| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $216 | $216 | $216 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $98 | $98 | $98 |
| Excision chalazion single CPT 67800 • Ophthalmology | $38 | $45 | $52 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $300 | $561 | $822 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $18 | $18 | $18 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $48 | $48 | $48 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $10 | $81 | $152 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $8 | $29 | $51 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $78 | $78 | $78 |
| Visual field examination CPT 92083 • Ophthalmology | $27 | $32 | $36 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $25 | $25 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $8 | $8 | $8 |
| Fundus photography CPT 92250 • Ophthalmology | $19 | $19 | $19 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $5 | $5 | $5 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $4 | $4 | $4 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $6 | $25 | $43 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,261 | $1,261 | $1,261 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $234 | $234 | $234 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $912 | $912 | $912 |
| Total shoulder replacement CPT 23472 • Orthopedics | $38 | $124 | $210 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,171 | $1,366 | $1,561 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $282 | $342 | $402 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $31 | $35 | $38 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $28 | $28 | $28 |
| Total hip replacement CPT 27130 • Orthopedics | $124 | $124 | $124 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,214 | $1,214 | $1,214 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $810 | $810 | $810 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,190 | $1,190 | $1,190 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $238 | $238 | $238 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $112 | $112 | $112 |
| Total knee replacement CPT 27447 • Orthopedics | $249 | $249 | $249 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $281 | $281 | $281 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $305 | $305 | $305 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $338 | $338 | $338 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $17 | $92 | $167 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $517 | $517 | $517 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $38 | $38 | $38 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $38 | $38 | $38 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $38 | $352 | $666 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $38 | $90 | $142 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $200 | $200 | $200 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $227 | $227 | $227 |
| Carpal tunnel release CPT 64721 • Orthopedics | $329 | $329 | $329 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $8 | $8 | $8 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $105 | $184 | $263 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $21 | $50 | $80 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $74 | $74 | $74 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $287 | $287 | $287 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $42 | $58 | $75 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $33 | $33 | $33 |