| Excision chalazion single CPT 67800 • Ophthalmology | $20 | $25 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $77 | $77 | $77 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $145 | $145 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $12 | $67 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $26 | $26 | $26 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $15 | $15 | $15 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $63 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $30 | $30 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $30 | $30 | $30 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $236 | $236 | $236 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $306 | $581 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $486 | $941 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $423 | $816 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,200 | $1,200 | $1,200 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $46 | $46 | $46 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $65 | $100 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $17 | $17 | $17 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $407 | $784 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $280 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $30 | $30 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $30 | $30 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $30 | $30 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $24 | $24 | $24 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $104 | $181 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $79 | $79 | $79 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $15 | $134 | $254 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $873 | $1,716 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $41 | $58 | $74 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $49 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $30 | $30 | $30 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $170 | $170 | $170 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $88 | $88 | $89 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $149 | $149 | $150 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $436 | $436 | $437 |