| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $16 | $16 | $16 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,142 | $1,142 | $1,142 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $58 | $58 | $58 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $30 | $30 | $30 |
| Excision chalazion single CPT 67800 • Ophthalmology | $87 | $87 | $87 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $113 | $113 | $113 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $23 | $23 | $23 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $73 | $73 | $73 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $25 | $25 | $25 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $37 | $37 | $37 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $12 | $12 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $15 | $15 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $7 | $7 | $7 |
| Fundus photography CPT 92250 • Ophthalmology | $7 | $7 | $7 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $8 | $8 | $8 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $7 | $7 | $7 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $44 | $44 | $44 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,241 | $1,241 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,159 | $1,159 | $1,159 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $751 | $751 | $751 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,414 | $1,414 | $1,414 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $158 | $158 | $158 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $268 | $268 | $268 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $175 | $175 | $175 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $58 | $58 | $58 |
| Total hip replacement CPT 27130 • Orthopedics | $1,255 | $1,255 | $1,255 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $276 | $276 | $276 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $816 | $816 | $816 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $180 | $180 | $180 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $180 | $180 | $180 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $564 | $564 | $564 |
| Total knee replacement CPT 27447 • Orthopedics | $1,253 | $1,253 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $119 | $119 | $119 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $155 | $155 | $155 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $50 | $50 | $50 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $18 | $18 | $18 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $105 | $105 | $105 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $385 | $385 | $385 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $79 | $79 | $79 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $712 | $712 | $712 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $96 | $96 | $96 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $30 | $30 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $794 | $794 | $794 |
| Carpal tunnel release CPT 64721 • Orthopedics | $325 | $325 | $325 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $60 | $60 | $60 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $52 | $52 | $52 |
| 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 | $55 | $55 | $55 |