| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,690 | $1,690 | $1,690 |
| Total shoulder replacement CPT 23472 • Orthopedics | $1,337 | $1,337 | $1,337 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $317 | $317 | $317 |
| Total knee replacement CPT 27447 • Orthopedics | $1,176 | $1,176 | $1,176 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $537 | $537 | $537 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $824 | $824 | $824 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $158 | $158 | $158 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $500 | $500 | $500 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $152 | $152 | $152 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $106 | $181 | $257 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $141 | $141 | $141 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $42 | $42 | $42 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $96 | $96 | $96 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $253 | $253 | $253 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $51 | $51 | $51 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $227 | $227 | $227 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $44 | $44 | $44 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $57 | $57 | $57 |
| Microdissection manual CPT 88381 • Pathology | $167 | $167 | $167 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $8 | $8 | $8 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $7 | $7 | $7 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $10 | $10 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $8 | $8 | $8 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $18 | $18 | $18 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $18 | $18 | $18 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $17 | $17 | $17 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $11 | $11 | $11 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $43 | $43 | $44 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $23 | $23 | $23 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $20 | $20 | $20 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $20 | $20 | $20 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $21 | $21 | $21 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $30 | $30 | $30 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $26 | $26 | $26 |
| 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 | $5 | $5 | $5 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $271 | $271 | $271 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $258 | $258 | $258 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $90 | $90 | $90 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $111 | $111 | $111 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $53 | $53 | $53 |
| Preventive visit established patient age 5-11 CPT 99393 • 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 | $111 | $111 | $111 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $201 | $201 | $201 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $169 | $169 | $169 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $95 | $95 | $96 |