| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $13 | $61 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,142 | $1,142 | $1,142 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $134 | $238 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $88 | $146 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $92 | $277 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $12 | $12 | $12 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $579 | $579 | $579 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $30 | $30 | $30 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $12 | $12 | $12 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $14 | $14 | $14 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $13 | $13 | $13 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $30 | $30 | $30 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $19 | $24 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $18 | $18 | $18 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $41 | $52 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $33 | $39 | $44 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,447 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $170 | $309 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,261 | $1,261 | $1,261 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,061 | $1,061 | $1,061 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,182 | $1,182 | $1,182 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $289 | $289 | $289 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $249 | $249 | $249 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $233 | $436 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $329 | $627 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $137 | $245 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $598 | $1,166 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $840 | $840 | $840 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $438 | $846 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $78 | $125 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $43 | $57 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $155 | $155 | $155 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $447 | $865 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $276 | $523 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $208 | $385 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $68 | $106 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $472 | $472 | $472 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $86 | $142 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $30 | $30 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $177 | $325 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $12 | $46 | $80 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $39 | $39 | $39 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $16 | $16 | $16 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $19 | $19 | $19 |