| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $55 | $55 | $55 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $571 | $856 | $1,141 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $134 | $238 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $44 | $58 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $46 | $254 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $49 | $49 | $49 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $579 | $579 | $579 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $142 | $142 | $143 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $9 | $9 | $9 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $13 | $13 | $13 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $11 | $11 | $11 |
| Visual field examination CPT 92083 • Ophthalmology | $30 | $32 | $34 |
| 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 | $7 | $11 | $15 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $18 | $27 | $36 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $13 | $13 | $13 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,447 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $788 | $1,545 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $270 | $270 | $270 |
| Total shoulder replacement CPT 23472 • Orthopedics | $212 | $212 | $212 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,103 | $1,103 | $1,103 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $332 | $332 | $332 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $116 | $116 | $116 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $78 | $125 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $627 | $1,224 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $307 | $583 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $900 | $900 | $900 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $180 | $180 | $180 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $100 | $169 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $642 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $28 | $28 | $28 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $80 | $130 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $67 | $105 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $200 | $371 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $472 | $472 | $472 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $63 | $96 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $371 | $712 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $418 | $807 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $167 | $303 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $119 | $119 | $119 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $21 | $21 | $21 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $137 | $137 | $137 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $97 | $176 | $254 |