| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $4 | $4 | $4 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $9 | $9 | $9 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $22 | $22 | $22 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $57 | $57 | $57 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $78 | $78 | $78 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $22 | $22 | $22 |
| Special stain group II CPT 88313 • Pathology | $9 | $9 | $9 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $70 | $70 | $70 |
| Frozen section pathology each additional CPT 88332 • Pathology | $7 | $7 | $7 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $72 | $72 | $72 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $18 | $18 | $18 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $111 | $111 | $111 |
| Microdissection manual CPT 88381 • Pathology | $213 | $213 | $213 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $16 | $16 | $16 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $16 | $16 | $16 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $17 | $17 | $17 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $14 | $14 | $14 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $32 | $32 | $32 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $32 | $32 | $32 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $27 | $27 | $27 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $29 | $29 | $29 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $19 | $19 | $19 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $94 | $94 | $94 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $94 | $94 | $94 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $94 | $94 | $94 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $64 | $64 | $64 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $32 | $32 | $32 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $33 | $33 | $33 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $30 | $30 | $30 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $32 | $32 | $32 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $34 | $34 | $34 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $31 | $31 | $31 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $28 | $28 | $28 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $14 | $14 | $14 |
| Immunization admin injection single CPT 90471 • Preventive Care | $9 | $9 | $9 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $6 | $6 | $6 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $395 | $395 | $395 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $272 | $272 | $272 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $123 | $123 | $123 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $24 | $24 | $24 |
| MMR vaccine CPT 90707 • Preventive Care | $117 | $117 | $117 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $59 | $59 | $59 |
| Varicella vaccine CPT 90716 • Preventive Care | $230 | $230 | $230 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $141 | $141 | $141 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $282 | $282 | $282 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $40 | $40 | $40 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $113 | $113 | $113 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $121 | $121 | $121 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $119 | $119 | $119 |