| Total hip replacement CPT 27130 • Orthopedics | $40 | $40 | $40 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $40 | $40 | $40 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $40 | $40 | $40 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $40 | $40 | $40 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $40 | $40 | $40 |
| Total knee replacement CPT 27447 • Orthopedics | $1,347 | $1,347 | $1,347 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $40 | $81 | $122 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $40 | $40 | $40 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $919 | $919 | $919 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $40 | $40 | $40 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $40 | $40 | $40 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $40 | $63 | $85 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $722 | $722 | $722 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $40 | $40 | $40 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $40 | $40 | $40 |
| Carpal tunnel release CPT 64721 • Orthopedics | $40 | $40 | $40 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $168 | $168 | $169 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $96 | $165 | $234 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $124 | $124 | $124 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $40 | $40 | $40 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $46 | $46 | $46 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $395 | $395 | $395 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $217 | $217 | $217 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $15 | $15 | $15 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $23 | $23 | $23 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $26 | $26 | $26 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $194 | $194 | $194 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $82 | $82 | $82 |
| Microdissection manual CPT 88381 • Pathology | $140 | $140 | $140 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $8 | $8 | $8 |
| 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 | $9 | $9 | $9 |
| 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 | $20 | $20 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $18 | $18 | $18 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $69 | $69 | $69 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $24 | $35 | $47 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $25 | $25 | $25 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $22 | $22 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $22 | $22 | $22 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $23 | $23 | $23 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $33 | $33 | $33 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $28 | $28 | $28 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $5 | $5 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |