| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $44 | $44 | $44 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $171 | $171 | $171 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $52 | $74 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $178 | $327 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $323 | $393 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $154 | $154 | $154 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $71 | $107 | $142 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $42 | $42 | $42 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $93 | $119 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $43 | $43 | $43 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $47 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $21 | $21 | $21 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $41 | $52 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $5 | $5 | $5 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $32 | $33 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $556 | $1,082 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $270 | $270 | $270 |
| Total shoulder replacement CPT 23472 • Orthopedics | $990 | $990 | $990 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,182 | $1,182 | $1,182 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $309 | $309 | $309 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $30 | $30 | $30 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $582 | $582 | $582 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $137 | $245 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $600 | $600 | $600 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $128 | $226 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $485 | $940 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $43 | $57 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $92 | $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 | $67 | $105 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $153 | $275 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $41 | $53 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $472 | $573 | $674 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $143 | $143 | $143 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $62 | $95 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $284 | $538 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $37 | $43 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $80 | $80 | $80 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $52 | $52 | $52 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $69 | $74 | $79 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $191 | $191 | $191 |