| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $80 | $80 | $80 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $80 | $80 | $80 |
| Visual field examination CPT 92083 • Ophthalmology | $80 | $80 | $80 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $80 | $80 | $80 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $80 | $80 | $80 |
| Fundus photography CPT 92250 • Ophthalmology | $80 | $80 | $80 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $80 | $80 | $80 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $80 | $80 | $80 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $80 | $80 | $80 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $80 | $80 | $80 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $80 | $80 | $80 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $80 | $80 | $80 |
| Total shoulder replacement CPT 23472 • Orthopedics | $80 | $80 | $80 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $80 | $80 | $80 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $80 | $80 | $80 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $80 | $80 | $80 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $80 | $80 | $80 |
| Total hip replacement CPT 27130 • Orthopedics | $80 | $80 | $80 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $80 | $80 | $80 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $80 | $80 | $80 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $80 | $80 | $80 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $80 | $80 | $80 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $80 | $80 | $80 |
| Total knee replacement CPT 27447 • Orthopedics | $80 | $80 | $80 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $80 | $80 | $80 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $80 | $80 | $80 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $80 | $80 | $80 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $80 | $80 | $80 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $80 | $80 | $80 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $80 | $80 | $80 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $80 | $80 | $80 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $80 | $80 | $80 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $80 | $80 | $80 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $80 | $80 | $80 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $80 | $80 | $80 |
| Carpal tunnel release CPT 64721 • Orthopedics | $80 | $80 | $80 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $80 | $80 | $80 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $80 | $80 | $80 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $80 | $80 | $80 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $80 | $80 | $80 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $80 | $80 | $80 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $80 | $80 | $80 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $80 | $80 | $80 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $80 | $80 | $80 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $80 | $80 | $80 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $80 | $80 | $80 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $80 | $80 | $80 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $80 | $80 | $80 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $80 | $80 | $80 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $80 | $80 | $80 |