| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $21 | $21 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $5 | $5 | $5 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $17 | $17 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $37 | $110 | $182 |
| Special stain group II CPT 88313 • Pathology | $5 | $34 | $62 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $79 | $79 | $79 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $40 | $68 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $47 | $77 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $93 | $93 | $93 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $3 | $3 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $11 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $9 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $12 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $11 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $20 | $22 | $25 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $76 | $76 | $76 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $76 | $80 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $54 | $56 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $27 | $27 |
| 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 | $25 | $25 | $25 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $22 | $22 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $35 | $35 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $16 | $22 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $14 | $19 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $11 | $13 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $268 | $268 | $268 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $258 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $95 | $99 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $19 |
| MMR vaccine CPT 90707 • Preventive Care | $93 | $94 | $94 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $34 | $34 | $34 |
| Varicella vaccine CPT 90716 • Preventive Care | $82 | $133 | $184 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $13 | $13 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $19 | $97 | $176 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $80 | $91 | $101 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $96 | $104 | $111 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $94 | $105 | $116 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $98 | $105 | $113 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $103 | $103 | $103 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $139 | $143 | $148 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $83 | $83 | $83 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $89 | $95 | $102 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $88 | $95 | $102 |