| Fundus photography CPT 92250 • Ophthalmology | $16 | $16 | $16 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $42 | $42 | $42 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $33 | $33 | $33 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $41 | $41 | $41 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,685 | $1,685 | $1,685 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $351 | $351 | $351 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $40 | $40 | $40 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $40 | $40 | $40 |
| Total knee replacement CPT 27447 • Orthopedics | $1,276 | $1,276 | $1,276 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $459 | $459 | $459 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $545 | $545 | $545 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $520 | $520 | $520 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $563 | $563 | $563 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $811 | $811 | $811 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $138 | $138 | $138 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $211 | $211 | $211 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $133 | $133 | $133 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $56 | $56 | $56 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $56 | $56 | $56 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $375 | $375 | $375 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $156 | $156 | $156 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $129 | $129 | $129 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $17 | $17 | $17 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $39 | $39 | $39 |
| Microdissection manual CPT 88381 • Pathology | $119 | $119 | $119 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $3 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $8 | $8 | $8 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $9 | $9 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $7 | $7 | $7 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $16 | $16 | $16 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $17 | $17 | $17 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $14 | $14 | $14 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $15 | $15 | $15 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $10 | $10 | $10 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $33 | $33 | $33 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $17 | $17 | $17 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $17 | $17 | $17 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $16 | $16 | $16 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $24 | $24 | $24 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $19 | $19 | $19 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $17 | $17 | $17 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $22 | $23 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $11 | $11 | $11 |
| Immunization admin injection single CPT 90471 • Preventive Care | $20 | $20 | $20 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $230 | $230 | $230 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $219 | $219 | $219 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $75 | $75 | $75 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $89 | $89 | $89 |