| 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 | $93 | $93 | $93 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $113 | $113 | $113 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $23 | $53 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $9 | $9 | $9 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $9 | $9 | $9 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $61 | $61 | $61 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $12 | $12 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $5 | $26 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $35 | $35 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $26 | $26 | $26 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $4 | $20 | $36 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $7 | $7 | $7 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,158 | $1,406 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $556 | $1,082 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,261 | $1,261 | $1,261 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,061 | $1,061 | $1,061 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $236 | $236 | $236 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $289 | $289 | $289 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $318 | $318 | $318 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $43 | $43 | $43 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $109 | $188 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $97 | $163 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $307 | $583 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $600 | $899 | $1,199 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $899 | $899 | $899 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $438 | $846 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $228 | $426 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $199 | $199 | $199 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $339 | $649 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $100 | $169 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $276 | $523 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $290 | $550 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $68 | $106 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $135 | $135 | $135 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $96 | $96 | $96 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $371 | $712 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $391 | $753 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $164 | $298 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $16 | $16 | $16 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $21 | $62 | $104 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $40 | $40 | $40 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $73 | $163 | $254 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $1,159 | $2,288 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $21 | $21 | $21 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $25 | $37 | $48 |