| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $750 | $13,971 | $40,000 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $57 | $403 | $750 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $57 | $403 | $750 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $60 | $60 | $60 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $94 | $94 | $94 |
| Special stain group II CPT 88313 • Pathology | $10 | $10 | $10 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $50 | $50 | $50 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $84 | $84 | $84 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $11 | $11 | $11 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $21 | $21 | $21 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $20 | $20 | $20 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $25 | $25 | $25 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $25 | $25 | $25 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $51 | $51 | $51 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $58 | $58 | $58 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $51 | $51 | $51 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $47 | $47 | $47 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $31 | $31 | $31 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $173 | $173 | $173 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $173 | $173 | $173 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $173 | $173 | $173 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $119 | $119 | $119 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $64 | $64 | $64 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $56 | $56 | $56 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $55 | $55 | $55 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $58 | $58 | $58 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $83 | $83 | $83 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $72 | $72 | $72 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $38 | $38 | $38 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $17 | $17 | $17 |
| Immunization admin injection single CPT 90471 • Preventive Care | $34 | $34 | $34 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $24 | $24 | $24 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $457 | $457 | $457 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $111 | $111 | $111 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $40 | $40 | $40 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $68 | $68 | $68 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $236 | $236 | $236 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $141 | $141 | $141 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $147 | $147 | $147 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $153 | $153 | $153 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $173 | $173 | $173 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $168 | $168 | $168 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $194 | $194 | $194 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $210 | $210 | $210 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $127 | $127 | $127 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $136 | $136 | $136 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $135 | $135 | $135 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $148 | $148 | $148 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $151 | $151 | $151 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $122 | $122 | $122 |