| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $151 | $151 | $151 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $45 | $45 | $45 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $146 | $146 | $146 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $57 | $57 | $57 |
| Excision chalazion single CPT 67800 • Ophthalmology | $80 | $80 | $80 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $328 | $328 | $328 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $73 | $73 | $73 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $5 | $5 | $5 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $67 | $67 | $67 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $37 | $37 | $37 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $10 | $10 | $10 |
| Visual field examination CPT 92083 • Ophthalmology | $39 | $39 | $39 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $49 | $49 | $49 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $5 | $5 | $5 |
| Fundus photography CPT 92250 • Ophthalmology | $24 | $24 | $24 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $6 | $6 | $6 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $7 | $7 | $7 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,052 | $2,052 | $2,052 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,159 | $1,159 | $1,159 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,241 | $1,241 | $1,241 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,810 | $1,810 | $1,810 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $999 | $999 | $999 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $362 | $362 | $362 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $47 | $47 | $47 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $244 | $244 | $244 |
| Total hip replacement CPT 27130 • Orthopedics | $1,527 | $1,527 | $1,527 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,429 | $1,429 | $1,429 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $869 | $869 | $869 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $210 | $210 | $210 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $750 | $750 | $750 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $197 | $197 | $197 |
| Total knee replacement CPT 27447 • Orthopedics | $1,526 | $1,526 | $1,526 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $100 | $100 | $100 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $73 | $73 | $73 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $349 | $349 | $349 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $122 | $122 | $122 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $474 | $474 | $474 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $490 | $490 | $490 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $71 | $71 | $71 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $34 | $34 | $34 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $30 | $30 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $933 | $933 | $933 |
| Carpal tunnel release CPT 64721 • Orthopedics | $433 | $433 | $433 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $14 | $14 | $14 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $10 | $10 | $10 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $97 | $97 | $97 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $42 | $42 | $42 |