| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $30 | $48 | $65 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,777 | $1,777 | $1,777 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,639 | $1,720 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,622 | $1,667 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $424 | $436 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $168 | $305 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $30 | $30 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $30 | $30 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $606 | $606 | $606 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $552 | $552 | $552 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $373 | $716 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $522 | $1,014 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $30 | $30 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $30 | $30 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $94 | $158 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $106 | $182 | $258 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $80 | $80 | $80 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $255 | $255 | $255 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $30 | $30 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $30 | $30 | $30 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $50 | $50 | $50 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $179 | $179 | $179 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $89 | $90 | $92 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $150 | $150 | $150 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $38 | $38 | $38 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $256 | $256 | $256 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $49 | $49 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $21 | $21 |
| 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 | $265 | $265 | $265 |
| Special stain group II CPT 88313 • Pathology | $62 | $62 | $62 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $64 | $72 | $79 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $68 | $68 | $68 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $77 | $77 | $77 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $93 | $102 | $111 |
| Microdissection manual CPT 88381 • Pathology | $196 | $196 | $196 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $4 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $10 | $10 |