| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $109 | $109 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $129 | $228 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $211 | $391 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $368 | $705 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $60 | $261 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $78 | $78 | $78 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $33 | $33 | $33 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $112 | $116 | $121 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $7 | $7 | $7 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $15 | $15 | $15 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $38 | $38 | $38 |
| Visual field examination CPT 92083 • Ophthalmology | $30 | $30 | $30 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $7 | $28 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $15 | $25 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $32 | $42 | $51 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $35 | $35 | $35 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $33 | $33 | $33 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,241 | $1,447 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $401 | $773 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,351 | $1,351 | $1,351 |
| Total shoulder replacement CPT 23472 • Orthopedics | $666 | $666 | $666 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $788 | $788 | $788 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $249 | $249 | $249 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $213 | $213 | $213 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $325 | $620 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $831 | $1,632 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $452 | $875 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $564 | $882 | $1,199 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $564 | $564 | $564 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $121 | $212 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $31 | $33 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $283 | $536 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $199 | $199 | $199 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $140 | $250 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $119 | $144 | $169 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $208 | $385 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $280 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $67 | $67 | $67 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $143 | $143 | $143 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $31 | $33 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $298 | $565 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $60 | $91 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $154 | $154 | $154 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $23 | $23 | $23 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $40 | $40 | $40 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $16 | $16 | $16 |