| Iridotomy laser surgery CPT 66761 • Ophthalmology | $296 | $296 | $296 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $663 | $663 | $663 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $355 | $355 | $355 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $171 | $171 | $171 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $1,192 | $1,192 | $1,192 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $515 | $515 | $515 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $357 | $357 | $357 |
| Excision chalazion single CPT 67800 • Ophthalmology | $121 | $121 | $121 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $201 | $201 | $201 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $147 | $147 | $147 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $88 | $88 | $88 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $124 | $124 | $124 |
| Visual field examination CPT 92083 • Ophthalmology | $62 | $62 | $62 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $26 | $26 | $26 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $29 | $29 | $29 |
| Fundus photography CPT 92250 • Ophthalmology | $36 | $36 | $36 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $57 | $57 | $57 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $62 | $62 | $62 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $61 | $61 | $61 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $265 | $265 | $265 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,790 | $1,790 | $1,790 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $314 | $314 | $314 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,311 | $1,311 | $1,311 |
| Total knee replacement CPT 27447 • Orthopedics | $1,590 | $1,590 | $1,590 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $161 | $161 | $161 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,067 | $1,067 | $1,067 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $602 | $602 | $602 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $673 | $673 | $673 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $699 | $699 | $699 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $1,041 | $1,041 | $1,041 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $141 | $141 | $141 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,124 | $1,124 | $1,124 |
| Carpal tunnel release CPT 64721 • Orthopedics | $457 | $457 | $457 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $157 | $157 | $157 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $113 | $113 | $113 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $105 | $105 | $105 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $21 | $21 | $21 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $41 | $41 | $41 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $232 | $232 | $232 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $225 | $225 | $225 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $126 | $126 | $126 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $139 | $139 | $139 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $304 | $304 | $304 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $94 | $94 | $94 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $14 | $14 | $14 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $18 | $18 | $18 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $17 | $17 | $17 |