| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $67 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $809 | $1,255 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $148 | $501 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $97 | $299 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $501 | $580 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $61 | $122 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $454 | $772 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $142 | $142 | $142 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $26 | $64 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $80 | $113 | $145 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $46 | $73 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $44 | $103 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $19 | $38 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $16 | $33 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $17 | $36 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $29 | $31 | $35 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $38 | $46 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $36 | $49 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $50 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,663 | $1,680 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $540 | $1,560 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,800 | $1,807 | $1,820 |
| Total shoulder replacement CPT 23472 • Orthopedics | $30 | $730 | $1,429 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,583 | $1,596 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $414 | $418 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $30 | $164 | $298 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $197 | $531 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $464 | $1,331 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $568 | $1,644 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $316 | $1,172 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $422 | $1,206 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,198 | $1,201 | $1,206 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $307 | $1,137 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $355 | $1,331 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $162 | $558 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $112 | $276 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $198 | $701 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $124 | $174 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $282 | $1,037 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $203 | $549 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $280 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $248 | $685 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $342 | $966 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $260 | $948 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $380 | $1,081 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $127 | $416 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $56 | $84 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $239 | $252 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $137 | $144 | $150 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $234 | $249 | $255 |