| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $38 | $146 | $254 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $40 | $242 | $444 |
| Excision chalazion single CPT 67800 • Ophthalmology | $15 | $15 | $15 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $417 | $417 | $417 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $91 | $91 | $91 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $6 | $34 | $62 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $97 | $97 | $97 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $33 | $33 | $33 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $6 | $33 | $60 |
| Visual field examination CPT 92083 • Ophthalmology | $10 | $10 | $10 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $11 | $21 | $31 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $58 | $58 | $58 |
| Fundus photography CPT 92250 • Ophthalmology | $21 | $31 | $40 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $8 | $8 | $8 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $33 | $34 | $34 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $12 | $12 | $12 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,602 | $1,602 | $1,603 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,340 | $1,346 | $1,351 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,540 | $1,540 | $1,540 |
| Total shoulder replacement CPT 23472 • Orthopedics | $248 | $248 | $248 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $728 | $728 | $728 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $246 | $246 | $246 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $152 | $152 | $152 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $502 | $502 | $502 |
| Total hip replacement CPT 27130 • Orthopedics | $597 | $895 | $1,193 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $191 | $793 | $1,396 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $491 | $736 | $981 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $202 | $202 | $202 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $40 | $510 | $980 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $183 | $548 | $914 |
| Total knee replacement CPT 27447 • Orthopedics | $893 | $1,085 | $1,276 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $92 | $275 | $458 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $40 | $40 | $40 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $382 | $463 | $545 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $39 | $39 | $39 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $665 | $775 | $886 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $111 | $334 | $557 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $390 | $455 | $520 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $553 | $553 | $553 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $40 | $61 | $81 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $603 | $703 | $803 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $193 | $555 | $917 |
| Carpal tunnel release CPT 64721 • Orthopedics | $249 | $291 | $333 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $14 | $14 | $14 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $49 | $73 | $97 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $19 | $19 | $19 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $67 | $136 | $206 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $250 | $250 | $250 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $9 | $9 | $9 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $30 | $35 | $40 |