| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,520 | $1,520 | $1,520 |
| Total knee replacement CPT 27447 • Orthopedics | $1,695 | $1,695 | $1,695 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $1,172 | $1,172 | $1,172 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $225 | $225 | $225 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,419 | $1,419 | $1,419 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $752 | $752 | $752 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $724 | $724 | $724 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $919 | $919 | $919 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $1,294 | $1,294 | $1,294 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $949 | $1,077 | $1,204 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,454 | $1,454 | $1,454 |
| Carpal tunnel release CPT 64721 • Orthopedics | $596 | $596 | $596 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $74 | $87 | $100 |
| Cytopathology concentration technique CPT 88108 • Pathology | $91 | $91 | $91 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $90 | $90 | $90 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $30 | $30 | $30 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $9 | $17 | $24 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $57 | $57 | $57 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $96 | $96 | $96 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $380 | $380 | $380 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $333 | $453 | $573 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $149 | $149 | $149 |
| Special stain group II CPT 88313 • Pathology | $109 | $109 | $109 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $79 | $107 | $135 |
| Frozen section pathology each additional CPT 88332 • Pathology | $73 | $73 | $73 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $120 | $120 | $120 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $140 | $140 | $140 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $160 | $160 | $160 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $17 | $17 | $17 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $10 | $13 | $16 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $19 | $19 | $19 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $19 | $19 | $19 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $40 | $40 | $40 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $46 | $46 | $46 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $40 | $40 | $40 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $37 | $37 | $37 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $24 | $24 | $24 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $136 | $136 | $136 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $136 | $136 | $136 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $136 | $136 | $136 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $94 | $94 | $94 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $31 | $40 | $49 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $44 | $44 | $44 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $43 | $43 | $43 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $28 | $28 | $28 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $64 | $64 | $64 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $31 | $31 | $31 |
| Immunization admin injection single CPT 90471 • Preventive Care | $27 | $27 | $27 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $20 | $20 | $20 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $22 | $22 | $22 |