| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $14 | $14 | $14 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $17 | $58 | $100 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $128 | $149 | $170 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $67 | $77 | $88 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $83 | $83 | $83 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $188 | $188 | $188 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $26 | $26 | $26 |
| Cytopathology concentration technique CPT 88108 • Pathology | $25 | $25 | $25 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $22 | $22 | $22 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $17 | $17 | $17 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $3 | $3 | $3 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $8 | $8 | $8 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $14 | $14 | $14 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $26 | $26 | $26 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $5 | $5 | $5 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $16 | $16 | $16 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $22 | $24 | $26 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $128 | $128 | $128 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $113 | $113 | $113 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $86 | $86 | $86 |
| Special stain group II CPT 88313 • Pathology | $31 | $31 | $31 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $79 | $79 | $79 |
| Frozen section pathology each additional CPT 88332 • Pathology | $8 | $8 | $8 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $14 | $14 | $14 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $27 | $27 | $27 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $60 | $76 | $93 |
| Microdissection manual CPT 88381 • Pathology | $19 | $89 | $159 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $5 | $7 | $8 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $12 | $12 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $7 | $9 | $11 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $24 | $24 | $25 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $28 | $28 | $29 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $18 | $21 | $25 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $12 | $17 | $23 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $14 | $14 | $15 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $84 | $84 | $84 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $83 | $83 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $83 | $83 | $84 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $58 | $58 | $58 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $30 | $30 | $31 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $16 | $21 | $27 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $26 | $26 | $27 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $16 | $22 | $27 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $40 | $40 | $40 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $20 | $27 | $34 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $5 | $5 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |