| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $1,275 | $1,275 | $1,275 |
| Total knee replacement CPT 27447 • Orthopedics | $1,333 | $1,333 | $1,333 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $607 | $607 | $607 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $932 | $932 | $932 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $566 | $566 | $566 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $141 | $141 | $141 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $157 | $164 | $171 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $12 | $159 | $305 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $309 | $309 | $309 |
| 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 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $44 | $44 | $44 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $285 | $285 | $285 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $5 | $5 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $16 | $22 | $28 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $37 | $137 | $238 |
| Special stain group II CPT 88313 • Pathology | $5 | $5 | $5 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $51 | $51 | $51 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $13 | $13 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $16 | $16 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $34 | $34 | $34 |
| Microdissection manual CPT 88381 • Pathology | $174 | $174 | $174 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $7 | $9 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $7 | $8 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $8 | $9 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $8 | $9 | $11 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $15 | $18 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $16 | $19 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $17 | $19 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $14 | $17 | $19 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $10 | $10 | $10 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $71 | $76 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $59 | $67 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $41 | $46 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $16 | $24 | $31 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $19 | $22 | $25 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $19 | $19 | $19 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $19 | $21 | $22 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $28 | $28 | $28 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $24 | $24 | $24 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $13 | $19 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $6 | $7 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $14 | $18 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $11 | $12 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $269 | $269 | $269 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $230 | $230 | $230 |