| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $558 | $558 | $558 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $110 | $110 | $110 |
| Excision chalazion single CPT 67800 • Ophthalmology | $68 | $68 | $68 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $328 | $328 | $328 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $110 | $110 | $110 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $5 | $5 | $5 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $49 | $49 | $49 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $17 | $17 | $17 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $40 | $40 | $40 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $12 | $12 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $22 | $22 | $22 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $21 | $21 | $21 |
| Fundus photography CPT 92250 • Ophthalmology | $15 | $15 | $15 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $21 | $21 | $21 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $9 | $9 | $9 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $34 | $34 | $34 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,892 | $1,892 | $1,892 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,628 | $1,628 | $1,628 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $200 | $200 | $200 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,089 | $1,089 | $1,089 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $177 | $177 | $177 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $337 | $337 | $337 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $51 | $51 | $51 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $30 | $30 |
| Total hip replacement CPT 27130 • Orthopedics | $1,119 | $1,119 | $1,119 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $871 | $871 | $871 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $856 | $856 | $856 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $189 | $189 | $189 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $197 | $197 | $197 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $116 | $116 | $116 |
| Total knee replacement CPT 27447 • Orthopedics | $1,199 | $1,199 | $1,199 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $290 | $290 | $290 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $31 | $31 | $31 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $553 | $553 | $553 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $34 | $34 | $34 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $786 | $786 | $786 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $701 | $701 | $701 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $98 | $98 | $98 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $142 | $142 | $142 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $512 | $512 | $512 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $492 | $492 | $492 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $34 | $34 | $34 |
| Carpal tunnel release CPT 64721 • Orthopedics | $211 | $211 | $211 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $35 | $35 | $35 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $283 | $283 | $283 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $132 | $132 | $132 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $28 | $28 | $28 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $41 | $41 | $41 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $16 | $16 | $16 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $42 | $42 | $42 |