| Total shoulder replacement CPT 23472 • Orthopedics | $955 | $8,918 | $16,873 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $955 | $6,268 | $11,581 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $955 | $1,476 | $1,835 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $150 | $552 | $955 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $955 | $965 | $974 |
| Total hip replacement CPT 27130 • Orthopedics | $955 | $6,695 | $10,981 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $955 | $955 | $955 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $955 | $955 | $955 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $955 | $955 | $955 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $955 | $955 | $955 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $955 | $5,755 | $10,554 |
| Total knee replacement CPT 27447 • Orthopedics | $955 | $5,855 | $10,756 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $955 | $2,640 | $5,646 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $76 | $394 | $955 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $955 | $1,524 | $1,835 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $955 | $955 | $955 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $955 | $2,517 | $4,080 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $1,180 | $1,506 | $1,835 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $1,180 | $1,506 | $1,835 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $955 | $1,395 | $1,835 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $955 | $3,167 | $5,378 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $955 | $3,277 | $4,795 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $955 | $3,162 | $4,450 |
| Carpal tunnel release CPT 64721 • Orthopedics | $955 | $1,015 | $1,075 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $955 | $955 | $955 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $432 | $694 | $955 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $342 | $618 | $955 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $342 | $576 | $955 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $955 | $2,962 | $5,908 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $53 | $354 | $955 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $26 | $490 | $955 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $376 | $629 | $955 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $955 | $955 | $955 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $376 | $629 | $955 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $131 | $543 | $955 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $56 | $363 | $955 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $955 | $1,015 | $1,075 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $376 | $665 | $955 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $955 | $955 | $955 |
| Cytopathology concentration technique CPT 88108 • Pathology | $47 | $47 | $47 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $49 | $49 | $49 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $16 | $16 | $16 |
| 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 | $17 | $17 | $17 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $26 | $26 | $26 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $23 | $23 | $23 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $30 | $30 | $30 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $35 | $53 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $211 | $211 | $211 |