| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $52 | $52 | $52 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $219 | $290 | $361 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $550 | $550 | $550 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $142 | $142 | $142 |
| Special stain group II CPT 88313 • Pathology | $62 | $82 | $102 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $79 | $79 | $79 |
| Frozen section pathology each additional CPT 88332 • Pathology | $69 | $69 | $69 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $68 | $90 | $112 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $77 | $103 | $128 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $54 | $73 | $93 |
| Microdissection manual CPT 88381 • Pathology | $263 | $263 | $263 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $10 | $14 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $10 | $10 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $12 | $12 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $12 | $23 | $34 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $71 | $71 | $71 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $28 | $28 | $28 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $25 | $48 | $71 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $65 | $65 | $65 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $42 | $42 | $42 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $241 | $241 | $241 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $84 | $162 | $241 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $241 | $241 | $241 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $57 | $57 | $58 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $30 | $30 | $30 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $79 | $79 | $79 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $27 | $52 | $76 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $27 | $27 | $27 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $40 | $40 | $40 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $34 | $34 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $31 | $31 | $31 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $25 | $40 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $20 | $31 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $453 | $648 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $92 | $92 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $54 | $54 | $54 |
| MMR vaccine CPT 90707 • Preventive Care | $93 | $93 | $93 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $96 | $96 | $96 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $163 | $163 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $13 | $13 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $28 | $28 | $28 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $106 | $178 | $249 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $111 | $186 | $260 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $105 | $163 | $270 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $105 | $118 | $131 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $105 | $201 | $298 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $119 | $179 | $270 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $373 | $373 | $373 |