| Office visit new patient low complexity CPT 99203 • Office Visits | $113 | $113 | $113 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $154 | $154 | $154 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $204 | $204 | $204 |
| Office visit established patient minimal CPT 99211 • Office Visits | $24 | $24 | $24 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $51 | $51 | $51 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $83 | $83 | $83 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $117 | $117 | $117 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $165 | $165 | $165 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $164 | $164 | $164 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $164 | $164 | $164 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $180 | $197 | $214 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $82 | $82 | $82 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $82 | $82 | $82 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $110 | $110 | $110 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $82 | $82 | $82 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $96 | $105 | $113 |
| Consultation office low complexity CPT 99243 • Office Visits | $12 | $17 | $21 |
| Consultation office high complexity CPT 99245 • Office Visits | $21 | $130 | $238 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $589 | $589 | $589 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $47 | $47 | $47 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,424 | $1,424 | $1,424 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $299 | $299 | $299 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,322 | $1,322 | $1,322 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $610 | $610 | $610 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $625 | $625 | $625 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $412 | $412 | $412 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $583 | $583 | $583 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $979 | $979 | $979 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $142 | $142 | $142 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $98 | $98 | $98 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $171 | $171 | $171 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $46 | $46 | $46 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $56 | $56 | $56 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $68 | $68 | $68 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,847 | $1,847 | $1,847 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,711 | $1,711 | $1,711 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,004 | $2,004 | $2,004 |
| Total hip replacement CPT 27130 • Orthopedics | $1,367 | $1,367 | $1,367 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,779 | $1,779 | $1,779 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,270 | $1,270 | $1,270 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $21 | $21 | $21 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,229 | $1,229 | $1,229 |
| Total knee replacement CPT 27447 • Orthopedics | $1,366 | $1,366 | $1,366 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $617 | $617 | $618 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $923 | $923 | $924 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,137 | $1,137 | $1,137 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $598 | $598 | $598 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $576 | $576 | $576 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $21 | $21 | $21 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $981 | $981 | $981 |