| Total knee replacement CPT 27447 • Orthopedics | $30 | $30 | $30 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $45 | $45 | $45 |
| 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 | $45 | $45 | $45 |
| 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 | $258 | $258 | $258 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $255 | $255 | $255 |
| 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 | $49 | $49 | $49 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $89 | $89 | $89 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $150 | $150 | $150 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $353 | $353 | $353 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $145 | $145 | $145 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $49 | $49 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $21 | $21 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $182 | $182 | $182 |
| Special stain group II CPT 88313 • Pathology | $62 | $62 | $62 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $79 | $79 | $79 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $68 | $68 | $68 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $77 | $77 | $77 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $93 | $93 | $93 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $10 | $10 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $10 | $10 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $12 | $12 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $12 | $12 | $12 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $25 | $25 | $25 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $84 | $84 | $84 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $34 | $34 | $34 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $20 | $20 | $20 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $35 | $35 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $20 | $20 | $20 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $10 | $10 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $258 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $92 | $92 |
| MMR vaccine CPT 90707 • Preventive Care | $93 | $93 | $93 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $163 | $163 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $13 | $13 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $187 | $187 | $187 |