| Consultation office high complexity CPT 99245 • Office Visits | $30 | $134 | $199 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $507 | $507 | $507 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $39 | $39 | $39 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,206 | $1,206 | $1,206 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,112 | $1,112 | $1,112 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $511 | $512 | $513 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $115 | $115 | $115 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $525 | $525 | $525 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $346 | $346 | $346 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $463 | $463 | $463 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $795 | $795 | $795 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $148 | $148 | $148 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $70 | $70 | $70 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $73 | $73 | $73 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $64 | $64 | $64 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $12 | $12 | $12 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $38 | $38 | $38 |
| Fundus photography CPT 92250 • Ophthalmology | $17 | $17 | $17 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $31 | $31 | $31 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $54 | $54 | $54 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,425 | $1,425 | $1,425 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,325 | $1,325 | $1,325 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,544 | $1,544 | $1,544 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $349 | $349 | $349 |
| Total hip replacement CPT 27130 • Orthopedics | $1,073 | $1,073 | $1,073 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,395 | $1,395 | $1,395 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $995 | $995 | $995 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $958 | $958 | $958 |
| Total knee replacement CPT 27447 • Orthopedics | $1,072 | $1,081 | $1,091 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $482 | $492 | $503 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $717 | $717 | $718 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $893 | $893 | $893 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $469 | $469 | $469 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $451 | $456 | $462 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $727 | $727 | $727 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $883 | $883 | $883 |
| Carpal tunnel release CPT 64721 • Orthopedics | $351 | $351 | $351 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $134 | $134 | $134 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $85 | $85 | $85 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $198 | $198 | $198 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $39 | $39 | $39 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $189 | $189 | $189 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $136 | $136 | $136 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $70 | $70 | $70 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $121 | $121 | $121 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $340 | $342 | $344 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $183 | $184 | $184 |
| Cytopathology concentration technique CPT 88108 • Pathology | $47 | $47 | $47 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $48 | $48 | $48 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $16 | $16 | $16 |