 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $744 | $744 | $744 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $543 | $543 | $543 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $91 | $91 | $91 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,185 | $1,185 | $1,185 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $518 | $518 | $518 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $341 | $350 | $358 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $484 | $484 | $484 |
| Excision chalazion single CPT 67800 • Ophthalmology | $102 | $102 | $102 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $851 | $851 | $851 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $118 | $118 | $118 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $58 | $58 | $58 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $63 | $63 | $63 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $60 | $60 | $60 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $85 | $85 | $85 |
| Visual field examination CPT 92083 • Ophthalmology | $18 | $18 | $18 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $17 | $17 | $17 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $33 | $33 | $33 |
| Fundus photography CPT 92250 • Ophthalmology | $11 | $11 | $11 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $45 | $45 | $45 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $31 | $31 | $31 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $55 | $61 | $66 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,378 | $1,378 | $1,378 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,295 | $1,295 | $1,295 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,502 | $1,670 | $1,839 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,200 | $1,200 | $1,200 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $292 | $292 | $292 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $520 | $520 | $520 |
| Total hip replacement CPT 27130 • Orthopedics | $1,063 | $1,063 | $1,063 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $991 | $991 | $991 |