| Facet joint injection lumbar second level CPT 64494 • Pain Management | $81 | $130 | $179 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $139 | $219 | $298 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $304 | $581 | $858 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $94 | $223 | $352 |
| Cytopathology concentration technique CPT 88108 • Pathology | $129 | $129 | $129 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $16 | $78 | $140 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $14 | $41 | $68 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $13 | $13 | $13 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $68 | $68 | $68 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $15 | $39 | $63 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $17 | $50 | $84 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $19 | $81 | $143 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $107 | $327 | $547 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $230 | $535 | $840 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $44 | $123 | $202 |
| Special stain group II CPT 88313 • Pathology | $37 | $90 | $142 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $56 | $129 | $203 |
| Frozen section pathology each additional CPT 88332 • Pathology | $17 | $64 | $110 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $36 | $111 | $187 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $42 | $131 | $220 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $64 | $177 | $289 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $12 | $12 | $12 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $22 | $33 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $24 | $40 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $13 | $27 | $40 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $13 | $20 | $27 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $21 | $45 | $68 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $27 | $49 | $71 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $24 | $42 | $59 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $6 | $35 | $63 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $17 | $17 | $17 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $91 | $130 | $170 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $73 | $121 | $170 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $123 | $170 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $63 | $88 | $114 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $32 | $53 | $73 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $27 | $50 | $73 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $24 | $24 | $24 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $31 | $50 | $69 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $38 | $59 | $80 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $37 | $52 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $9 | $18 | $26 |
| Immunization admin injection single CPT 90471 • Preventive Care | $22 | $37 | $52 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $16 | $21 | $26 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $228 | $239 | $250 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $414 | $414 | $414 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $84 | $90 | $97 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $30 | $41 |
| MMR vaccine CPT 90707 • Preventive Care | $67 | $79 | $91 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $40 | $54 | $68 |