| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $33 | $33 | $33 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $21 | $21 | $21 |
| Excision chalazion single CPT 67800 • Ophthalmology | $124 | $124 | $124 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $143 | $143 | $143 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $23 | $23 | $23 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $23 | $23 | $23 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $73 | $73 | $73 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $9 | $9 | $9 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $34 | $34 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $15 | $15 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $30 | $30 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $5 | $5 | $5 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $27 | $27 | $27 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $63 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,241 | $1,241 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,545 | $1,545 | $1,545 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,351 | $1,351 | $1,351 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,414 | $1,414 | $1,414 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $236 | $236 | $236 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $442 | $442 | $442 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $66 | $66 | $66 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $87 | $87 | $87 |
| Total hip replacement CPT 27130 • Orthopedics | $1,255 | $1,255 | $1,255 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,224 | $1,224 | $1,224 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $233 | $233 | $233 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $180 | $180 | $180 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $240 | $240 | $240 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $113 | $113 | $113 |
| Total knee replacement CPT 27447 • Orthopedics | $940 | $940 | $940 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $114 | $114 | $114 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $142 | $142 | $142 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $350 | $350 | $350 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $85 | $85 | $85 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $784 | $784 | $784 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $275 | $275 | $275 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $530 | $530 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $472 | $472 | $472 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $143 | $143 | $143 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $190 | $190 | $190 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $807 | $807 | $807 |
| Carpal tunnel release CPT 64721 • Orthopedics | $425 | $425 | $425 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $32 | $32 | $32 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $51 | $51 | $51 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $21 | $21 | $21 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $127 | $127 | $127 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $60 | $60 | $60 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $8 | $8 | $8 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $49 | $49 | $49 |