| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $609 | $609 | $610 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $45 | $45 | $45 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $45 | $230 | $415 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $45 | $45 | $45 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $969 | $969 | $969 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $147 | $147 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $87 | $87 | $87 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $39 | $39 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $45 | $45 | $45 |
| Fundus photography CPT 92250 • Ophthalmology | $21 | $21 | $21 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $73 | $73 | $73 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,966 | $1,966 | $1,966 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $45 | $45 | $45 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,139 | $2,139 | $2,140 |
| Total hip replacement CPT 27130 • Orthopedics | $45 | $45 | $45 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $45 | $45 | $45 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $45 | $45 | $45 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $1,416 | $1,416 | $1,416 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,414 | $1,414 | $1,414 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $45 | $45 | $45 |
| Total knee replacement CPT 27447 • Orthopedics | $45 | $764 | $1,483 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $45 | $353 | $661 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $327 | $327 | $327 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $45 | $533 | $1,021 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $45 | $333 | $622 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $45 | $45 | $45 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $45 | $45 | $45 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $45 | $45 | $45 |
| Carpal tunnel release CPT 64721 • Orthopedics | $45 | $45 | $45 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $186 | $186 | $186 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $290 | $290 | $290 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $285 | $285 | $285 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $2,377 | $2,377 | $2,377 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $84 | $84 | $84 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $53 | $53 | $53 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $45 | $45 | $45 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $45 | $45 | $45 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $192 | $192 | $192 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $99 | $99 | $99 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $168 | $168 | $168 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $456 | $456 | $456 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $188 | $188 | $188 |
| Cytopathology concentration technique CPT 88108 • Pathology | $33 | $33 | $33 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $32 | $32 | $32 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $18 | $18 | $18 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $14 | $14 | $14 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $24 | $24 | $24 |