| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $80 | $295 | $511 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $80 | $93 | $106 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $80 | $597 | $1,115 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $80 | $274 | $468 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $80 | $200 | $319 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $80 | $254 | $428 |
| Excision chalazion single CPT 67800 • Ophthalmology | $80 | $101 | $122 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $80 | $317 | $553 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $80 | $95 | $110 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $80 | $80 | $80 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $80 | $85 | $89 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $48 | $64 | $80 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $80 | $100 | $119 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $57 | $80 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $52 | $80 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $54 | $80 |
| Fundus photography CPT 92250 • Ophthalmology | $15 | $48 | $80 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $34 | $57 | $80 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $52 | $66 | $80 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $43 | $61 | $80 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $80 | $828 | $1,577 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $80 | $776 | $1,472 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $80 | $879 | $1,678 |
| Total shoulder replacement CPT 23472 • Orthopedics | $80 | $718 | $1,355 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $80 | $794 | $1,507 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $80 | $240 | $399 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $80 | $205 | $330 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $80 | $316 | $552 |
| Total hip replacement CPT 27130 • Orthopedics | $80 | $642 | $1,204 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $80 | $822 | $1,564 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $80 | $601 | $1,121 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $80 | $616 | $1,153 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $80 | $616 | $1,152 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $80 | $579 | $1,078 |
| Total knee replacement CPT 27447 • Orthopedics | $80 | $641 | $1,202 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $80 | $315 | $550 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $80 | $180 | $279 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $80 | $456 | $831 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $80 | $120 | $160 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $80 | $543 | $1,006 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $80 | $307 | $533 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $80 | $297 | $514 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $80 | $366 | $652 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $80 | $499 | $918 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $80 | $467 | $854 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $80 | $556 | $1,031 |
| Carpal tunnel release CPT 64721 • Orthopedics | $80 | $251 | $423 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $80 | $117 | $154 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $80 | $163 | $246 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $80 | $104 | $127 |