| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $39 | $39 | $39 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $57 | $57 | $57 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $68 | $68 | $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 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $357 | $357 | $357 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $48 | $48 | $48 |
| 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 femoral fracture CPT 27244 • 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 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 | $90 | $132 | $175 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $292 | $292 | $293 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $92 | $92 | $92 |
| 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 V CPT 88307 • Pathology | $251 | $251 | $251 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $39 | $39 | $39 |
| Microdissection manual CPT 88381 • Pathology | $174 | $174 | $174 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $9 | $9 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $10 | $10 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $10 | $10 | $10 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $21 | $21 | $21 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $24 | $24 | $24 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $21 | $21 | $21 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $48 | $48 | $48 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $27 | $27 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $23 | $23 | $23 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $22 | $22 | $23 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $23 | $23 | $23 |