| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $22 | $22 | $22 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $799 | $799 | $799 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $477 | $477 | $477 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $66 | $66 | $66 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $347 | $347 | $347 |
| Excision chalazion single CPT 67800 • Ophthalmology | $20 | $20 | $20 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $540 | $540 | $540 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $59 | $59 | $59 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $8 | $8 | $8 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $50 | $50 | $50 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $5 | $5 | $5 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $104 | $104 | $104 |
| Visual field examination CPT 92083 • Ophthalmology | $26 | $26 | $26 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $15 | $15 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $3 | $3 | $3 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $39 | $39 | $39 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $7 | $7 | $7 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,160 | $1,160 | $1,160 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $150 | $150 | $150 |
| Total shoulder replacement CPT 23472 • Orthopedics | $990 | $990 | $990 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $788 | $788 | $788 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $357 | $357 | $357 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $332 | $332 | $332 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $407 | $407 | $407 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,224 | $1,224 | $1,224 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $816 | $816 | $816 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $900 | $900 | $900 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $180 | $180 | $180 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $113 | $113 | $113 |
| Total knee replacement CPT 27447 • Orthopedics | $871 | $871 | $871 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $57 | $57 | $57 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $309 | $309 | $309 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $501 | $501 | $501 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $34 | $34 | $34 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,004 | $1,004 | $1,004 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $472 | $472 | $472 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $91 | $91 | $91 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $191 | $191 | $191 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $45 | $45 | $45 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $753 | $753 | $753 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $30 | $30 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $30 | $30 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $194 | $194 | $194 |
| 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 | $167 | $167 | $167 |