| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $369 | $552 | $644 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $96 | $461 | $644 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $518 | $602 | $644 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $279 | $522 | $644 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $279 | $553 | $644 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $369 | $552 | $644 |
| Excision chalazion single CPT 67800 • Ophthalmology | $96 | $461 | $644 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $369 | $575 | $644 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $96 | $461 | $644 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $96 | $461 | $644 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $96 | $461 | $644 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $96 | $507 | $644 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $604 | $631 | $644 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $604 | $631 | $644 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $644 | $661 | $710 |
| Total shoulder replacement CPT 23472 • Orthopedics | $644 | $668 | $717 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $518 | $602 | $644 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $369 | $552 | $644 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $96 | $461 | $644 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $449 | $630 | $798 |
| Total hip replacement CPT 27130 • Orthopedics | $644 | $668 | $717 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $644 | $668 | $717 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $604 | $631 | $644 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $604 | $631 | $644 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $518 | $602 | $644 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $644 | $668 | $717 |
| Total knee replacement CPT 27447 • Orthopedics | $644 | $662 | $717 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $369 | $575 | $644 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $96 | $461 | $644 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $454 | $597 | $644 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $96 | $461 | $644 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $604 | $631 | $644 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $454 | $581 | $644 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $454 | $597 | $644 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $454 | $581 | $644 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $604 | $631 | $644 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $604 | $631 | $644 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $604 | $631 | $644 |
| Carpal tunnel release CPT 64721 • Orthopedics | $369 | $552 | $644 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $96 | $507 | $644 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $279 | $522 | $644 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $279 | $522 | $644 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $279 | $522 | $644 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $604 | $682 | $798 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $279 | $522 | $644 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $96 | $461 | $644 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $279 | $522 | $644 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $96 | $461 | $644 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $279 | $522 | $644 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $96 | $461 | $644 |