| Consultation office high complexity CPT 99245 • Office Visits | $236 | $236 | $236 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $634 | $634 | $634 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $53 | $53 | $53 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,474 | $1,474 | $1,474 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $680 | $680 | $681 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $697 | $697 | $697 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $459 | $459 | $460 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $650 | $650 | $650 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $1,090 | $1,090 | $1,090 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $106 | $106 | $106 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $19 | $19 | $19 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $61 | $61 | $61 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $76 | $76 | $77 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,983 | $1,983 | $1,983 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,855 | $1,855 | $1,855 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,159 | $2,159 | $2,159 |
| Total hip replacement CPT 27130 • Orthopedics | $1,510 | $1,510 | $1,510 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,963 | $1,963 | $1,963 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,405 | $1,405 | $1,405 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,358 | $1,358 | $1,358 |
| Total knee replacement CPT 27447 • Orthopedics | $1,509 | $1,509 | $1,509 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $687 | $687 | $687 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $1,055 | $1,055 | $1,055 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,260 | $1,260 | $1,260 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $664 | $664 | $664 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $640 | $640 | $641 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $1,102 | $1,102 | $1,102 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,248 | $1,248 | $1,248 |
| Carpal tunnel release CPT 64721 • Orthopedics | $507 | $507 | $507 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $97 | $146 | $194 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $12 | $12 | $12 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $161 | $161 | $161 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $301 | $301 | $301 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $87 | $87 | $87 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $57 | $57 | $57 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $287 | $287 | $287 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $201 | $201 | $201 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $104 | $104 | $104 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $174 | $174 | $174 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $516 | $516 | $516 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $285 | $285 | $285 |
| 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 | $12 | $12 | $12 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $20 | $20 | $20 |
| 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 V CPT 88307 • Pathology | $63 | $141 | $218 |