| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $232 | $232 | $232 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $67 | $103 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $225 | $225 | $225 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $77 | $83 | $88 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $154 | $154 | $154 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $434 | $434 | $434 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $239 | $239 | $239 |
| Cytopathology concentration technique CPT 88108 • Pathology | $53 | $53 | $53 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $20 | $20 | $20 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $5 | $5 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $17 | $17 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $37 | $135 | $233 |
| Special stain group II CPT 88313 • Pathology | $5 | $36 | $66 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $81 | $81 | $81 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $41 | $69 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $48 | $80 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $95 | $95 | $95 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $11 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $10 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $11 | $11 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $21 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $21 | $22 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $18 | $18 | $19 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $66 | $71 | $76 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $72 | $76 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $26 | $27 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $25 | $25 | $25 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $23 | $23 | $23 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $22 | $22 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $35 | $35 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $14 | $19 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $13 | $19 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $11 | $13 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $269 | $269 | $269 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $258 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $52 | $68 | $84 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $19 |
| MMR vaccine CPT 90707 • Preventive Care | $15 | $53 | $91 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $34 | $37 | $40 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $174 | $184 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $13 | $13 |