| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $55 | $55 | $55 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $415 | $799 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $182 | $334 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $57 | $85 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $124 | $124 | $124 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $17 | $64 | $112 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $42 | $42 | $42 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $14 | $54 | $93 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $18 | $70 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $12 | $19 | $26 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $14 | $15 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $18 | $18 | $18 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $4 | $20 | $36 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $47 | $47 | $47 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,158 | $1,406 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $92 | $155 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,414 | $1,414 | $1,414 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $236 | $236 | $236 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $44 | $44 | $44 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $199 | $199 | $199 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $307 | $583 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $180 | $180 | $180 |
| 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 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $299 | $568 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $309 | $309 | $309 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $58 | $86 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $25 | $25 | $25 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $381 | $732 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $147 | $265 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $101 | $101 | $101 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $96 | $96 | $96 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $371 | $712 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $391 | $753 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $167 | $303 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $80 | $80 | $81 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $194 | $194 | $194 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $14 | $46 | $79 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $191 | $191 | $191 |