| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $351 | $618 | $977 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $35 | $551 | $977 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $351 | $528 | $595 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $35 | $455 | $595 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $35 | $457 | $977 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $595 | $857 | $1,104 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $35 | $646 | $977 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $35 | $551 | $977 |
| Cytopathology concentration technique CPT 88108 • Pathology | $52 | $52 | $52 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $51 | $51 | $51 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $18 | $18 | $18 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $14 | $14 | $14 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $21 | $21 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $17 | $17 | $17 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $26 | $26 | $26 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $32 | $32 | $32 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $26 | $57 | $116 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $216 | $216 | $216 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $325 | $325 | $325 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $65 | $112 | $136 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $46 | $62 | $77 |
| Frozen section pathology each additional CPT 88332 • Pathology | $41 | $41 | $41 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $46 | $116 | $150 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $170 | $170 | $170 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $59 | $75 | $91 |
| Microdissection manual CPT 88381 • Pathology | $150 | $150 | $150 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $25 | $41 | $50 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $23 | $34 | $46 |
| Immunization admin injection single CPT 90471 • Preventive Care | $28 | $28 | $28 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $21 | $21 | $21 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $111 | $111 | $111 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $172 | $172 | $172 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $180 | $180 | $180 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $136 | $136 | $136 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $210 | $210 | $210 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $204 | $204 | $204 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $185 | $211 | $237 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $256 | $256 | $256 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $109 | $109 | $109 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $120 | $143 | $165 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $120 | $142 | $165 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $136 | $158 | $181 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $139 | $162 | $184 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $196 | $196 | $196 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $159 | $185 | $211 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $54 | $431 | $977 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $154 | $528 | $977 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $90 | $351 | $584 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $559 | $887 | $977 |