| Unlisted nervous system procedure CPT 64999 • Pain Management | $896 | $896 | $896 |
| Cytopathology concentration technique CPT 88108 • Pathology | $6 | $36 | $57 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $40 | $65 | $113 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $14 | $31 | $57 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $12 | $20 | $33 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $17 | $31 | $46 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $8 | $33 | $62 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $22 | $44 | $75 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $21 | $29 | $34 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $3 | $26 | $44 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $11 | $38 | $55 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $68 | $154 | $192 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $39 | $154 | $293 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $7 | $60 | $103 |
| Special stain group II CPT 88313 • Pathology | $12 | $49 | $76 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $69 | $73 | $76 |
| Frozen section pathology each additional CPT 88332 • Pathology | $13 | $30 | $40 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $24 | $92 | $205 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $40 | $63 | $80 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $34 | $78 | $130 |
| Microdissection manual CPT 88381 • Pathology | $41 | $76 | $135 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $7 | $12 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $13 | $20 | $27 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $13 | $22 | $27 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $15 | $20 | $27 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $12 | $15 | $18 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $27 | $35 | $45 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $27 | $47 | $67 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $23 | $30 | $40 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $25 | $32 | $42 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $17 | $24 | $35 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $78 | $224 | $500 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $78 | $86 | $93 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $78 | $86 | $93 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $54 | $76 | $112 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $37 | $48 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $29 | $37 | $48 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $26 | $34 | $43 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $27 | $47 | $66 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $24 | $57 | $94 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $23 | $46 | $80 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $7 | $21 | $34 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $10 | $18 |
| Immunization admin injection single CPT 90471 • Preventive Care | $7 | $21 | $34 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $5 | $12 | $18 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $320 | $355 | $413 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $237 | $254 | $272 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $103 | $116 | $129 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $22 | $26 |
| MMR vaccine CPT 90707 • Preventive Care | $97 | $111 | $123 |