| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $785 | $785 | $785 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $52 | $140 | $229 |
| Special stain group II CPT 88313 • Pathology | $5 | $96 | $186 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $109 | $109 | $109 |
| Frozen section pathology each additional CPT 88332 • Pathology | $66 | $66 | $66 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $84 | $156 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $95 | $175 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $19 | $112 | $205 |
| Microdissection manual CPT 88381 • Pathology | $473 | $473 | $473 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $11 | $11 | $11 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $9 | $9 | $9 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $22 | $22 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $22 | $22 | $22 |
| 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 | $19 | $19 | $19 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $98 | $98 | $98 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $73 | $73 | $73 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $73 | $73 | $73 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $31 | $31 | $31 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $21 | $21 | $21 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $25 | $25 | $25 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $10 | $10 | $10 |
| Immunization admin injection single CPT 90471 • Preventive Care | $23 | $23 | $23 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $11 | $11 | $11 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $303 | $308 | $314 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $258 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $45 | $73 | $101 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $15 | $18 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $92 | $96 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $34 | $37 | $40 |
| Varicella vaccine CPT 90716 • Preventive Care | $159 | $173 | $187 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $133 | $133 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $220 | $220 | $220 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $136 | $136 | $136 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $130 | $130 | $130 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $90 | $90 | $90 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $102 | $102 | $102 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $169 | $169 | $169 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $185 | $185 | $185 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $74 | $74 | $74 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $79 | $79 | $79 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $85 | $85 | $85 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $94 | $94 | $94 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $130 | $130 | $130 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $145 | $145 | $145 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $109 | $109 | $109 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $166 | $166 | $166 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $155 | $155 | $155 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $129 | $129 | $129 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $9 | $9 | $9 |