| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $22 | $55 | $88 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $571 | $571 | $571 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $52 | $74 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $178 | $327 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $323 | $393 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $49 | $69 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $566 | $566 | $566 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $30 | $54 | $79 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $42 | $62 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $15 | $15 | $15 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $13 | $49 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $61 | $61 | $61 |
| Visual field examination CPT 92083 • Ophthalmology | $60 | $60 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $24 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $15 | $18 | $21 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $41 | $51 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $53 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $47 | $47 | $47 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $788 | $1,545 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,800 | $1,800 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $707 | $707 | $707 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,103 | $1,103 | $1,103 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $309 | $309 | $309 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $66 | $66 | $66 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $291 | $291 | $291 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $454 | $878 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $97 | $163 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $102 | $175 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $900 | $900 | $900 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $240 | $240 | $240 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $438 | $846 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $642 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $58 | $85 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $284 | $297 | $309 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $53 | $75 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $17 | $17 | $17 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $407 | $784 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $153 | $275 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $41 | $53 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $956 | $956 | $956 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $110 | $190 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $553 | $1,075 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $47 | $65 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $32 | $32 | $32 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $52 | $52 | $52 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $103 | $103 | $103 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $127 | $191 | $254 |