| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $453 | $453 | $453 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $432 | $432 | $432 |
| Excision chalazion single CPT 67800 • Ophthalmology | $48 | $48 | $48 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $106 | $106 | $106 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $11 | $11 | $11 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $5 | $5 | $5 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $16 | $16 | $16 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $12 | $37 | $61 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $73 | $95 | $117 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $27 | $43 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $18 | $28 | $37 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $50 | $50 | $50 |
| Fundus photography CPT 92250 • Ophthalmology | $36 | $39 | $42 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $31 | $33 | $35 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $29 | $29 | $29 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $45 | $45 | $45 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,226 | $1,226 | $1,226 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $169 | $169 | $169 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $381 | $381 | $381 |
| Total shoulder replacement CPT 23472 • Orthopedics | $752 | $752 | $752 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,176 | $1,176 | $1,176 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $309 | $309 | $309 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $257 | $257 | $257 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $45 | $259 | $472 |
| Total hip replacement CPT 27130 • Orthopedics | $1,139 | $1,139 | $1,139 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $347 | $347 | $347 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,236 | $1,236 | $1,236 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $42 | $657 | $1,273 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $42 | $75 | $109 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $840 | $840 | $840 |
| Total knee replacement CPT 27447 • Orthopedics | $171 | $171 | $171 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $256 | $256 | $256 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $28 | $28 | $28 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $407 | $407 | $407 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $116 | $116 | $116 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $474 | $474 | $474 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $294 | $294 | $294 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $419 | $419 | $419 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $507 | $507 | $507 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $153 | $153 | $153 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $827 | $827 | $827 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,000 | $1,000 | $1,000 |
| Carpal tunnel release CPT 64721 • Orthopedics | $204 | $204 | $204 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $17 | $17 | $17 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $94 | $200 | $306 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $24 | $50 | $76 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $19 | $19 | $19 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $307 | $307 | $307 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $39 | $39 | $40 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $39 | $39 | $39 |