| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $188 | $350 | $513 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $784 | $784 | $784 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $201 | $201 | $201 |
| Special stain group II CPT 88313 • Pathology | $143 | $143 | $143 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $79 | $79 | $79 |
| Frozen section pathology each additional CPT 88332 • Pathology | $100 | $100 | $100 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $159 | $159 | $159 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $182 | $182 | $182 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $60 | $60 | $60 |
| Microdissection manual CPT 88381 • Pathology | $370 | $370 | $370 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $6 | $8 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $9 | $9 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $9 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $12 | $12 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $20 | $20 | $20 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $41 | $41 | $41 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $48 | $48 | $48 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $24 | $24 | $24 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $22 | $22 | $22 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $25 | $25 | $25 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $142 | $142 | $142 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $48 | $48 | $48 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $48 | $48 | $48 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $33 | $45 | $57 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $30 | $30 | $30 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $46 | $46 | $46 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $20 | $32 | $45 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $47 | $47 | $47 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $40 | $40 | $40 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $58 | $58 | $58 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $11 | $11 | $11 |
| Immunization admin injection single CPT 90471 • Preventive Care | $4 | $4 | $4 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $9 | $9 | $9 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $230 | $230 | $230 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $104 | $104 | $104 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $20 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $100 | $100 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $39 | $39 | $39 |
| Varicella vaccine CPT 90716 • Preventive Care | $195 | $195 | $195 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $133 | $133 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $219 | $219 | $219 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $81 | $96 | $111 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $116 | $116 | $116 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $120 | $120 | $120 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $100 | $117 | $135 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $133 | $133 | $133 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $167 | $167 | $167 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $77 | $77 | $77 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $87 | $87 | $87 |