| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $45 | $201 | $357 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $45 | $245 | $444 |
| Excision chalazion single CPT 67800 • Ophthalmology | $91 | $91 | $91 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $470 | $584 | $697 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $17 | $17 | $17 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $3 | $3 | $3 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $10 | $10 | $10 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $6 | $6 | $6 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $8 | $8 | $8 |
| Visual field examination CPT 92083 • Ophthalmology | $14 | $29 | $43 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $17 | $22 | $28 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $19 | $32 | $45 |
| Fundus photography CPT 92250 • Ophthalmology | $45 | $45 | $45 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $8 | $8 | $8 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $36 | $36 | $36 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $8 | $8 | $8 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,683 | $1,683 | $1,683 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $45 | $101 | $157 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,710 | $1,710 | $1,710 |
| Total shoulder replacement CPT 23472 • Orthopedics | $196 | $196 | $196 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $240 | $851 | $1,462 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $298 | $298 | $298 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $181 | $264 | $347 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $45 | $50 | $54 |
| Total hip replacement CPT 27130 • Orthopedics | $45 | $84 | $122 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $45 | $106 | $166 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $45 | $291 | $537 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,229 | $1,229 | $1,229 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $166 | $166 | $166 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $45 | $413 | $781 |
| Total knee replacement CPT 27447 • Orthopedics | $45 | $502 | $960 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $45 | $151 | $257 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $331 | $331 | $331 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $45 | $67 | $89 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $84 | $84 | $84 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $45 | $398 | $750 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $45 | $273 | $501 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $45 | $50 | $55 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $70 | $70 | $70 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $45 | $331 | $617 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $45 | $112 | $178 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $45 | $529 | $1,013 |
| Carpal tunnel release CPT 64721 • Orthopedics | $45 | $188 | $330 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $74 | $74 | $74 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $21 | $116 | $210 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $19 | $48 | $76 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $253 | $253 | $253 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $780 | $780 | $780 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $20 | $20 | $20 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $41 | $41 | $41 |