| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $163 | $163 | $163 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $461 | $461 | $461 |
| Excision chalazion single CPT 67800 • Ophthalmology | $124 | $124 | $124 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $283 | $424 | $565 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $30 | $57 | $84 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $7 | $7 | $7 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $14 | $14 | $14 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $24 | $36 | $48 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $37 | $37 | $37 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $35 | $59 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $24 | $24 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $24 | $24 | $24 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $20 | $20 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $37 | $37 | $37 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $6 | $32 | $58 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,529 | $1,529 | $1,529 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $713 | $713 | $713 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $333 | $998 | $1,663 |
| Total shoulder replacement CPT 23472 • Orthopedics | $130 | $716 | $1,301 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $290 | $290 | $290 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $265 | $322 | $378 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $31 | $161 | $292 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $80 | $171 | $261 |
| Total hip replacement CPT 27130 • Orthopedics | $1,155 | $1,155 | $1,155 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $805 | $805 | $805 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $221 | $221 | $221 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $221 | $662 | $1,103 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $779 | $779 | $779 |
| Total knee replacement CPT 27447 • Orthopedics | $231 | $231 | $231 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $80 | $131 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $69 | $69 | $69 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $93 | $155 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $144 | $144 | $144 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $101 | $101 | $101 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $488 | $488 | $488 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $232 | $435 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $176 | $528 | $880 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $168 | $168 | $168 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $30 | $30 |
| Carpal tunnel release CPT 64721 • Orthopedics | $76 | $76 | $76 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $22 | $22 | $22 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $92 | $131 | $170 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $10 | $65 | $120 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $22 | $22 | $22 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $302 | $302 | $302 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $7 | $36 | $65 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $22 | $22 | $22 |