| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $291 | $291 | $291 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $89 | $89 | $89 |
| Excision chalazion single CPT 67800 • Ophthalmology | $12 | $12 | $12 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $150 | $576 | $1,001 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $130 | $130 | $130 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $22 | $22 | $22 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $72 | $80 | $89 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $47 | $66 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $12 | $12 | $12 |
| Visual field examination CPT 92083 • Ophthalmology | $61 | $61 | $61 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $31 | $38 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $19 | $19 | $19 |
| Fundus photography CPT 92250 • Ophthalmology | $19 | $27 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $37 | $73 | $109 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $85 | $85 | $85 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $71 | $101 | $132 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,207 | $1,207 | $1,207 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $44 | $44 | $44 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $376 | $1,127 | $1,878 |
| Total shoulder replacement CPT 23472 • Orthopedics | $44 | $398 | $752 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $251 | $961 | $1,672 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $338 | $395 | $451 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $261 | $308 | $355 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $67 | $67 | $67 |
| Total hip replacement CPT 27130 • Orthopedics | $200 | $200 | $200 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $173 | $952 | $1,730 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $870 | $870 | $870 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $44 | $44 | $44 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $958 | $958 | $958 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $180 | $180 | $180 |
| Total knee replacement CPT 27447 • Orthopedics | $200 | $200 | $200 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $462 | $462 | $462 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $220 | $281 | $343 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $681 | $681 | $681 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $176 | $176 | $177 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $44 | $44 | $44 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $416 | $416 | $416 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $287 | $287 | $287 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $507 | $507 | $507 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $511 | $511 | $511 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $90 | $90 | $90 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $101 | $101 | $101 |
| Carpal tunnel release CPT 64721 • Orthopedics | $291 | $291 | $291 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $9 | $47 | $86 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $100 | $181 | $262 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $20 | $78 | $136 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $14 | $14 | $14 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $44 | $141 | $239 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $6 | $22 | $39 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $36 | $36 | $36 |