| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,878 | $1,878 | $1,878 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $755 | $755 | $755 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $727 | $727 | $727 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $1,324 | $1,324 | $1,324 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $1,986 | $1,986 | $1,986 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $204 | $204 | $204 |
| Carpal tunnel release CPT 64721 • Orthopedics | $576 | $576 | $576 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $170 | $170 | $170 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $284 | $284 | $284 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $112 | $112 | $112 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $596 | $596 | $596 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $66 | $66 | $66 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $194 | $194 | $194 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $137 | $137 | $137 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $351 | $351 | $351 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $108 | $108 | $108 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $203 | $203 | $203 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $250 | $250 | $250 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $68 | $68 | $68 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $12 | $12 | $12 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $23 | $40 | $58 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $3 | $3 | $3 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $5 | $5 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $25 | $33 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $37 | $37 | $37 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $66 | $66 | $66 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $12 | $12 | $12 |
| Special stain group II CPT 88313 • Pathology | $5 | $5 | $5 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $28 | $28 | $28 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $13 | $13 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $16 | $16 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $19 | $19 | $19 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $16 | $19 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $18 | $18 | $18 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $18 | $18 | $18 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $29 | $37 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $25 | $37 | $48 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $37 | $37 | $37 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $76 | $96 | $117 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $96 | $117 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $66 | $80 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $40 | $54 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $35 | $47 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $48 | $48 | $48 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $19 | $20 | $22 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $9 | $13 | $17 |