| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $84 | $84 | $84 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $32 | $32 | $32 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $107 | $142 | $177 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $64 | $84 | $104 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $54 | $85 | $116 |
| Visual field examination CPT 92083 • Ophthalmology | $46 | $51 | $57 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $18 | $28 | $38 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $13 | $27 | $42 |
| Fundus photography CPT 92250 • Ophthalmology | $40 | $42 | $43 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $25 | $25 | $25 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $60 | $60 | $60 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $66 | $103 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $780 | $1,574 | $2,368 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $161 | $161 | $161 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,972 | $1,972 | $1,972 |
| Total shoulder replacement CPT 23472 • Orthopedics | $658 | $658 | $658 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,741 | $1,741 | $1,741 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $193 | $193 | $193 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $367 | $367 | $367 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $206 | $265 | $324 |
| Total hip replacement CPT 27130 • Orthopedics | $585 | $585 | $585 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $760 | $760 | $760 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,297 | $1,297 | $1,297 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $889 | $889 | $889 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $124 | $124 | $124 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,247 | $1,247 | $1,247 |
| Total knee replacement CPT 27447 • Orthopedics | $148 | $934 | $1,720 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $267 | $267 | $267 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $323 | $323 | $323 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $60 | $60 | $60 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $17 | $17 | $17 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $775 | $775 | $775 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $617 | $617 | $617 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $397 | $397 | $397 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $753 | $753 | $753 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $99 | $99 | $99 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $94 | $94 | $94 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $129 | $129 | $129 |
| Carpal tunnel release CPT 64721 • Orthopedics | $482 | $482 | $482 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $89 | $89 | $89 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $77 | $77 | $77 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $57 | $57 | $57 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $71 | $71 | $71 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $299 | $299 | $299 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $30 | $30 | $30 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $36 | $36 | $36 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $80 | $295 | $510 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $37 | $134 | $231 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $61 | $63 | $65 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $54 | $61 | $67 |