| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,270 | $1,270 | $1,270 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $548 | $548 | $548 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $346 | $354 | $362 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $484 | $484 | $484 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $795 | $795 | $795 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $86 | $86 | $86 |
| Visual field examination CPT 92083 • Ophthalmology | $28 | $28 | $28 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $33 | $33 | $33 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $48 | $48 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $17 | $17 | $17 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $54 | $54 | $54 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,797 | $1,797 | $1,797 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,672 | $1,672 | $1,672 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,544 | $1,544 | $1,544 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $478 | $478 | $478 |
| Total hip replacement CPT 27130 • Orthopedics | $1,353 | $1,353 | $1,353 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,759 | $1,759 | $1,759 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,256 | $1,256 | $1,256 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,208 | $1,208 | $1,208 |
| Total knee replacement CPT 27447 • Orthopedics | $1,091 | $1,221 | $1,352 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $503 | $555 | $608 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $718 | $811 | $904 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,126 | $1,126 | $1,126 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $592 | $592 | $592 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $462 | $515 | $569 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $865 | $865 | $865 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,051 | $1,051 | $1,051 |
| Carpal tunnel release CPT 64721 • Orthopedics | $418 | $418 | $418 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $25 | $25 | $25 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $240 | $240 | $240 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $236 | $236 | $236 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $47 | $47 | $47 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $225 | $225 | $225 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $162 | $162 | $162 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $84 | $84 | $84 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $144 | $144 | $144 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $344 | $375 | $405 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $183 | $184 | $184 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $49 | $49 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $50 | $50 | $50 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $17 | $17 | $17 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $14 | $14 | $14 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $21 | $21 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $16 | $16 | $16 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $24 | $24 | $24 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $31 | $31 | $31 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $27 | $27 | $27 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $203 | $209 | $215 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $325 | $325 | $325 |