| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $48 | $48 | $48 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $391 | $391 | $391 |
| Excision chalazion single CPT 67800 • Ophthalmology | $12 | $12 | $12 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $549 | $549 | $549 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $77 | $77 | $77 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $5 | $46 | $87 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $99 | $126 | $154 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $8 | $8 | $8 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $79 | $104 | $129 |
| Visual field examination CPT 92083 • Ophthalmology | $28 | $28 | $28 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $28 | $41 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $24 | $39 | $55 |
| Fundus photography CPT 92250 • Ophthalmology | $40 | $40 | $40 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $23 | $23 | $23 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $5 | $5 | $5 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $6 | $6 | $6 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,093 | $1,093 | $1,093 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,028 | $1,028 | $1,028 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $796 | $796 | $796 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,271 | $1,271 | $1,271 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $284 | $284 | $284 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $371 | $371 | $371 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $141 | $141 | $141 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $26 | $26 | $26 |
| Total hip replacement CPT 27130 • Orthopedics | $564 | $564 | $564 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $220 | $220 | $220 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,046 | $1,046 | $1,046 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $538 | $538 | $538 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $108 | $108 | $108 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $101 | $101 | $101 |
| Total knee replacement CPT 27447 • Orthopedics | $563 | $563 | $563 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $380 | $380 | $380 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $190 | $190 | $190 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $91 | $91 | $91 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $704 | $704 | $704 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $40 | $40 | $40 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $357 | $357 | $357 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $91 | $91 | $91 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $40 | $40 | $40 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $675 | $675 | $675 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $510 | $510 | $510 |
| Carpal tunnel release CPT 64721 • Orthopedics | $416 | $416 | $416 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $15 | $15 | $15 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $127 | $127 | $127 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $8 | $8 | $8 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $126 | $126 | $126 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $211 | $211 | $211 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $40 | $40 | $40 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $33 | $33 | $33 |