| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $80 | $80 | $80 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $80 | $80 | $80 |
| Cytopathology concentration technique CPT 88108 • Pathology | $80 | $80 | $80 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $80 | $80 | $80 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $80 | $80 | $80 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $80 | $80 | $80 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $80 | $80 | $80 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $80 | $80 | $80 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $80 | $80 | $80 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $80 | $80 | $80 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $80 | $80 | $80 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $80 | $80 | $80 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $80 | $80 | $80 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $80 | $80 | $80 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $80 | $80 | $80 |
| Special stain group II CPT 88313 • Pathology | $80 | $80 | $80 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $80 | $80 | $80 |
| Frozen section pathology each additional CPT 88332 • Pathology | $80 | $80 | $80 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $80 | $80 | $80 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $80 | $80 | $80 |
| Microdissection manual CPT 88381 • Pathology | $80 | $80 | $80 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $80 | $80 | $80 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $80 | $80 | $80 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $80 | $80 | $80 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $80 | $80 | $80 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $80 | $80 | $80 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $80 | $80 | $80 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $80 | $80 | $80 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $80 | $80 | $80 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $80 | $80 | $80 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $80 | $80 | $80 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $80 | $80 | $80 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $80 | $80 | $80 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $80 | $80 | $80 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $80 | $80 | $80 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $80 | $80 | $80 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $80 | $80 | $80 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $80 | $80 | $80 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $80 | $80 | $80 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $80 | $80 | $80 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $80 | $80 | $80 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $80 | $80 | $80 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $80 | $80 | $80 |
| Immunization admin injection single CPT 90471 • Preventive Care | $80 | $80 | $80 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $80 | $80 | $80 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $80 | $80 | $80 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $80 | $80 | $80 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $80 | $80 | $80 |
| MMR vaccine CPT 90707 • Preventive Care | $80 | $80 | $80 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $80 | $80 | $80 |