| Cytogenetics molecular interpretation CPT 88291 • Pathology | $68 | $68 | $68 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $35 | $35 | $35 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $7 | $25 | $44 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $15 | $33 | $52 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $49 | $174 | $299 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $444 | $444 | $444 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $36 | $77 | $118 |
| Special stain group II CPT 88313 • Pathology | $30 | $59 | $88 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $103 | $103 | $103 |
| Frozen section pathology each additional CPT 88332 • Pathology | $110 | $110 | $110 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $67 | $67 | $67 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $76 | $76 | $76 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $129 | $129 | $129 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $12 | $12 | $12 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $11 | $12 | $13 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $24 | $40 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $13 | $15 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $13 | $15 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $19 | $25 | $30 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $21 | $28 | $34 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $19 | $39 | $59 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $24 | $29 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $73 | $121 | $170 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $91 | $130 | $170 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $73 | $121 | $170 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $50 | $82 | $114 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $49 | $73 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $21 | $28 | $34 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $20 | $20 | $20 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $69 | $69 | $69 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $42 | $45 | $49 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $17 | $17 | $18 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $7 | $8 | $9 |
| Immunization admin injection single CPT 90471 • Preventive Care | $24 | $25 | $27 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $17 | $18 | $20 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $130 | $233 | $336 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $231 | $231 | $231 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $97 | $98 | $99 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $9 | $14 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $77 | $89 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $40 | $54 | $68 |
| Varicella vaccine CPT 90716 • Preventive Care | $157 | $176 | $196 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $137 | $141 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $186 | $186 | $186 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $99 | $109 | $120 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $103 | $103 | $103 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $107 | $107 | $107 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $121 | $121 | $121 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $118 | $146 | $174 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $136 | $159 | $182 |