| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $50 | $69 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $66 | $102 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $137 | $137 | $137 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $30 | $53 | $76 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $118 | $118 | $118 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $30 | $94 | $157 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $45 | $45 | $45 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $30 | $51 | $71 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $30 | $69 | $108 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $30 | $52 | $73 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $104 | $117 | $130 |
| Consultation office low complexity CPT 99243 • Office Visits | $30 | $30 | $30 |
| Consultation office high complexity CPT 99245 • Office Visits | $204 | $229 | $255 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $545 | $545 | $545 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $45 | $45 | $45 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $666 | $1,302 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $483 | $544 | $605 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $30 | $30 | $30 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $30 | $30 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $323 | $616 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $218 | $405 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $541 | $541 | $541 |
| Excision chalazion single CPT 67800 • Ophthalmology | $74 | $114 | $155 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $966 | $966 | $966 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $42 | $42 | $42 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $68 | $68 | $68 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $33 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $41 | $51 |
| Fundus photography CPT 92250 • Ophthalmology | $18 | $24 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $8 | $8 | $8 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $64 | $64 | $64 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,721 | $1,721 | $1,721 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,592 | $1,592 | $1,592 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| 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 | $30 | $30 |
| Total hip replacement CPT 27130 • Orthopedics | $1,275 | $1,275 | $1,275 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,657 | $1,657 | $1,657 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $608 | $1,186 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,200 | $1,200 | $1,200 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $586 | $1,141 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $652 | $1,274 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $305 | $580 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $451 | $872 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |