| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $150 | $150 | $150 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $238 | $238 | $238 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $41 | $41 | $41 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $41 | $41 | $41 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $46 | $46 | $46 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $41 | $41 | $41 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $41 | $41 | $41 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $171 | $171 | $171 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $85 | $85 | $85 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $126 | $126 | $126 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $418 | $418 | $418 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $178 | $178 | $178 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $100 | $100 | $100 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $27 | $27 | $27 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $54 | $54 | $54 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $63 | $63 | $63 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $106 | $106 | $106 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $79 | $152 | $226 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $339 | $339 | $339 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $108 | $108 | $108 |
| Special stain group II CPT 88313 • Pathology | $79 | $79 | $79 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $88 | $88 | $88 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $65 | $65 | $65 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $103 | $103 | $103 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $122 | $122 | $122 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $4 | $4 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $14 | $14 | $14 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $13 | $13 | $13 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $14 | $14 | $14 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $14 | $14 | $14 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $12 | $12 | $12 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $14 | $14 | $14 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $14 | $14 | $14 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $13 | $13 | $13 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $14 | $14 | $14 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $58 | $58 | $58 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $58 | $58 | $58 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $58 | $58 | $58 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $40 | $40 | $40 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $24 | $24 | $24 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $14 | $14 | $14 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $26 | $26 | $26 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $27 | $28 | $30 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $11 | $12 | $13 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $19 | $28 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $15 | $21 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $271 | $320 | $369 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $254 | $254 | $254 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $115 | $115 | $115 |