| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $50 | $70 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $334 | $941 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $193 | $357 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $261 | $510 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $427 | $427 | $427 |
| Excision chalazion single CPT 67800 • Ophthalmology | $49 | $61 | $74 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $615 | $693 | $772 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $117 | $147 | $177 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $66 | $73 | $80 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $93 | $105 | $118 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $37 | $68 | $83 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $56 | $83 | $117 |
| Visual field examination CPT 92083 • Ophthalmology | $49 | $54 | $58 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $32 | $36 | $37 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $22 | $32 | $44 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $25 | $32 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $29 | $32 | $35 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $8 | $30 | $53 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $47 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,372 | $1,513 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,162 | $1,162 | $1,162 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,491 | $1,646 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,061 | $1,061 | $1,061 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,301 | $1,439 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $303 | $376 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $30 | $147 | $264 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $212 | $395 |
| Total hip replacement CPT 27130 • Orthopedics | $1,090 | $1,090 | $1,090 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,224 | $1,224 | $1,224 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $495 | $960 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $180 | $539 | $898 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $897 | $897 | $897 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $480 | $931 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $757 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $224 | $419 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $140 | $250 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $75 | $401 | $728 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $85 | $140 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $405 | $781 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $450 | $450 | $450 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $434 | $497 | $530 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $205 | $555 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $373 | $715 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $370 | $710 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $886 | $886 | $886 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $269 | $433 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $40 | $60 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $205 | $232 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $119 | $119 | $119 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $184 | $219 | $255 |