| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $38 | $38 | $38 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $32 | $32 | $32 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $260 | $260 | $260 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $390 | $390 | $390 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $101 | $101 | $101 |
| Special stain group II CPT 88313 • Pathology | $74 | $74 | $74 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $37 | $37 | $37 |
| Frozen section pathology each additional CPT 88332 • Pathology | $47 | $47 | $47 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $77 | $77 | $77 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $89 | $89 | $89 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $105 | $105 | $105 |
| Microdissection manual CPT 88381 • Pathology | $183 | $183 | $183 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| 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 | $11 | $11 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $11 | $11 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $26 | $26 | $26 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $22 | $22 | $22 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $21 | $21 | $21 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $13 | $13 | $13 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $78 | $78 | $78 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $54 | $54 | $55 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $29 | $29 | $29 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $25 | $25 | $25 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $24 | $24 | $25 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $26 | $26 | $26 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $38 | $38 | $38 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $33 | $33 | $33 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $5 | $5 |
| Immunization admin injection single CPT 90471 • Preventive Care | $5 | $8 | $10 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $10 | $10 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $335 | $335 | $335 |
| 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 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $109 | $109 | $109 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $113 | $113 | $113 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $118 | $118 | $118 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $132 | $132 | $133 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $128 | $128 | $128 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $161 | $161 | $161 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $113 | $113 | $113 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $116 | $116 | $116 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $122 | $122 | $122 |