| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $55 | $55 | $55 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $414 | $414 | $414 |
| Excision chalazion single CPT 67800 • Ophthalmology | $160 | $160 | $160 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $751 | $876 | $1,001 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $37 | $111 | $185 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $22 | $22 | $22 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $89 | $116 | $144 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $5 | $45 | $85 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $121 | $121 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $12 | $12 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $27 | $38 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $48 | $48 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $27 | $35 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $37 | $46 | $56 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $58 | $58 | $59 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $35 | $40 | $44 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,724 | $1,724 | $1,724 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $811 | $811 | $811 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $939 | $939 | $939 |
| Total shoulder replacement CPT 23472 • Orthopedics | $44 | $774 | $1,503 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $836 | $1,254 | $1,672 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $338 | $338 | $338 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $44 | $59 | $74 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $44 | $272 | $500 |
| Total hip replacement CPT 27130 • Orthopedics | $666 | $666 | $666 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $173 | $952 | $1,730 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $932 | $932 | $932 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,278 | $1,278 | $1,278 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $958 | $958 | $958 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $899 | $899 | $899 |
| Total knee replacement CPT 27447 • Orthopedics | $932 | $932 | $932 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $462 | $462 | $462 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $314 | $314 | $314 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $681 | $681 | $681 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $44 | $44 | $44 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $224 | $224 | $224 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $594 | $594 | $594 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $44 | $44 | $44 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $72 | $72 | $72 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $767 | $767 | $767 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $179 | $179 | $179 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $44 | $44 | $44 |
| Carpal tunnel release CPT 64721 • Orthopedics | $85 | $85 | $85 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $9 | $9 | $9 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $10 | $55 | $99 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $8 | $72 | $136 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $19 | $19 | $19 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $272 | $272 | $272 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $44 | $59 | $74 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $31 | $31 | $31 |