| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $66 | $109 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $635 | $1,141 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $122 | $306 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $242 | $510 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $366 | $414 | $462 |
| Excision chalazion single CPT 67800 • Ophthalmology | $30 | $61 | $79 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $358 | $565 | $772 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $91 | $134 | $177 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $29 | $54 | $80 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $60 | $100 | $139 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $32 | $58 | $83 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $74 | $89 | $117 |
| Visual field examination CPT 92083 • Ophthalmology | $34 | $36 | $39 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $16 | $25 | $37 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $19 | $31 | $44 |
| Fundus photography CPT 92250 • Ophthalmology | $7 | $17 | $28 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $31 | $31 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $11 | $24 | $32 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $38 | $55 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,069 | $1,362 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $513 | $996 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,162 | $1,481 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $909 | $909 | $909 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,014 | $1,295 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $259 | $361 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $206 | $206 | $206 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $165 | $284 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $440 | $849 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $540 | $1,049 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $269 | $748 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $180 | $475 | $770 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $769 | $983 | $1,198 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $262 | $725 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $303 | $848 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $140 | $359 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $85 | $195 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $224 | $567 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $70 | $109 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $243 | $669 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $190 | $351 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $299 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $231 | $433 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $224 | $613 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $223 | $609 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $360 | $691 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $111 | $272 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $65 | $100 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $67 | $143 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $92 | $115 | $137 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $158 | $222 | $255 |