| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $94 | $94 | $94 |
| Cytopathology concentration technique CPT 88108 • Pathology | $91 | $91 | $91 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $16 | $53 | $90 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $14 | $14 | $14 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $18 | $21 | $24 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $17 | $37 | $57 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $19 | $57 | $96 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $153 | $266 | $380 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $230 | $282 | $333 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $60 | $104 | $149 |
| Special stain group II CPT 88313 • Pathology | $37 | $73 | $109 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $56 | $67 | $79 |
| Frozen section pathology each additional CPT 88332 • Pathology | $17 | $17 | $17 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $51 | $86 | $120 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $42 | $91 | $140 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $64 | $112 | $160 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $14 | $17 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $9 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $13 | $16 | $19 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $13 | $16 | $19 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $21 | $31 | $40 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $27 | $36 | $46 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $24 | $32 | $40 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $6 | $22 | $37 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $17 | $21 | $24 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $91 | $113 | $136 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $73 | $104 | $136 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $106 | $136 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $63 | $78 | $94 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $32 | $41 | $49 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $27 | $35 | $44 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $24 | $33 | $43 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $28 | $30 | $31 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $38 | $51 | $64 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $27 | $31 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $9 | $9 | $9 |
| Immunization admin injection single CPT 90471 • Preventive Care | $17 | $22 | $27 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $19 | $19 | $20 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $250 | $250 | $250 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $84 | $84 | $84 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $20 | $22 |
| MMR vaccine CPT 90707 • Preventive Care | $91 | $91 | $91 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $40 | $47 | $54 |
| Varicella vaccine CPT 90716 • Preventive Care | $124 | $124 | $124 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $133 | $133 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $176 | $176 | $176 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $103 | $103 | $103 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $136 | $136 | $136 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $140 | $140 | $140 |