| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $16 | $24 | $33 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $222 | $222 | $222 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $617 | $629 | $641 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $146 | $631 | $1,115 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $110 | $330 | $550 |
| Excision chalazion single CPT 67800 • Ophthalmology | $34 | $34 | $34 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $33 | $218 | $403 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $21 | $80 | $139 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $3 | $28 | $52 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $98 | $98 | $98 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $28 | $41 | $55 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $5 | $43 | $80 |
| Visual field examination CPT 92083 • Ophthalmology | $58 | $58 | $58 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $22 | $28 | $35 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $12 | $36 | $60 |
| Fundus photography CPT 92250 • Ophthalmology | $33 | $33 | $34 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $4 | $30 | $56 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $9 | $34 | $60 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $8 | $20 | $33 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,892 | $1,892 | $1,892 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $34 | $830 | $1,627 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,001 | $1,501 | $2,001 |
| Total shoulder replacement CPT 23472 • Orthopedics | $778 | $778 | $778 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $884 | $1,325 | $1,767 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $314 | $382 | $449 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $33 | $157 | $281 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $297 | $297 | $297 |
| Total hip replacement CPT 27130 • Orthopedics | $298 | $895 | $1,491 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $174 | $958 | $1,741 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $856 | $1,039 | $1,222 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $33 | $488 | $943 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $920 | $920 | $920 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $34 | $595 | $1,156 |
| Total knee replacement CPT 27447 • Orthopedics | $1,119 | $1,358 | $1,598 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $579 | $579 | $580 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $34 | $154 | $274 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $114 | $425 | $736 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $344 | $516 | $688 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $168 | $646 | $1,123 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $70 | $386 | $701 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $458 | $555 | $653 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $495 | $495 | $495 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $205 | $205 | $205 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $148 | $566 | $984 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $559 | $839 | $1,118 |
| Carpal tunnel release CPT 64721 • Orthopedics | $42 | $233 | $424 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $33 | $52 | $71 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $60 | $171 | $282 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $132 | $132 | $132 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $17 | $147 | $278 |