| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $673 | $673 | $673 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $367 | $520 | $673 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $40 | $40 | $40 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Physical therapy evaluation low complexity CPT 97161 • 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 | $25 | $25 | $25 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $26 | $26 | $26 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $22 | $22 |
| Immunization admin injection single CPT 90471 • Preventive Care | $20 | $20 | $20 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $13 | $13 | $13 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $316 | $316 | $316 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $19 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $40 | $40 | $40 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $112 | $112 | $112 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $109 | $109 | $109 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $112 | $112 | $112 |
| 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 | $138 | $138 | $138 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $97 | $97 | $97 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $103 | $103 | $103 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $96 | $96 | $96 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $105 | $105 | $105 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $116 | $116 | $116 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $115 | $115 | $115 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $673 | $673 | $673 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $675 | $751 | $828 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $675 | $751 | $828 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $383 | $606 | $828 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $828 | $839 | $849 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $828 | $828 | $828 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $514 | $730 | $849 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $514 | $730 | $849 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $828 | $828 | $828 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $6 | $6 | $6 |
| Radiation therapy simulation complex CPT 77290 • Radiation Therapy | $181 | $181 | $181 |
| 3-dimensional radiation therapy plan CPT 77295 • Radiation Therapy | $236 | $236 | $236 |
| Radiation physics consultation CPT 77336 • Radiation Therapy | $40 | $40 | $40 |
| Radiation treatment delivery superficial CPT 77407 • Radiation Therapy | $68 | $68 | $68 |
| Radiation treatment delivery 3 or more MeV CPT 77412 • Radiation Therapy | $116 | $116 | $116 |
| Proton beam treatment simple CPT 77520 • Radiation Therapy | $812 | $812 | $812 |
| Proton beam treatment complex CPT 77523 • Radiation Therapy | $1,062 | $1,062 | $1,062 |
| Respiratory assist device BiPAP without backup HCPCS E0470 • Sleep Medicine | $154 | $154 | $154 |
| CPAP device continuous positive airway pressure HCPCS E0601 • Sleep Medicine | $66 | $66 | $66 |
| Post-void residual urine measurement CPT 51798 • Urology | $28 | $28 | $28 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $383 | $535 | $673 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $514 | $1,158 | $2,133 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $587 | $587 | $587 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $514 | $920 | $1,417 |