| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $199 | $199 | $199 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $108 | $146 | $184 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $306 | $306 | $306 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $92 | $92 | $92 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $268 | $268 | $268 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $399 | $566 | $733 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $221 | $248 | $302 |
| Cytopathology concentration technique CPT 88108 • Pathology | $120 | $120 | $120 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $76 | $76 | $76 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $50 | $50 | $50 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $29 | $29 | $29 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $51 | $51 | $51 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $12 | $26 | $41 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $20 | $43 | $66 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $14 | $14 | $14 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $80 | $80 | $80 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $75 | $75 | $75 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $165 | $172 | $178 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $291 | $291 | $291 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $204 | $204 | $204 |
| Special stain group II CPT 88313 • Pathology | $147 | $147 | $147 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $125 | $125 | $125 |
| Frozen section pathology each additional CPT 88332 • Pathology | $62 | $62 | $62 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $56 | $56 | $56 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $70 | $70 | $70 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $49 | $104 | $159 |
| Microdissection manual CPT 88381 • Pathology | $50 | $90 | $131 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $7 | $12 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $5 | $9 | $13 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $5 | $8 | $11 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $13 | $26 | $39 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $6 | $9 | $13 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $14 | $21 | $28 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $32 | $50 | $69 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $27 | $43 | $58 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $25 | $43 | $61 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $8 | $12 | $16 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $77 | $77 | $77 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $77 | $77 | $77 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $47 | $62 | $77 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $33 | $43 | $53 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $17 | $26 | $35 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $15 | $23 | $31 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $15 | $20 | $30 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $16 | $24 | $31 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $44 | $61 | $77 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $19 | $28 | $38 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $12 | $15 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $9 | $13 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $12 | $15 |