| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $37 | $596 | $1,155 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $1,190 | $1,190 | $1,190 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $25 | $406 | $786 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $1,110 | $1,110 | $1,110 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,807 | $1,807 | $1,807 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $143 | $143 | $143 |
| Visual field examination CPT 92083 • Ophthalmology | $27 | $27 | $27 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $14 | $14 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $83 | $83 | $83 |
| Fundus photography CPT 92250 • Ophthalmology | $40 | $40 | $40 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $104 | $104 | $104 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $40 | $50 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $3,248 | $3,248 | $3,248 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $3,039 | $3,039 | $3,039 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,610 | $1,610 | $1,610 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $30 | $30 |
| Total hip replacement CPT 27130 • Orthopedics | $2,477 | $2,477 | $2,477 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $3,223 | $3,223 | $3,223 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $2,299 | $2,299 | $2,299 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $2,226 | $2,226 | $2,226 |
| Total knee replacement CPT 27447 • Orthopedics | $1,148 | $1,811 | $2,475 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $484 | $799 | $1,114 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $742 | $1,213 | $1,683 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $2,061 | $2,061 | $2,061 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $1,079 | $1,079 | $1,079 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $453 | $746 | $1,039 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $2,295 | $2,295 | $2,295 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $2,604 | $2,604 | $2,604 |
| Carpal tunnel release CPT 64721 • Orthopedics | $1,044 | $1,044 | $1,044 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $128 | $128 | $128 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $26 | $26 | $26 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $607 | $607 | $607 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $30 | $30 | $30 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $119 | $119 | $119 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $580 | $580 | $580 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $410 | $410 | $410 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $214 | $214 | $214 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $360 | $360 | $360 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $332 | $687 | $1,043 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $136 | $136 | $136 |
| Cytopathology concentration technique CPT 88108 • Pathology | $116 | $116 | $116 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $121 | $121 | $121 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $41 | $41 | $41 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $32 | $32 | $32 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $54 | $54 | $54 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $24 | $24 | $24 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $56 | $56 | $56 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $74 | $74 | $74 |