| 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 | $529 | $529 | $530 |
| 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 | $232 | $433 |
| 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 | $52 | $74 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $49 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $242 | $242 | $242 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $170 | $170 | $170 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $88 | $88 | $89 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $150 | $150 | $150 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $437 | $437 | $437 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $240 | $240 | $240 |
| 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 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $219 | $219 | $219 |
| Special stain group II CPT 88313 • Pathology | $62 | $62 | $62 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $30 | $55 | $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 | $92 | $92 | $93 |
| Microdissection manual CPT 88381 • Pathology | $159 | $159 | $159 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $10 | $10 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $12 | $12 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $11 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $24 | $24 | $24 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $28 | $28 | $28 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $24 | $24 | $25 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $22 | $22 | $22 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $14 | $14 | $14 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $83 | $83 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $83 | $83 | $83 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $58 | $58 | $58 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $30 | $30 | $30 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $27 | $27 | $27 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $26 | $26 | $27 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $27 | $27 | $27 |