| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $55 | $111 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $799 | $799 | $799 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $347 | $515 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $183 | $357 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $323 | $393 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $74 | $74 | $74 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $77 | $77 | $77 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $85 | $85 | $85 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $93 | $128 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $50 | $69 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $18 | $88 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $48 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $10 | $29 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $33 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $35 | $35 | $35 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $8 | $8 | $8 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $13 | $43 | $71 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $265 | $1,026 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $131 | $232 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,261 | $1,261 | $1,261 |
| Total shoulder replacement CPT 23472 • Orthopedics | $283 | $283 | $283 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,182 | $1,182 | $1,182 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $289 | $350 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $249 | $249 | $249 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $291 | $291 | $291 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $78 | $125 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $586 | $1,142 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $423 | $816 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $240 | $240 | $240 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $579 | $1,128 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $642 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $157 | $284 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $216 | $216 | $216 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $190 | $350 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $120 | $209 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $153 | $275 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $200 | $371 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $506 | $506 | $506 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $669 | $669 | $669 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $373 | $949 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $69 | $108 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $164 | $298 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $94 | $157 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $26 | $26 | $26 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $60 | $60 | $60 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $19 | $19 | $19 |