| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $46 | $79 | $112 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $118 | $118 | $118 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $357 | $357 | $357 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $337 | $337 | $337 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $68 | $68 | $68 |
| Excision chalazion single CPT 67800 • Ophthalmology | $71 | $71 | $71 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $59 | $59 | $59 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $108 | $108 | $108 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $65 | $65 | $65 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $7 | $7 | $7 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $39 | $39 | $39 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $10 | $34 | $59 |
| Visual field examination CPT 92083 • Ophthalmology | $24 | $35 | $47 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $12 | $21 | $30 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $5 | $5 | $5 |
| Fundus photography CPT 92250 • Ophthalmology | $12 | $14 | $16 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $32 | $32 | $33 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $34 | $36 | $38 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $21 | $21 | $21 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,633 | $1,633 | $1,634 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,056 | $1,056 | $1,056 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,211 | $1,211 | $1,211 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,353 | $1,353 | $1,353 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,507 | $1,507 | $1,507 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $270 | $328 | $385 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $301 | $301 | $301 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $189 | $189 | $189 |
| Total hip replacement CPT 27130 • Orthopedics | $843 | $843 | $843 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $782 | $782 | $782 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $781 | $781 | $781 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,148 | $1,148 | $1,148 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $172 | $172 | $172 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $752 | $752 | $752 |
| Total knee replacement CPT 27447 • Orthopedics | $842 | $842 | $842 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $81 | $81 | $81 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $146 | $207 | $268 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $329 | $329 | $329 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $162 | $162 | $162 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $200 | $200 | $200 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $79 | $79 | $79 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $353 | $353 | $353 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $64 | $64 | $64 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $137 | $137 | $137 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $161 | $161 | $161 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $488 | $488 | $488 |
| Carpal tunnel release CPT 64721 • Orthopedics | $380 | $380 | $380 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $15 | $80 | $145 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $68 | $79 | $90 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $116 | $116 | $116 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $106 | $106 | $106 |