| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $30 | $30 | $30 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $71 | $71 | $71 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $90 | $90 | $90 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $14 | $14 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $35 | $40 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,930 | $1,930 | $1,930 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $30 | $30 | $30 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,639 | $1,639 | $1,639 |
| Total hip replacement CPT 27130 • Orthopedics | $30 | $30 | $30 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $30 | $30 | $30 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $30 | $30 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $30 | $30 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $30 | $30 | $30 |
| 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 | $26 | $59 | $93 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $68 | $68 | $68 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $278 | $278 | $278 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $64 | $64 | $64 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $53 | $53 | $53 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $192 | $192 | $192 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $97 | $97 | $97 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $166 | $166 | $166 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $379 | $419 | $460 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $204 | $204 | $204 |
| Cytopathology concentration technique CPT 88108 • Pathology | $51 | $51 | $51 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $57 | $57 | $57 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $27 | $27 | $27 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $12 | $12 | $12 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $25 | $25 | $25 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $28 | $28 | $28 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $26 | $26 | $26 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $34 | $34 | $34 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $182 | $206 | $229 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $349 | $349 | $349 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $85 | $85 | $85 |
| Special stain group II CPT 88313 • Pathology | $61 | $61 | $61 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $48 | $48 | $48 |
| Frozen section pathology each additional CPT 88332 • Pathology | $45 | $45 | $45 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $79 | $79 | $79 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $91 | $91 | $91 |