| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $37 | $37 | $37 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $97 | $97 | $97 |
| Excision chalazion single CPT 67800 • Ophthalmology | $20 | $20 | $20 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $658 | $767 | $876 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $42 | $42 | $42 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $29 | $29 | $29 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $11 | $11 | $11 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $7 | $23 | $39 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $30 | $30 | $30 |
| Visual field examination CPT 92083 • Ophthalmology | $21 | $35 | $50 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $20 | $26 | $32 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $16 | $16 | $16 |
| Fundus photography CPT 92250 • Ophthalmology | $17 | $17 | $17 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $24 | $24 | $24 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $17 | $17 | $17 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $12 | $26 | $41 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,554 | $1,554 | $1,554 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $907 | $907 | $907 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $254 | $972 | $1,690 |
| Total shoulder replacement CPT 23472 • Orthopedics | $663 | $995 | $1,326 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,035 | $1,256 | $1,478 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $250 | $250 | $250 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $152 | $234 | $317 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $104 | $104 | $104 |
| Total hip replacement CPT 27130 • Orthopedics | $177 | $177 | $177 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $967 | $967 | $967 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $743 | $743 | $743 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $225 | $225 | $225 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $153 | $153 | $153 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $42 | $42 | $42 |
| Total knee replacement CPT 27447 • Orthopedics | $42 | $109 | $176 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $342 | $342 | $342 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $25 | $147 | $270 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $216 | $216 | $216 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $71 | $114 | $157 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $89 | $89 | $89 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $472 | $472 | $472 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $42 | $180 | $319 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $318 | $318 | $318 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $570 | $734 | $898 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $613 | $613 | $613 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $139 | $139 | $139 |
| Carpal tunnel release CPT 64721 • Orthopedics | $42 | $165 | $288 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $75 | $113 | $151 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $27 | $67 | $106 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $62 | $101 | $141 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $85 | $85 | $85 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $242 | $242 | $242 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $32 | $54 | $76 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $38 | $38 | $38 |