| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $67 | $67 | $67 |
| Visual field examination CPT 92083 • Ophthalmology | $21 | $21 | $21 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $12 | $12 | $12 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $42 | $42 | $42 |
| Fundus photography CPT 92250 • Ophthalmology | $48 | $48 | $48 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $45 | $45 | $45 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,105 | $2,105 | $2,105 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $48 | $48 | $48 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,710 | $1,710 | $1,710 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,739 | $1,739 | $1,739 |
| Total hip replacement CPT 27130 • Orthopedics | $48 | $48 | $48 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $48 | $48 | $48 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $48 | $48 | $48 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $48 | $48 | $48 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $48 | $48 | $48 |
| Total knee replacement CPT 27447 • Orthopedics | $45 | $47 | $48 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $45 | $47 | $48 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $48 | $48 | $48 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $45 | $47 | $48 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $48 | $48 | $48 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $48 | $48 | $48 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $45 | $47 | $48 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $831 | $831 | $831 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $48 | $48 | $48 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $48 | $48 | $48 |
| Carpal tunnel release CPT 64721 • Orthopedics | $48 | $48 | $48 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $45 | $45 | $45 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $125 | $203 | $282 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $275 | $275 | $275 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $48 | $48 | $48 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $55 | $55 | $55 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $48 | $48 | $48 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $104 | $104 | $104 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $194 | $194 | $194 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $98 | $98 | $98 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $176 | $176 | $176 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $353 | $410 | $468 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $145 | $145 | $145 |
| Cytopathology concentration technique CPT 88108 • Pathology | $45 | $45 | $45 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $51 | $51 | $51 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $24 | $24 | $24 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $10 | $10 | $10 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $24 | $24 | $24 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $23 | $23 | $23 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $30 | $30 | $30 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $21 | $21 | $21 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $182 | $189 | $195 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $297 | $297 | $297 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $71 | $71 | $71 |