| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $87 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $785 | $785 | $785 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $186 | $342 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $200 | $406 | $510 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $30 | $166 | $302 |
| Excision chalazion single CPT 67800 • Ophthalmology | $86 | $86 | $86 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $391 | $620 | $850 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $97 | $137 | $177 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $57 | $61 | $66 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $62 | $91 | $120 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $47 | $63 | $83 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $71 | $91 | $117 |
| Visual field examination CPT 92083 • Ophthalmology | $18 | $38 | $58 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $11 | $28 | $37 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $12 | $33 | $44 |
| Fundus photography CPT 92250 • Ophthalmology | $11 | $24 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $24 | $27 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $25 | $27 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $44 | $54 | $65 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,149 | $1,149 | $1,149 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $548 | $1,066 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,220 | $1,530 | $1,841 |
| Total shoulder replacement CPT 23472 • Orthopedics | $969 | $969 | $969 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,077 | $1,077 | $1,077 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $284 | $284 | $284 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $237 | $237 | $237 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $214 | $397 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $446 | $862 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $574 | $1,119 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $416 | $803 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $428 | $825 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $427 | $824 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $401 | $771 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $723 | $1,279 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $336 | $584 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $219 | $219 | $219 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $506 | $898 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $114 | $114 | $114 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $375 | $719 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $206 | $382 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $314 | $545 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $248 | $466 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $656 | $656 | $656 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $326 | $621 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $390 | $750 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $164 | $298 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $110 | $138 | $165 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $176 | $219 | $262 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $53 | $53 | $53 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $66 | $66 | $66 |