| Peripheral nerve block injection CPT 64450 • Pain Management | $45 | $2,242 | $4,439 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $4,439 | $4,439 | $4,439 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $296 | $2,368 | $4,439 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $55 | $2,247 | $4,439 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $149 | $2,294 | $4,439 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $60 | $2,250 | $4,439 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $131 | $2,285 | $4,439 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $318 | $2,379 | $4,439 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $95 | $2,267 | $4,439 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $4,439 | $4,439 | $4,439 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $17 | $17 | $17 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $15 | $15 | $15 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $11 | $11 | $11 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $4 | $4 | $4 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $7 | $7 | $7 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $15 | $15 | $15 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $51 | $51 | $51 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $90 | $90 | $90 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $17 | $17 | $17 |
| Special stain group II CPT 88313 • Pathology | $8 | $8 | $8 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $39 | $39 | $39 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $18 | $18 | $18 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $22 | $22 | $22 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $26 | $26 | $26 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $11 | $11 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $105 | $105 | $105 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $21 | $21 | $21 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $19 | $19 | $19 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $20 | $20 | $20 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $316 | $316 | $316 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $99 | $99 | $99 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $16 | $16 | $16 |
| MMR vaccine CPT 90707 • Preventive Care | $91 | $91 | $91 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $34 | $34 | $34 |
| Varicella vaccine CPT 90716 • Preventive Care | $184 | $184 | $184 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $99 | $99 | $99 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $200 | $200 | $200 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $122 | $122 | $122 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $109 | $109 | $109 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $114 | $114 | $114 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $120 | $120 | $120 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $162 | $162 | $162 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $175 | $175 | $175 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $122 | $122 | $122 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $100 | $100 | $100 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $140 | $140 | $140 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $138 | $138 | $138 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $131 | $131 | $131 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $143 | $143 | $143 |