| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $650 | $660 | $670 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $650 | $660 | $670 |
| Total shoulder replacement CPT 23472 • Orthopedics | $650 | $660 | $670 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $650 | $660 | $670 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $650 | $1,205 | $1,759 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $60 | $268 | $475 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $586 | $618 | $650 |
| Total hip replacement CPT 27130 • Orthopedics | $650 | $660 | $670 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $650 | $660 | $670 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $650 | $660 | $670 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $650 | $660 | $670 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $650 | $660 | $670 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $650 | $660 | $670 |
| Total knee replacement CPT 27447 • Orthopedics | $650 | $660 | $670 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $650 | $660 | $670 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $457 | $466 | $475 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $650 | $660 | $670 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $650 | $660 | $670 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $650 | $796 | $942 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $650 | $739 | $827 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $650 | $739 | $827 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $650 | $660 | $670 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $650 | $660 | $670 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $650 | $1,205 | $1,759 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $650 | $1,205 | $1,759 |
| Carpal tunnel release CPT 64721 • Orthopedics | $586 | $618 | $650 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $60 | $268 | $475 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $475 | $573 | $670 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $475 | $573 | $670 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $475 | $573 | $670 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $650 | $1,205 | $1,759 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $457 | $466 | $475 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $475 | $573 | $670 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $457 | $466 | $475 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $457 | $466 | $475 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $475 | $573 | $670 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $475 | $573 | $670 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $475 | $573 | $670 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $475 | $573 | $670 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $475 | $573 | $670 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $475 | $573 | $670 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $49 | $49 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $51 | $51 | $51 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $17 | $17 | $17 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $12 | $12 | $12 |
| 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 | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $5 | $5 | $5 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $22 | $22 | $22 |