| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $94 | $444 | $650 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $112 | $412 | $650 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $475 | $1,244 | $3,203 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $475 | $1,192 | $2,992 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $475 | $1,178 | $3,463 |
| Total shoulder replacement CPT 23472 • Orthopedics | $475 | $1,038 | $2,763 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $475 | $1,101 | $3,081 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $475 | $650 | $823 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $50 | $481 | $650 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $475 | $689 | $1,020 |
| Total hip replacement CPT 27130 • Orthopedics | $475 | $999 | $2,570 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $475 | $1,238 | $3,176 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $475 | $937 | $2,260 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $475 | $950 | $2,324 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $475 | $1,025 | $2,324 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $475 | $924 | $2,196 |
| Total knee replacement CPT 27447 • Orthopedics | $475 | $999 | $2,569 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $475 | $701 | $1,078 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $350 | $508 | $650 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $475 | $756 | $1,354 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $335 | $552 | $650 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $475 | $890 | $2,027 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $475 | $709 | $1,059 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $475 | $689 | $1,018 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $475 | $749 | $1,318 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $475 | $858 | $1,866 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $475 | $888 | $2,014 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $475 | $1,017 | $2,291 |
| Carpal tunnel release CPT 64721 • Orthopedics | $475 | $663 | $888 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $50 | $363 | $650 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $475 | $553 | $650 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $188 | $491 | $650 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $215 | $528 | $650 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $475 | $1,032 | $2,737 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $97 | $479 | $650 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $50 | $380 | $650 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $350 | $528 | $650 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $184 | $462 | $650 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $350 | $459 | $650 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $182 | $461 | $650 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $262 | $502 | $650 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $475 | $628 | $888 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $367 | $523 | $650 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $475 | $475 | $475 |
| Cytopathology concentration technique CPT 88108 • Pathology | $22 | $22 | $22 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $32 | $32 | $32 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $30 | $30 | $30 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $14 | $14 | $14 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $35 | $35 | $35 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $20 | $20 | $20 |