| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $276 | $276 | $276 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $118 | $118 | $118 |
| Excision chalazion single CPT 67800 • Ophthalmology | $32 | $32 | $32 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $44 | $272 | $501 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $44 | $87 | $130 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $4 | $4 | $4 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $14 | $79 | $143 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $13 | $49 | $85 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $7 | $39 | $71 |
| Visual field examination CPT 92083 • Ophthalmology | $36 | $36 | $36 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $31 | $38 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $19 | $19 | $19 |
| Fundus photography CPT 92250 • Ophthalmology | $35 | $35 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $28 | $28 | $28 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $6 | $6 | $6 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $44 | $44 | $44 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,293 | $1,293 | $1,293 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $324 | $324 | $324 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,409 | $1,644 | $1,878 |
| Total shoulder replacement CPT 23472 • Orthopedics | $301 | $902 | $1,503 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $251 | $961 | $1,672 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $316 | $383 | $451 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $261 | $308 | $355 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $63 | $188 | $313 |
| Total hip replacement CPT 27130 • Orthopedics | $666 | $666 | $666 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $173 | $952 | $1,730 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $187 | $187 | $187 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $895 | $895 | $895 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $894 | $894 | $894 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,199 | $1,199 | $1,199 |
| Total knee replacement CPT 27447 • Orthopedics | $1,331 | $1,331 | $1,331 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $431 | $431 | $431 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $47 | $47 | $47 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $146 | $146 | $146 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $18 | $97 | $176 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $559 | $559 | $559 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $594 | $594 | $594 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $86 | $86 | $86 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $724 | $724 | $725 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $44 | $124 | $204 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $895 | $895 | $895 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $506 | $506 | $506 |
| Carpal tunnel release CPT 64721 • Orthopedics | $212 | $212 | $212 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $17 | $17 | $17 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $39 | $69 | $99 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $14 | $44 | $74 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $93 | $93 | $93 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $387 | $1,028 | $1,670 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $39 | $39 | $39 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $31 | $31 | $31 |