| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $179 | $326 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $30 | $246 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $84 | $123 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $399 | $771 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $85 | $123 | $142 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $8 | $64 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $145 | $145 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $74 | $110 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $43 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $28 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $5 | $23 | $29 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $25 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $46 | $52 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $27 | $37 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $6 | $33 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,551 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $973 | $1,545 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $360 | $1,320 | $1,800 |
| Total shoulder replacement CPT 23472 • Orthopedics | $30 | $953 | $1,414 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $158 | $1,103 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $289 | $381 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $30 | $195 | $332 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $349 | $581 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $948 | $1,255 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $1,109 | $1,631 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $634 | $1,166 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $817 | $1,199 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $809 | $1,198 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $627 | $1,127 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $947 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $85 | $447 | $568 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $28 | $122 | $309 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $351 | $500 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $76 | $169 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $569 | $1,045 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $290 | $550 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $298 | $529 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $245 | $674 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $533 | $956 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $489 | $948 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $553 | $1,075 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $305 | $433 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $83 | $158 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $21 | $160 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $12 | $95 | $137 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $127 | $222 | $254 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $867 | $2,287 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $15 | $40 | $74 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $49 |