| Laminectomy lumbar single level CPT 63047 • Orthopedics | $45 | $45 | $45 |
| Carpal tunnel release CPT 64721 • Orthopedics | $45 | $45 | $45 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $45 | $45 | $45 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $94 | $94 | $94 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $133 | $133 | $133 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $45 | $45 | $45 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $78 | $78 | $78 |
| 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 | $144 | $144 | $145 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $18 | $18 | $18 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $27 | $27 | $27 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $182 | $182 | $182 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $59 | $59 | $59 |
| Microdissection manual CPT 88381 • Pathology | $84 | $84 | $84 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $9 | $9 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $9 | $9 |
| 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 | $21 | $21 | $21 |
| 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 | $16 | $16 | $16 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $11 | $11 | $11 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $50 | $50 | $50 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $50 | $50 | $50 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $34 | $34 | $34 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $24 | $24 | $24 |
| 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 | $22 | $22 | $22 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $28 | $28 | $28 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $24 | $24 | $24 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $20 | $20 | $20 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $10 | $10 | $10 |
| Immunization admin injection single CPT 90471 • Preventive Care | $20 | $20 | $20 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $230 | $230 | $230 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $219 | $219 | $219 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $87 | $87 | $87 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $106 | $106 | $107 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $120 | $120 | $120 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $77 | $77 | $77 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $83 | $83 | $83 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $69 | $69 | $69 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $71 | $71 | $71 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $81 | $94 | $107 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $148 | $194 | $241 |
| 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 | $126 | $126 | $126 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $130 | $130 | $130 |