| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $499 | $499 | $499 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $148 | $148 | $148 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $236 | $236 | $236 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $36 | $36 | $36 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $100 | $100 | $100 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $379 | $379 | $379 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $204 | $212 | $221 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $182 | $182 | $182 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $25 | $25 | $25 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $25 | $25 | $25 |
| Microdissection manual CPT 88381 • Pathology | $131 | $131 | $131 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $3 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $6 | $6 | $6 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $10 | $10 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $6 | $6 | $6 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $14 | $14 | $14 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $16 | $16 | $16 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $23 | $23 | $23 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $12 | $12 | $12 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $8 | $8 | $8 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $56 | $56 | $56 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $17 | $17 | $17 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $15 | $15 | $15 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $15 | $20 | $25 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $16 | $16 | $16 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $23 | $23 | $23 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $19 | $19 | $19 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $5 | $5 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $271 | $271 | $271 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $113 | $113 | $113 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $98 | $113 | $127 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $123 | $123 | $123 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $142 | $142 | $142 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $81 | $81 | $81 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $89 | $89 | $89 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $99 | $99 | $99 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $276 | $276 | $276 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $149 | $149 | $149 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $136 | $136 | $136 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $136 | $136 | $136 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $106 | $106 | $106 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $276 | $276 | $276 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $68 | $68 | $68 |
| Spirometry CPT 94010 • Pulmonology | $25 | $25 | $25 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $35 | $35 | $35 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $7 | $7 | $7 |