| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $39 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $36 | $36 | $36 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $53 | $72 | $91 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $63 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $5,459 | $5,459 | $5,459 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $5,100 | $5,100 | $5,100 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $719 | $1,026 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $157 | $284 |
| Total hip replacement CPT 27130 • Orthopedics | $3,124 | $3,124 | $3,124 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $4,062 | $4,062 | $4,062 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $1,467 | $2,904 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $840 | $1,019 | $1,199 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $1,419 | $2,808 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $1,576 | $3,121 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $722 | $1,415 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $1,092 | $2,153 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $1,317 | $2,604 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $1,370 | $1,370 | $1,370 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $530 | $925 | $1,319 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $1,205 | $2,381 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $1,581 | $3,131 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $3,549 | $3,549 | $3,549 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $30 | $30 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $30 | $30 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $258 | $258 | $258 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $255 | $547 | $840 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $684 | $1,339 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $11 | $11 | $11 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $49 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $30 | $30 | $30 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $170 | $170 | $170 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $88 | $88 | $89 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $149 | $149 | $150 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $436 | $436 | $437 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $240 | $240 | $240 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $65 | $81 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $84 | $84 | $84 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $28 | $28 | $28 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $17 | $21 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $28 | $35 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $28 | $28 | $28 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $40 | $40 | $40 |