| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $48 | $48 | $48 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $48 | $241 | $434 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $48 | $48 | $48 |
| Excision chalazion single CPT 67800 • Ophthalmology | $163 | $163 | $163 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $747 | $880 | $1,014 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $148 | $148 | $148 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $101 | $101 | $101 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $92 | $92 | $92 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $130 | $130 | $130 |
| Visual field examination CPT 92083 • Ophthalmology | $64 | $64 | $64 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $15 | $15 | $15 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $48 | $48 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $22 | $22 | $22 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $39 | $39 | $39 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $40 | $40 | $40 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $49 | $59 | $68 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $48 | $48 | $48 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,013 | $2,013 | $2,014 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,573 | $1,573 | $1,573 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $450 | $450 | $450 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $341 | $341 | $341 |
| Total hip replacement CPT 27130 • Orthopedics | $48 | $48 | $48 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $48 | $48 | $48 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $48 | $48 | $48 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $48 | $48 | $48 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $48 | $48 | $48 |
| Total knee replacement CPT 27447 • Orthopedics | $48 | $722 | $1,396 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $48 | $335 | $622 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $308 | $308 | $308 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $48 | $505 | $961 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $190 | $190 | $190 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $48 | $48 | $48 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $48 | $48 | $48 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $48 | $317 | $585 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $48 | $48 | $48 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,240 | $1,240 | $1,240 |
| Carpal tunnel release CPT 64721 • Orthopedics | $48 | $48 | $48 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $48 | $111 | $175 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $121 | $207 | $293 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $92 | $92 | $92 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $85 | $85 | $85 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $48 | $48 | $48 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $121 | $121 | $121 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $460 | $460 | $460 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $19 | $19 | $19 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $20 | $20 | $20 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $30 | $30 | $30 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $63 | $63 | $63 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $251 | $251 | $251 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $108 | $108 | $108 |