| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $70 | $70 | $70 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $332 | $332 | $332 |
| Excision chalazion single CPT 67800 • Ophthalmology | $21 | $21 | $21 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $614 | $614 | $614 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $92 | $92 | $92 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $21 | $50 | $79 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $70 | $79 | $88 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $8 | $28 | $47 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $71 | $71 | $71 |
| Visual field examination CPT 92083 • Ophthalmology | $25 | $25 | $25 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $17 | $23 | $30 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $16 | $30 | $44 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $20 | $20 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $37 | $37 | $37 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $7 | $28 | $49 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $20 | $20 | $20 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,077 | $1,077 | $1,077 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $215 | $215 | $215 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $328 | $328 | $328 |
| Total shoulder replacement CPT 23472 • Orthopedics | $197 | $197 | $197 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $219 | $219 | $219 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $268 | $268 | $268 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $155 | $155 | $155 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $369 | $369 | $369 |
| Total hip replacement CPT 27130 • Orthopedics | $817 | $817 | $817 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $227 | $227 | $227 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $543 | $543 | $543 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $559 | $559 | $559 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $167 | $167 | $167 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $732 | $732 | $732 |
| Total knee replacement CPT 27447 • Orthopedics | $175 | $175 | $175 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $272 | $272 | $272 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $203 | $250 | $296 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $158 | $158 | $158 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $77 | $77 | $77 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $146 | $146 | $146 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $388 | $388 | $388 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $75 | $75 | $75 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $95 | $95 | $95 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $621 | $621 | $621 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $81 | $81 | $81 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $146 | $146 | $146 |
| Carpal tunnel release CPT 64721 • Orthopedics | $398 | $398 | $398 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $15 | $15 | $15 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $9 | $9 | $9 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $14 | $14 | $14 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $111 | $167 | $222 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $182 | $182 | $182 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $6 | $21 | $36 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $43 | $43 | $44 |