| Corneal transplant endothelial CPT 65756 • Ophthalmology | $992 | $992 | $992 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $41 | $41 | $41 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $41 | $41 | $41 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $41 | $41 | $41 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $41 | $41 | $41 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $41 | $41 | $41 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $41 | $41 | $41 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $41 | $41 | $41 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $41 | $41 | $41 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $41 | $41 | $41 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $41 | $41 | $41 |
| Excision chalazion single CPT 67800 • Ophthalmology | $41 | $41 | $41 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $104 | $104 | $104 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $74 | $74 | $74 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $137 | $137 | $137 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $79 | $79 | $79 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $114 | $114 | $114 |
| Visual field examination CPT 92083 • Ophthalmology | $86 | $86 | $86 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $44 | $44 | $44 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $41 | $41 | $41 |
| Fundus photography CPT 92250 • Ophthalmology | $41 | $41 | $41 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $41 | $41 | $41 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $41 | $41 | $41 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $62 | $83 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,562 | $1,562 | $1,562 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $41 | $41 | $41 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,626 | $1,626 | $1,626 |
| Total shoulder replacement CPT 23472 • Orthopedics | $41 | $41 | $41 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,453 | $1,453 | $1,453 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $41 | $41 | $41 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $41 | $41 | $41 |
| Total hip replacement CPT 27130 • Orthopedics | $41 | $41 | $41 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $41 | $41 | $41 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $41 | $41 | $41 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $41 | $41 | $41 |
| Total knee replacement CPT 27447 • Orthopedics | $41 | $41 | $41 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $526 | $526 | $526 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $41 | $41 | $41 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $41 | $41 | $41 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $41 | $41 | $41 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $41 | $41 | $41 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $41 | $41 | $41 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $41 | $41 | $41 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $41 | $41 | $41 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $41 | $41 | $41 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $41 | $41 | $41 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $41 | $41 | $41 |
| Carpal tunnel release CPT 64721 • Orthopedics | $41 | $41 | $41 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $41 | $41 | $41 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $242 | $242 | $242 |