| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $55 | $55 | $55 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $89 | $89 | $89 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $95 | $95 | $95 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $291 | $291 | $291 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $92 | $92 | $92 |
| Excision chalazion single CPT 67800 • Ophthalmology | $62 | $62 | $62 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $78 | $78 | $78 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $12 | $12 | $12 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $9 | $9 | $9 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $31 | $31 | $31 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $61 | $61 | $61 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $12 | $12 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $30 | $30 |
| Fundus photography CPT 92250 • Ophthalmology | $13 | $13 | $13 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $4 | $4 | $4 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $40 | $40 | $40 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $41 | $41 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $232 | $232 | $232 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $654 | $654 | $654 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $236 | $236 | $236 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $223 | $223 | $223 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $239 | $239 | $239 |
| Total hip replacement CPT 27130 • Orthopedics | $251 | $251 | $251 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,166 | $1,166 | $1,166 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,200 | $1,200 | $1,200 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $45 | $45 | $45 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $104 | $104 | $104 |
| Total knee replacement CPT 27447 • Orthopedics | $1,253 | $1,253 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $31 | $31 | $31 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $100 | $100 | $100 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,046 | $1,046 | $1,046 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $275 | $275 | $275 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $371 | $371 | $371 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $96 | $96 | $96 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $446 | $446 | $446 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $108 | $108 | $108 |
| Carpal tunnel release CPT 64721 • Orthopedics | $75 | $75 | $75 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $7 | $7 | $7 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $39 | $39 | $39 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $14 | $14 | $14 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $15 | $15 | $15 |