| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $178 | $327 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $49 | $49 | $49 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $57 | $57 | $57 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $23 | $67 | $112 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $7 | $7 | $7 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $73 | $73 | $73 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $13 | $13 | $13 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $18 | $18 | $18 |
| Visual field examination CPT 92083 • Ophthalmology | $30 | $45 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $32 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $35 | $35 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $41 | $52 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $5 | $18 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $39 | $47 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $92 | $155 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,351 | $1,351 | $1,351 |
| Total shoulder replacement CPT 23472 • Orthopedics | $990 | $990 | $990 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $788 | $788 | $788 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $50 | $50 | $50 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $291 | $291 | $291 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $486 | $941 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $102 | $175 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $240 | $240 | $240 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $100 | $169 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $78 | $125 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $157 | $284 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $284 | $284 | $284 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $101 | $173 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $93 | $157 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $208 | $385 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $68 | $106 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $111 | $191 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $86 | $142 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $30 | $30 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $47 | $64 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $8 | $19 | $30 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $39 | $39 | $39 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $16 | $16 | $16 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $73 | $73 | $73 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $2,287 | $2,287 | $2,288 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $41 | $41 | $41 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $49 |