| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $178 | $327 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $347 | $404 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $49 | $74 | $98 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $154 | $154 | $154 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $107 | $107 | $107 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $23 | $53 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $73 | $109 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $25 | $25 | $25 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $37 | $56 | $74 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $47 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $7 | $19 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $4 | $17 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $4 | $28 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $47 | $55 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $595 | $1,159 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,351 | $1,575 | $1,800 |
| Total shoulder replacement CPT 23472 • Orthopedics | $30 | $30 | $30 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $788 | $788 | $788 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $309 | $309 | $309 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $332 | $332 | $332 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $36 | $43 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $454 | $878 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $627 | $1,224 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $598 | $1,166 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $840 | $1,019 | $1,199 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $614 | $1,198 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $438 | $846 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $454 | $877 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $228 | $426 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $213 | $213 | $213 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $140 | $250 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $127 | $127 | $127 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $67 | $105 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $43 | $55 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $147 | $265 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $472 | $472 | $472 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $87 | $143 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $62 | $95 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $391 | $753 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $167 | $303 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $12 | $12 | $12 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $194 | $194 | $194 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $14 | $46 | $79 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $127 | $191 | $254 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $41 | $41 | $41 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $6 | $6 | $6 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $37 | $42 | $48 |