| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $155 | $155 | $155 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $251 | $251 | $251 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $127 | $127 | $127 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $31 | $31 | $31 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $11 | $11 | $11 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $12 | $12 | $12 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $19 | $19 | $19 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $33 | $33 | $33 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $39 | $39 | $39 |
| Special stain group II CPT 88313 • Pathology | $32 | $32 | $32 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $31 | $31 | $31 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $35 | $35 | $35 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $12 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $10 | $10 | $10 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $25 | $25 | $25 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $20 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $14 | $14 | $14 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $27 | $27 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $22 | $22 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $35 | $35 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $19 | $19 | $19 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $18 | $18 | $18 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $15 | $15 | $15 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $268 | $268 | $268 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $197 | $197 | $197 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $84 | $84 | $84 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $19 |
| MMR vaccine CPT 90707 • Preventive Care | $94 | $94 | $94 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $40 | $40 | $40 |
| Varicella vaccine CPT 90716 • Preventive Care | $184 | $184 | $184 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $133 | $133 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $190 | $190 | $190 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $101 | $101 | $101 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $106 | $106 | $106 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $94 | $94 | $94 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $95 | $95 | $95 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $161 | $161 | $161 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $127 | $127 | $127 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $83 | $83 | $83 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $97 | $97 | $97 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $82 | $82 | $82 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $81 | $81 | $81 |