| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $137 | $245 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $323 | $393 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $20 | $20 | $20 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $107 | $107 | $107 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $42 | $42 | $42 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $145 | $145 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $13 | $13 | $13 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $75 | $98 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $26 | $30 | $34 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $25 | $32 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $7 | $28 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $21 | $21 | $21 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $39 | $45 | $51 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $4 | $4 | $4 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,447 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $131 | $232 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $180 | $180 | $180 |
| Total shoulder replacement CPT 23472 • Orthopedics | $141 | $141 | $141 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $158 | $158 | $158 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $289 | $289 | $289 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $32 | $32 | $32 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $87 | $87 | $87 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $329 | $627 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $586 | $1,142 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $452 | $875 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $120 | $120 | $120 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $240 | $240 | $240 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $128 | $226 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $485 | $940 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $43 | $57 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $43 | $57 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $203 | $375 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $25 | $25 | $25 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |
| 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 | $674 | $674 | $674 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $374 | $717 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $62 | $95 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $418 | $807 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $30 | $30 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $12 | $12 | $12 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $258 | $258 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $27 | $82 | $137 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $73 | $73 | $73 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $1,144 | $1,144 | $1,144 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $11 | $11 | $11 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $25 | $37 | $48 |