| Facet joint injection lumbar first level CPT 64493 • Pain Management | $248 | $248 | $248 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $126 | $126 | $126 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $123 | $123 | $123 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $657 | $657 | $657 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $236 | $236 | $236 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $33 | $33 | $33 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $25 | $25 | $25 |
| 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 | $74 | $74 | $74 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $74 | $74 | $74 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $26 | $26 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $24 | $24 | $24 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $25 | $25 | $25 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $19 | $19 | $19 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $15 | $15 | $15 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $13 | $13 | $13 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $255 | $255 | $255 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $89 | $89 | $89 |
| MMR vaccine CPT 90707 • Preventive Care | $84 | $84 | $84 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $32 | $32 | $32 |
| Varicella vaccine CPT 90716 • Preventive Care | $166 | $166 | $166 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $242 | $242 | $242 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $96 | $96 | $96 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $125 | $125 | $125 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $88 | $88 | $88 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $124 | $124 | $124 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $120 | $120 | $120 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $130 | $130 | $130 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $87 | $87 | $87 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $92 | $92 | $92 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $77 | $77 | $77 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $84 | $84 | $84 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $87 | $87 | $87 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $92 | $92 | $92 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $95 | $95 | $95 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $312 | $312 | $312 |
| Spirometry CPT 94010 • Pulmonology | $41 | $41 | $41 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $16 | $16 | $16 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $10 | $10 | $10 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $98 | $98 | $98 |
| Diffusing capacity (DLCO) CPT 94729 • Pulmonology | $15 | $15 | $15 |
| Pulse oximetry single measurement CPT 94760 • Pulmonology | $3 | $3 | $3 |
| Sleep study unattended CPT 95800 • Sleep Medicine | $117 | $117 | $117 |
| Polysomnography age 6 or older CPT 95810 • Sleep Medicine | $631 | $631 | $631 |
| Polysomnography with CPAP titration CPT 95811 • Sleep Medicine | $594 | $594 | $594 |