| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $17 | $17 | $17 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $666 | $666 | $666 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $269 | $326 | $384 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $113 | $184 | $254 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $40 | $242 | $444 |
| Excision chalazion single CPT 67800 • Ophthalmology | $58 | $58 | $58 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $596 | $596 | $596 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $87 | $87 | $87 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $30 | $44 | $59 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $52 | $52 | $52 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $5 | $20 | $35 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $5 | $5 | $5 |
| Visual field examination CPT 92083 • Ophthalmology | $24 | $24 | $24 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $18 | $23 | $28 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $37 | $39 | $40 |
| Fundus photography CPT 92250 • Ophthalmology | $5 | $23 | $40 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $3 | $3 | $3 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $21 | $26 | $31 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $8 | $8 | $8 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,490 | $1,490 | $1,491 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,028 | $1,200 | $1,371 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $805 | $805 | $805 |
| Total shoulder replacement CPT 23472 • Orthopedics | $924 | $924 | $924 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,032 | $1,032 | $1,032 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $261 | $261 | $261 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $190 | $190 | $190 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $224 | $224 | $224 |
| Total hip replacement CPT 27130 • Orthopedics | $862 | $1,005 | $1,149 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $40 | $730 | $1,419 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,010 | $1,010 | $1,011 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $781 | $781 | $781 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $104 | $104 | $104 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $196 | $588 | $980 |
| Total knee replacement CPT 27447 • Orthopedics | $804 | $975 | $1,147 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $40 | $262 | $484 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $175 | $175 | $175 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $519 | $631 | $742 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $15 | $15 | $15 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $133 | $508 | $883 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $236 | $353 | $471 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $453 | $453 | $453 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $441 | $441 | $441 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $623 | $623 | $623 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $40 | $439 | $838 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $953 | $953 | $953 |
| Carpal tunnel release CPT 64721 • Orthopedics | $71 | $213 | $356 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $40 | $40 | $40 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $89 | $143 | $197 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $94 | $94 | $94 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $39 | $117 | $195 |