| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $89 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $954 | $1,506 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $146 | $494 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $268 | $984 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $496 | $564 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $60 | $119 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $450 | $772 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $112 | $132 | $142 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $40 | $69 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $73 | $109 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $42 | $71 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $60 | $107 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $14 | $45 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $33 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $28 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $26 | $30 | $35 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $33 | $37 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $36 | $54 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $47 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,612 | $1,640 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $519 | $1,497 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,740 | $1,780 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $30 | $720 | $1,411 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,547 | $1,566 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $413 | $415 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $30 | $163 | $296 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $154 | $526 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $473 | $1,360 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $548 | $1,585 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $304 | $1,126 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $406 | $1,159 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $798 | $1,198 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $283 | $1,044 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $386 | $1,453 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $158 | $541 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $118 | $294 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $191 | $675 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $122 | $169 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $276 | $1,016 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $200 | $539 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $277 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $187 | $657 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $331 | $933 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $249 | $906 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $364 | $1,032 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $123 | $401 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $42 | $79 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $226 | $247 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $137 | $140 | $142 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $222 | $246 | $255 |