| Visual field examination CPT 92083 • Ophthalmology | $60 | $60 | $60 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $41 | $51 |
| Fundus photography CPT 92250 • Ophthalmology | $21 | $21 | $21 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $18 | $18 | $18 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $64 | $64 | $64 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,721 | $1,721 | $1,721 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,592 | $1,592 | $1,592 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,061 | $1,061 | $1,061 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $788 | $788 | $788 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $157 | $284 |
| Total hip replacement CPT 27130 • Orthopedics | $627 | $951 | $1,275 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,657 | $1,657 | $1,657 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $175 | $680 | $1,186 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $840 | $840 | $840 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,198 | $1,198 | $1,198 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $789 | $965 | $1,141 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $652 | $1,274 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $305 | $580 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $213 | $261 | $309 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $350 | $611 | $872 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $17 | $93 | $169 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $209 | $637 | $1,064 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $564 | $564 | $564 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $543 | $543 | $543 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $473 | $915 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,107 | $1,107 | $1,107 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $236 | $442 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $16 | $16 | $16 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $258 | $258 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $137 | $137 | $137 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $15 | $134 | $254 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $81 | $81 | $81 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $31 | $31 | $31 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $37 | $42 | $48 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $241 | $241 | $241 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $172 | $172 | $172 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $67 | $77 | $88 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $150 | $152 | $154 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $433 | $433 | $434 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $239 | $239 | $239 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $51 | $53 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $53 | $53 | $53 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $18 | $18 | $18 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $12 | $12 | $13 |