| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $138 | $340 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $347 | $404 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $12 | $21 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $71 | $71 | $71 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $7 | $45 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $15 | $81 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $13 | $50 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $12 | $70 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $30 | $46 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $35 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $19 | $37 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $34 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $18 | $24 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $42 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $7 | $36 | $66 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $265 | $1,026 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $401 | $773 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $900 | $1,350 | $1,800 |
| Total shoulder replacement CPT 23472 • Orthopedics | $212 | $212 | $212 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,182 | $1,182 | $1,182 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $232 | $232 | $232 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $43 | $43 | $43 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $140 | $251 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $627 | $1,224 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $307 | $583 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $135 | $240 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $614 | $1,199 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $297 | $564 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $328 | $627 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $309 | $309 | $309 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $140 | $250 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $127 | $127 | $127 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $153 | $275 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $674 | $674 | $674 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $956 | $956 | $956 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $215 | $474 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $418 | $807 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $177 | $325 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $119 | $138 | $157 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $16 | $60 | $104 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $8 | $8 | $8 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $254 | $254 | $255 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $873 | $1,716 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $6 | $6 | $6 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $49 |