| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $70 | $70 | $70 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $752 | $752 | $752 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $48 | $185 | $322 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $48 | $183 | $288 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $48 | $234 | $421 |
| Excision chalazion single CPT 67800 • Ophthalmology | $78 | $93 | $108 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $361 | $518 | $676 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $74 | $74 | $74 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $33 | $50 | $67 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $92 | $116 | $139 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $37 | $60 | $83 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $56 | $87 | $117 |
| Visual field examination CPT 92083 • Ophthalmology | $17 | $25 | $33 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $23 | $24 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $20 | $31 | $42 |
| Fundus photography CPT 92250 • Ophthalmology | $14 | $15 | $16 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $27 | $27 | $27 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $38 | $38 | $38 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $45 | $62 | $70 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,154 | $1,629 | $2,105 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $48 | $625 | $1,203 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,244 | $1,759 | $2,274 |
| Total shoulder replacement CPT 23472 • Orthopedics | $951 | $951 | $951 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,062 | $1,062 | $1,062 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $269 | $380 | $490 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $237 | $307 | $378 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $197 | $197 | $197 |
| Total hip replacement CPT 27130 • Orthopedics | $48 | $467 | $886 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $48 | $649 | $1,251 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $48 | $468 | $888 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $803 | $1,137 | $1,470 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $914 | $914 | $914 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $48 | $402 | $757 |
| Total knee replacement CPT 27447 • Orthopedics | $48 | $852 | $1,621 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $48 | $368 | $684 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $199 | $199 | $199 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $48 | $581 | $1,048 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $131 | $131 | $131 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $48 | $421 | $794 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $48 | $206 | $363 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $48 | $362 | $640 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $456 | $456 | $456 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $727 | $727 | $727 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $48 | $348 | $647 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $48 | $441 | $835 |
| Carpal tunnel release CPT 64721 • Orthopedics | $48 | $183 | $317 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $114 | $147 | $180 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $79 | $79 | $79 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $106 | $106 | $106 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $65 | $170 | $275 |