| Facet joint injection lumbar second level CPT 64494 • Pain Management | $7,500 | $7,500 | $7,500 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $134 | $3,817 | $7,500 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $7,500 | $7,500 | $7,500 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $7,500 | $7,500 | $7,500 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $7,500 | $7,500 | $7,500 |
| Cytopathology concentration technique CPT 88108 • Pathology | $117 | $117 | $117 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $12 | $75 | $106 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $11 | $32 | $42 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $45 | $45 | $45 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $12 | $51 | $70 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $56 | $56 | $56 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $60 | $60 | $60 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $3 | $47 | $69 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $57 | $83 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $67 | $92 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $36 | $382 | $555 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $785 | $785 | $785 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $52 | $170 | $229 |
| Special stain group II CPT 88313 • Pathology | $5 | $126 | $186 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $109 | $109 | $109 |
| Frozen section pathology each additional CPT 88332 • Pathology | $66 | $66 | $66 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $108 | $156 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $122 | $175 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $19 | $143 | $205 |
| Microdissection manual CPT 88381 • Pathology | $473 | $473 | $473 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $11 | $11 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $9 | $9 | $9 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $22 | $22 | $22 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $22 | $22 | $22 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $98 | $98 | $98 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $73 | $73 | $73 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $73 | $73 | $73 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $31 | $31 | $31 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $21 | $21 | $21 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $25 | $25 | $25 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $10 | $10 | $10 |
| Immunization admin injection single CPT 90471 • Preventive Care | $23 | $23 | $23 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $11 | $11 | $11 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $303 | $329 | $369 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $254 | $256 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $45 | $87 | $115 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $15 | $19 | $22 |
| MMR vaccine CPT 90707 • Preventive Care | $92 | $101 | $110 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $32 | $38 | $44 |
| Varicella vaccine CPT 90716 • Preventive Care | $159 | $187 | $215 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $140 | $147 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $220 | $227 | $242 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $136 | $136 | $136 |