| Total knee replacement CPT 27447 • Orthopedics | $45 | $45 | $45 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $45 | $45 | $45 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $45 | $45 | $45 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $45 | $45 | $45 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $45 | $93 | $141 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $45 | $45 | $45 |
| Carpal tunnel release CPT 64721 • Orthopedics | $45 | $45 | $45 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $45 | $101 | $157 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $210 | $210 | $210 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $41 | $41 | $41 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $45 | $177 | $309 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $146 | $186 | $225 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $73 | $75 | $77 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $353 | $353 | $353 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $145 | $145 | $145 |
| Cytopathology concentration technique CPT 88108 • Pathology | $42 | $42 | $42 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $13 | $30 | $47 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $22 | $22 | $22 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $10 | $10 | $10 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $22 | $22 | $22 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $21 | $21 | $21 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $17 | $28 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $32 | $47 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $37 | $134 | $182 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $277 | $277 | $277 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $67 | $67 | $67 |
| Special stain group II CPT 88313 • Pathology | $5 | $27 | $48 |
| Frozen section pathology each additional CPT 88332 • Pathology | $37 | $37 | $37 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $38 | $63 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $45 | $75 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $32 | $32 | $32 |
| Microdissection manual CPT 88381 • Pathology | $84 | $84 | $84 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $11 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $10 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $8 | $9 | $11 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $18 | $19 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $18 | $18 | $19 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $66 | $71 | $76 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $69 | $76 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $34 | $40 | $52 |