| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Visual field examination CPT 92083 • Ophthalmology | $26 | $55 | $85 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $57 | $84 |
| Fundus photography CPT 92250 • Ophthalmology | $7 | $11 | $15 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $67 | $67 | $67 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $8 | $30 | $52 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $63 | $71 | $79 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $311 | $982 | $1,654 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $344 | $1,073 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $412 | $412 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $449 | $449 | $449 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $208 | $387 |
| Total hip replacement CPT 27130 • Orthopedics | $1,833 | $1,833 | $1,833 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $75 | $120 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $1,049 | $1,864 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $228 | $426 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $169 | $308 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $737 | $1,444 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $755 | $755 | $755 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $529 | $668 | $946 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $778 | $1,348 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $1,008 | $1,986 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $204 | $204 | $204 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $350 | $586 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $179 | $329 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $121 | $190 | $258 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $112 | $183 | $255 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $313 | $596 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $15 | $15 | $15 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $54 | $66 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $160 | $201 | $242 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $72 | $114 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $170 | $178 | $187 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $88 | $95 | $108 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $150 | $175 | $199 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $318 | $378 | $437 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $68 | $183 | $240 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $49 | $49 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $39 | $58 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $219 | $219 | $219 |
| Special stain group II CPT 88313 • Pathology | $62 | $62 | $62 |