| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $18 | $56 | $119 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $776 | $776 | $776 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $355 | $541 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $172 | $340 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $44 | $84 | $123 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $57 | $57 | $57 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $20 | $81 | $142 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $42 | $62 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $73 | $121 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $11 | $50 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $8 | $85 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $26 | $39 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $17 | $22 | $26 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $41 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $14 | $23 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $5 | $5 | $5 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $40 | $40 | $40 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $52 | $57 | $61 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,614 | $1,946 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $663 | $1,295 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $270 | $270 | $270 |
| Total shoulder replacement CPT 23472 • Orthopedics | $30 | $30 | $30 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $315 | $315 | $315 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $309 | $309 | $309 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $146 | $146 | $146 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $284 | $284 | $285 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $454 | $878 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $627 | $1,224 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $452 | $875 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $75 | $120 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $315 | $599 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $410 | $789 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $228 | $426 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $142 | $213 | $284 |
| 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 | $67 | $105 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $221 | $413 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $167 | $304 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $49 | $67 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $478 | $478 | $478 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $215 | $474 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $326 | $622 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $232 | $433 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $8 | $83 | $157 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $10 | $57 | $104 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $69 | $69 | $69 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $38 | $146 | $254 |