| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $312 | $312 | $312 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $484 | $484 | $484 |
| Excision chalazion single CPT 67800 • Ophthalmology | $93 | $93 | $93 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $44 | $97 | $150 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $30 | $30 | $30 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $3 | $3 | $3 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $22 | $55 | $89 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $6 | $46 | $85 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $43 | $57 | $71 |
| Visual field examination CPT 92083 • Ophthalmology | $25 | $25 | $25 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $19 | $23 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $13 | $13 | $13 |
| Fundus photography CPT 92250 • Ophthalmology | $11 | $23 | $35 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $44 | $44 | $44 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $29 | $44 | $58 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $27 | $48 | $69 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,207 | $1,207 | $1,207 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $259 | $259 | $259 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $150 | $1,014 | $1,878 |
| Total shoulder replacement CPT 23472 • Orthopedics | $44 | $472 | $900 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $668 | $668 | $668 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $316 | $316 | $316 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $44 | $58 | $71 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $25 | $25 | $25 |
| Total hip replacement CPT 27130 • Orthopedics | $106 | $106 | $106 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $138 | $934 | $1,730 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $694 | $694 | $694 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $639 | $639 | $639 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $128 | $128 | $128 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $143 | $143 | $143 |
| Total knee replacement CPT 27447 • Orthopedics | $998 | $998 | $998 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $92 | $92 | $92 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $44 | $44 | $44 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $97 | $97 | $97 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $44 | $57 | $71 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $839 | $839 | $839 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $297 | $297 | $297 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $46 | $46 | $46 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $44 | $65 | $87 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $716 | $716 | $716 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $817 | $817 | $817 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $202 | $202 | $202 |
| Carpal tunnel release CPT 64721 • Orthopedics | $77 | $77 | $77 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $43 | $43 | $43 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $10 | $136 | $262 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $18 | $46 | $74 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $46 | $46 | $46 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $39 | $39 | $39 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $4 | $39 | $74 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $29 | $29 | $29 |