| Discectomy lumbar single level CPT 63030 • Orthopedics | $141 | $141 | $141 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $157 | $157 | $157 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $232 | $232 | $232 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $103 | $103 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $225 | $225 | $225 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $126 | $126 | $126 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $5 | $5 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $16 | $16 | $16 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $37 | $37 | $37 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $12 | $12 | $12 |
| Special stain group II CPT 88313 • Pathology | $5 | $5 | $5 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $13 | $13 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $16 | $16 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $11 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $11 | $11 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $20 | $20 |
| 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 | $76 | $76 | $76 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $31 | $31 | $31 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $25 | $25 | $25 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $22 | $22 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $11 | $17 | $22 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $11 | $13 | $15 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $11 | $12 | $12 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $301 | $309 | $316 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $99 | $99 | $99 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $19 |
| MMR vaccine CPT 90707 • Preventive Care | $91 | $97 | $103 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $34 | $38 | $41 |
| Varicella vaccine CPT 90716 • Preventive Care | $184 | $184 | $184 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $176 | $191 | $206 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $101 | $101 | $101 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $113 | $118 | $122 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $92 | $105 | $118 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $109 | $121 | $133 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $129 | $134 | $140 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $127 | $138 | $149 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $98 | $98 | $98 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $97 | $97 | $97 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $104 | $108 | $112 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $114 | $118 | $123 |