| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $295 | $295 | $295 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $31 | $31 | $31 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $11 | $11 | $11 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $19 | $19 | $19 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $17 | $17 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $39 | $39 | $39 |
| Special stain group II CPT 88313 • Pathology | $32 | $39 | $46 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $31 | $31 | $31 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $35 | $35 | $35 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $10 | $10 | $10 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $25 | $25 | $25 |
| 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 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $14 | $14 | $14 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $26 | $26 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $22 | $22 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $35 | $35 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $15 | $17 | $19 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $7 | $7 | $7 |
| Immunization admin injection single CPT 90471 • Preventive Care | $15 | $15 | $16 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $12 | $13 | $15 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $251 | $293 | $336 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $197 | $214 | $231 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $84 | $94 | $105 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $80 | $90 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $29 | $34 | $40 |
| Varicella vaccine CPT 90716 • Preventive Care | $157 | $176 | $196 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $113 | $123 | $133 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $207 | $213 | $220 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $90 | $123 | $156 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $90 | $127 | $163 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $94 | $132 | $170 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $105 | $149 | $193 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $109 | $148 | $187 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $118 | $168 | $217 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $235 | $235 | $235 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $90 | $116 | $141 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $82 | $116 | $150 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $88 | $119 | $150 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $91 | $128 | $164 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $105 | $136 | $168 |