| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $30 | $30 | $30 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $554 | $554 | $554 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $30 | $30 | $30 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $30 | $30 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $30 | $30 | $30 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $664 | $664 | $664 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $71 | $71 | $71 |
| Visual field examination CPT 92083 • Ophthalmology | $24 | $24 | $24 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $22 | $22 | $22 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $30 | $30 |
| Fundus photography CPT 92250 • Ophthalmology | $43 | $43 | $43 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $67 | $67 | $67 |
| 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 | $2,095 | $2,095 | $2,095 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $468 | $468 | $468 |
| 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 | $778 | $1,526 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $30 | $30 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $350 | $350 | $350 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $531 | $1,031 |
| 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 | $319 | $608 |
| 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 | $179 | $179 | $179 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $281 | $281 | $282 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $278 | $278 | $278 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $463 | $463 | $463 |
| 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 | $460 | $460 | $461 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $67 | $128 | $190 |
| 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 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $20 | $20 | $20 |