| 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 | $523 | $523 | $523 |
| 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 | $488 | $488 | $488 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $30 | $30 | $30 |
| 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 | $30 | $30 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $227 | $227 | $227 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $224 | $224 | $224 |
| 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 | $42 | $42 | $43 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $150 | $150 | $150 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $78 | $78 | $78 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $132 | $132 | $132 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $384 | $384 | $384 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $211 | $211 | $211 |
| Cytopathology concentration technique CPT 88108 • Pathology | $50 | $50 | $50 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $22 | $22 | $22 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $45 | $45 | $45 |
| Special stain group II CPT 88313 • Pathology | $63 | $63 | $63 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $81 | $81 | $81 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $69 | $69 | $69 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $79 | $79 | $79 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $61 | $78 | $95 |
| Microdissection manual CPT 88381 • Pathology | $163 | $163 | $163 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $8 | $8 | $9 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $10 | $10 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $9 | $9 | $10 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $20 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $18 | $18 | $18 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $70 | $70 | $70 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $48 | $48 | $48 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $25 | $25 | $25 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $22 | $22 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $22 | $22 | $22 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $23 | $23 | $23 |