| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $38 | $38 | $38 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $67 | $67 | $67 |
| Excision chalazion single CPT 67800 • Ophthalmology | $38 | $38 | $38 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $298 | $298 | $298 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $11 | $61 | $110 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $9 | $9 | $9 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $76 | $76 | $76 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $33 | $36 | $40 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $9 | $52 | $94 |
| Visual field examination CPT 92083 • Ophthalmology | $21 | $24 | $26 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $31 | $31 | $31 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $58 | $58 | $58 |
| Fundus photography CPT 92250 • Ophthalmology | $17 | $21 | $25 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $31 | $31 | $32 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $7 | $23 | $40 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $41 | $41 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,122 | $1,122 | $1,122 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $268 | $268 | $268 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $337 | $1,010 | $1,684 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,240 | $1,240 | $1,240 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $728 | $728 | $728 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $264 | $307 | $351 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $40 | $40 | $40 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $62 | $238 | $414 |
| Total hip replacement CPT 27130 • Orthopedics | $895 | $895 | $895 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,047 | $1,047 | $1,047 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $40 | $40 | $40 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $101 | $101 | $101 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $40 | $122 | $205 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $457 | $457 | $457 |
| Total knee replacement CPT 27447 • Orthopedics | $128 | $128 | $128 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $229 | $229 | $229 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $108 | $108 | $108 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $273 | $273 | $273 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $40 | $291 | $541 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $40 | $40 | $40 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $390 | $390 | $390 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $364 | $364 | $364 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $40 | $40 | $40 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $40 | $81 | $122 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $121 | $121 | $121 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $459 | $459 | $459 |
| Carpal tunnel release CPT 64721 • Orthopedics | $50 | $50 | $50 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $138 | $138 | $138 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $73 | $142 | $211 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $67 | $72 | $77 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $18 | $18 | $18 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $67 | $67 | $67 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $28 | $28 | $28 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $32 | $32 | $32 |