| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $57 | $57 | $57 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $57 | $419 | $781 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $57 | $332 | $607 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $8,305 | $18,410 | $28,516 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $74 | $7,537 | $15,000 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $36 | $46 | $57 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $32,000 | $32,000 | $32,000 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $19,682 | $19,682 | $19,682 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $30,000 | $30,000 | $30,000 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $740 | $740 | $740 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $57 | $107 | $152 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $1,511 | $20,755 | $40,000 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $57 | $57 | $57 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $57 | $57 | $57 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $12 | $12 | $12 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $44 | $44 | $44 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $9 | $9 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| 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 | $68 | $68 | $68 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $68 | $68 | $68 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $47 | $47 | $47 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $24 | $24 | $24 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $23 | $23 | $23 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $28 | $28 | $28 |
| Immunization admin injection single CPT 90471 • Preventive Care | $16 | $16 | $16 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $111 | $111 | $111 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $16 | $16 | $16 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $51 | $51 | $51 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $89 | $89 | $89 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $112 | $112 | $112 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $143 | $143 | $143 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $101 | $101 | $101 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $107 | $107 | $107 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $243 | $243 | $243 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $800 | $14,658 | $28,516 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $800 | $14,658 | $28,516 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $142 | $142 | $142 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $19,682 | $19,682 | $19,682 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $1,294 | $14,905 | $28,516 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $1,294 | $14,905 | $28,516 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $1,294 | $14,905 | $28,516 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $2,630 | $15,573 | $28,516 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $57 | $1,343 | $2,630 |
| Radiation therapy simulation simple CPT 77280 • Radiation Therapy | $116 | $116 | $116 |
| Radiation therapy simulation complex CPT 77290 • Radiation Therapy | $321 | $321 | $321 |
| 3-dimensional radiation therapy plan CPT 77295 • Radiation Therapy | $407 | $407 | $407 |
| Radiation therapy dose calculation CPT 77300 • Radiation Therapy | $54 | $54 | $54 |
| IMRT radiation therapy plan CPT 77301 • Radiation Therapy | $1,198 | $1,198 | $1,198 |